PURPOSE:
The Blood Bank as a section of the Department of Pathology and Laboratory Medicine is committed to quality care services to the patients twenty-four (24) hours a day, seven (7) days a week all year round including official holidays. A well-trained staff provides the services and practices that are based on internationally accepted standards and regulations. The services are:
· Donor Blood Collection
· Blood Component Therapy
· Collection Apheresis
· Therapeutic Apheresis
· Peripheral Blood Stem Cell Collection and Storage
The Stem Cell Processing Laboratory, as part of the Blood Bank and under the jurisdiction of the Blood Bank Medical Director, provides the following services:
· Processing for the Cryopreservation of the Stem Cell Collect
· Storage by Cryopreservation
· Thawing and Release of the Stem Cell Collect
GOALS:
The Blood Bank has established goals with the intention of providing continuous quality patient-care, constant improvement, and quality management as well as continuing medical education (CME) to the Medical and House staff and the Blood Bank staff members. These goals aim:
1. 1. To maintain professional and technical competence by offering CME to the Blood Bank staff.
2. 2. To preserve quality while maintaining cost-effectiveness.
3. 3. To provide continuous performance improvement program.
4. 4. To stay abreast of and introduce new methodology, technology, standards and regulations.
5. 5. To assure quality patient care by blood transfusion audits.
6. 6. To provide CME to Medical, House and Nursing Staff.
TYPE AND AGES OF THE PATIENTS GIVEN CARE:
The Blood Bank provides care to patients of all ages and categories these include, but are not limited to: Age: Fetus Neonate Pediatric Adult Geriatric
Type: Intrauterine Medical Surgical Solid Organ Transplant Peripheral Blood Stem Cell Transplant Dialysis Trauma Whole blood Exchange transfusion Red blood cell Exchange transfusion Plasma exchange transfusion
SCOPE OF CURRENT AND PLANNED SERVICES/PRACTICE:
The Blood Bank is a Hospital-based transfusion service and donor unit, providing, but not exclusive to: blood collection, processing, storage and distribution. The Blood Bank includes a processing area, a donor room, an apheresis facility and a stem cell processing lab. The Blood Bank provides blood components for patients upon physician request. The Blood Bank provides its services twenty-four (24) hours a day, and can manage emergency situations, problematic transfusion recipients, massive transfusion, while providing irradiation, bed-side filtration, and quality products based on internationally accepted standards. The Blood Bank also offers an Autologous Blood Program and a Blood Donor Registry:
Autologous Program including:
· Pre-surgical blood deposit
· Induction hemodilution
· Intra-operative blood salvage
· Post-operative blood salvage
Blood Donation Registry:
Encourages healthy blood donors to altruistically donate whole blood every four (4) months to save patients.
The Departments serviced include:
· Emergency Unit
· Out patient Dept
· Operating room
· Recovery room
· Kidney room
· ICU
· CCU
· RCU
· Hospitalized patient, including, not exclusive to:1. Internal medicine
1. Internal medicine 2. Surgery 3. OB-GYN 4. Pediatrics 5. Oncology patients 6. Stem cell and solid organ transplant transfusion support 7. Therapeutic Apheresis
The patients serviced include:
· Community members
· Medical, House and Nursing Staff
· Internal Personnel
AVAILABILITY OF STAFF/STAFFING:
The Blood Bank is located on the third floor of the AUB medical center and is available for patient care services twenty-four (24) hours a day, seven (7) days a week, providing the following services:
General:
· Component therapy
· Storage of blood components
· Administration of components
· Massive Transfusion
· Emergency Transfusion
· Transfusion reactions
· Irradiation of cellular blood components
· Filtration of blood components
· Autologous blood transfusion
· Blood safety
· Documentation
Donor Room:
· Interview
· Vital signs, weight, and hemoglobin level
· Blood Collection
Blood Bank Processing Area:
· ABO blood group & Rh type
· Direct Antiglobulin test--DAT
· Indirect Antiglobulin test--IAT
· Identification of unexpected antibodies
· Quantitative IAT (Titer of unexpected antibodies)
· Infectious screening
· Phenotyping
· Crossmatching
· Component preparation
· Storage
· Irradiation
· Investigation of transfusion reactions
· Investigation of Hemolytic Disease of the Newborn and Fetus
· Documentation
· Quality management
Apheresis Facility:
· Plateletpheresis
· Granulocyte Collection
· Therapeutic Plateletpheresis
· Therapeutic Plasmapheresis
· Therapeutic Leukapheresis
· Therapeutic Red Cell exchange
· Peripheral Blood Stem Cell collection
All tests are performed on whole blood, serum or plasma. STAT samples are given priority over routine requisitions. In cases of multiple STAT orders the catastrophe policy is implemented.
