A blood banker from Indiana reports that one of the QA monitors that his 100-bed hospital (where they transfuse about 120-150 RBCs per month) routinely looks at is the number of transfusions that 'hang' for more than 4 hours. Despite numerous attempts by the nursing dept. (education, timed pumps, threatened disciplinary action, etc), their institution has been unable to eliminate about 1-3 instances per month where transfusions exceed the four-hour limit by 5-15 minutes. When asked at the last audit committee meeting about how important it is to comply with a maximum transfusion duration of 4 hours, the inquiring blood bank physician said that he thought it had been an AABB standard for years. (Editor's note: Actually, the Circular of Information (PDF file) gives 4 hours as the maximum duration for an infusion. However, the AABB Technical Manual comments that if it is anticipated that an infusion time of greater than 4 hours may be required, a physician covering the transfusion service should be notified to assess the individual clinical situation.) The inquiring blood banker is concerned about an increased risk of contamination once a unit has been spiked, etc. However, none of the inspectors from the JCAHO, the AABB or the State Health Department who have inspected either hospital where he practices has ever said anything about transfusions exceeding the four-hour time limit. The inquiring blood banker asks the e-Network for suggestions of realistic solutions to reduce the occurrence of transfusions that exceed four hours in duration.

In response to the above, the following replies were submitted.

ADDENDA May 13, 2002

1. A blood banker reported that when he used to work at a major medical center in Los Angeles, the laboratory would encourage nurses and physicians to request split units if they anticipated an infusion lasting more than 4 hours. The responding blood banker was not privy to the audits looking at infusion times, but he is of the impression that a significant number of requests were received for split units to be infused slowly, to avoid hanging a full unit beyond four hours. He also believes that an aggressive inservice campaign and a willingness to provide split units were reasons for success in avoiding excessively long 'hang times'.

2. A blood banker in Texas is of the opinion that the excessive 'hang time' problem could be solved by determining if the same physician ordered the blood that hangs too long. Perhaps there is a physician order which says "Transfuse 1 unit of blood over 4 hours". Is that a standard for that particular physician? Are all the patients receiving this order suffering from congestive heart failure? Once those questions are answered, the problem can be approached in 2 different ways.

1. Re-educate the physician that 2 hours is the generally accepted time for a unit to transfuse unless the patient's condition warrants special consideration (Maybe he/she thinks 4 hours is the norm).
2. If the patients all have CHF or something similar which requires transfusing very slowly, offer to divide the unit and give it out in 2 bags, each containing half a unit so that it can go in slowly and still protect the patient.

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Ira A. Shulman, MD
CBBS e-Network Forum Editor & Moderator