The 24-hour Blood Bank services are covered by three (3) shifts:
· 7 am - 4 pm
· 4 pm - 11 pm
· 11 pm - 7 am
The Blood Bank services are provided by:
1. 1. Qualified competent staff members including: Medical Technologists
o 1 senior and 4 cover the day shift
o 1 supervisor and 2 technologists and 1 phlebotomist cover the evening shift
o 1 technologist covers the overnight shift
Phlebotomists
o 1 day shift
o 1 evening shift
Lab Aid
o 1 day shift
2. 2. Clinical Pathology Resident
3. 3. Clinical Pathologist Medical Director
METHODS USED TO ASSESS & MEET THE PATIENT NEEDS/SERVICES:
The Blood Bank is a hospital-based donor collection and transfusion center. It works on a blood replacement donor system, and promotes the recently implemented a blood donor registry. All blood donors are volunteers. The blood components are made available in the general inventory after a series of screening tests, during which they are kept in quarantine. The blood units are released upon a written request from the physician. The Blood Bank also provides therapeutic apheresis upon written request of the physician. The trained clinical pathology residents, under the direct supervision and guidance of the Blood Bank medical director, administer these procedures.
RECOGNIZED STANDARDS AND GUIDELINES USED:
The Blood Bank follows the American association of Blood Banks (AABB) standards, and the Medical Center, Department and Section Policies and regulations.
Quality Control:
Quality control is applied on all methodologies and equipment according to the AABB standards. The Blood Bank Director is responsible for the overall quality control plan of the Blood Bank. The Director authorizes and delegates participation in the program to all the Blood Bank personnel. The Senior Blood Bank technologist is responsible for writing, implementing, and reviewing the plan and the overall management of the Quality Control Program. The plan should be revised annually or as needed. The Senior Blood Bank technologist, under the supervision and approval of the Blood Bank Director, is responsible for staff training, evaluations and competencies. The Blood Bank Director is responsible for review of results, evaluations of problems, and review of actions taken to resolve issues. The Blood Bank Director must determine the needs for procedures. All actions should be carried out according to specifications of the manufacturer and/or inspection agencies requirement.
Proficiency Program
The proficiency program routinely applies proficiency testing to assess the efficiency and accuracy of the tests performed. The Blood Bank Medical Director is responsible for the Blood Bank monitoring. The Blood Bank Senior technologist is responsible for the implementation of the program. Blood Bank Senior technologist is responsible for the participation of the monitoring program, which includes:
· Reporting of results in a timely and accurate manner
· Review of the test results
· Evaluation of problems
· Implementation of corrective actions
The Blood Bank Medical Director will coordinate all survey data for the Blood Bank, and develop a plan to ensure that all the staff members working in a particular area of the service are routinely challenged by the testing material. The Blood Bank Medical Director will inform the staff members of proficiency failures and counsel the employees who performed the test.
DEPARTMENT PERFORMANCE IMPROVEMENT PLAN:
The Blood Bank participates in the performance improvement activities of the Department. The Blood Bank Medical Director is responsible for the overall Performance Improvement Plan (PIP) of the section, with the Blood Bank Senior technologist taking responsibility for organizing and overseeing data collection and analysis, and implementation of actions designed to improve quality of services. The Blood Bank Senior technologist, with the approval of the Blood Bank Medical Director, may assign a designated person from the staff members to assist in this plan (the delegate). The delegate will serve on the PI committee of the department.
The criteria used by the Blank Bank are:
· Appropriate utilization of the Blood Bank services
· Appropriate ordering of the Blood Bank services
· Appropriate collection and transport of the specimens
· Accurate identification including, but not exclusive to: blood units, technologists performing the tests, patients, donors, phlebotomist and transfusionist and witness
· Accurate specimen processing and handling
· Accurate reporting of results
· Accurate documentation
· Proficiency testing and competency evaluation
· Clinical Risk Management
· Client satisfaction, including but not exclusive to: Physician, Patient and Donor
The data sources come from the following:
· Laboratory meetings (Dept. Faculty meetings)
· Quality improvement checklists (CAP)
· Client complaints
· Staff observations
· Incident reports
· Laboratory requisitions
· Accession logs
· Report forms
· Proficiency results
· Policies and Procedures
The Blood Bank quality indicators include but are not exclusive to:
· Blood Bank documentation
· Turn around time of STAT procedures
Reporting:
The Blood Bank Medical Director will report the analyzed data monthly to the Chairman of the Department.
THE BLOOD UTILIZATION COMMITTEE:
The Blood Utilization Committee functions as an advisory body to the Blood Bank and reports to the Chief of Staff. Dilemmas, transfusion reactions, requirements, and incidents are brought to the attention of the committee. The committee reviews the charts brought forth by the blood audits.