TRANSFER RED BLOOD CELL

STANDARD OPERATING PROCEDURE FOR

INTER-HOSPITAL TRANSFER OF RED BLOOD CELLS

WITHIN THE

PROVINCE OF NEWFOUNDLAND AND LABRADOR

USING THE GOLDEN HOUR 24 / 2 SHIPPING CONTAINER

Provincial Blood

Coordinating Program

_________________________________________________________________________ This document may be incorporated into each Regional Policy/Procedure Manual.

NL08.001

Version: 2.0

Effective Date: 2011-01-21

Page 2 of 13

Standard Operating Procedure for

Inter-Hospital Transfer of

Red Blood Cells

TITLE: Standard Operating Procedure for Inter-Hospital Transfer of Red

Blood Cells within the Province of Newfoundland and Labrador using

the Golden Hour 24/2 Shipping Container. PURPOSE:

To describe the procedure for packing and shipping red blood cells

from one hospital/region to another hospital/region within the province

of Newfoundland and Labrador.

1.0 Prerequisites 1.1 Monitored temperature controlled refrigerator

1.2 Monitored temperature controlled freezer

1.3 Canadian Society for Transfusion Medicine, Standards for Hospital

Transfusion Services, Version 2, Ottawa, ON: Canadian Society for

Transfusion Medicine, September, 2007

1.4 Canadian Standards Association Standards for Blood and Blood

Components, Z902-10, Canadian Standards Association, 2010

1.5 Facility Policies and Procedures for the Storage of Red Blood Cells

1.6 Temperature Records for the Storage Equipment

1.7 Documentation of Training for the Interhospital Transfer of Red Blood

Cells.

2.0 Equipment and Supplies

2.1 Golden Hour 24/2 Shipping Container

2.2 Plastic shipping bag with ties

2.3 Security or tamperproof device

2.4 Interhospital Transfer Form, IHT-NL001 or Meditech Equivalent

2.5 Interhospital Transfer Notification Form, IHT-NL002 or hospital equivalent

2.6 Courier Log Sheet, IHT-NL003, where applicable

2.7 Address/Shipping Label, IHT-NL004 or hospital equivalent

2.8 Pre-Conditioning of Shipping Container Form, IHT-NL005

2.9 Log Tag (Temperature Monitoring Device), Log Tag Interface and software

2.10 Red Blood Cells (RBC’s)

Provincial Blood



NL08.001

Version: 2.0


Page 3 of 13



Red Blood Cells

3.0 Policy Statements

3.1 All red blood cells shall be shipped in such a manner that the red blood cells

are maintained within specified conditions at all times.

3.2 Transported red blood cells with a required storage temperature of 1-60C

shall be maintained at a temperature of 1-100C.

3.3 Transportation time shall not exceed the validated limits (24 hours) of the

shipping container.

Provincial Blood



NL08.001

Version: 2.0


Page 4 of 13



Red Blood Cells

4.0 Process Flowchart

4.1 Shipping Site Process Flow

Inspect red

blood cells

Initiate

documentation

Pack red blood cells

with Log Tag

Complete

Documentation

Place address label

and tamper proof

device on shipping

container

Transfer shipping

container to shipping

department

Notify receiving

hospital

Document

inspection

Inspect shipping

containers

Select units

and forms

Pre-condition

shipping container

Retrieve Transfer

schedule

Provincial Blood



NL08.001

Version: 2.0


Page 5 of 13



Red Blood Cells

4.2 Receiving Site Process Flow

Remove Log Tag

and download data

Document Receipt

Information on form

Document inspection

Place red blood cells in

inventory

Complete Documentation

Inspect red blood cells

upon receipt

Inspect shipping

containers

Receive incoming

Shipping Container

Retrieve Fax

Notification

Was temperature

acceptable upon

receipt?

Quarantine red blood cells

for destruction as per lab

policy

NO

YES

Provincial Blood



NL08.001

Version: 2.0


Page 6 of 13



Red Blood Cells

5.0 Transfer Schedule

5.1 A transfer schedule shall be developed by each region that identifies the

shipping site, receiving site and date for transfer of red blood cells.

5.2 The transfer schedule must be followed to ensure that the same red blood

cells are not shipped repeatedly.

5.3 If you are unable to ship at the designated time, notify the receiving site so

that the receiving site’s inventory is not negatively impacted.

5.4 Obtain the forecasted outside temperature for the transit time of the

shipment if shipping by air.

5.5 Determine the temperature of the courier van or bus prior to initiating

transfer of red blood cells. In most cases, the temperature of the courier may

be greater than 4°C in both summer and winter seasons. Therefore the

summer profile would be used.

6.0 Pre-condition shipping container

6.1 General Information:

6.1.1 The shipping container consists of the following components:

6.1.1.1 Thermal isolation chamber (TIC) or black box (includes

lid).

6.1.1.2 Vacuum insulated panels (VIP) or insulated panels.

6.1.1.3 Corrugated cardboard sleeve (CCS) or cardboard box.

6.1.2 The insulated panels fit into the cardboard box; referred to as the

insulated shipping container. The black box fits into the insulated

shipping container after preconditioning.

6.1.3 It is recommended that the insulated shipping containers and black

boxes be given a unique identification number.

6.1.4 Obtain the forecasted ambient temperature by accessing a weather

forecasting centre such as the Environment Canada at: http://www.weatheroffice.gc.ca/forecast/canada/index_e.html?id=NL

6.1.5 Precondition the black box prior to shipping as stated in 6.2.

Provincial Blood



NL08.001

Version: 2.0


Page 7 of 13



Red Blood Cells

6.1.6 Obtain the Pre-Conditioning of Shipping Container form. A copy

of the form should be placed on the door of the refrigerator and

freezer used to pre-condition the black boxes.

6.1.7 Document on the Pre-Conditioning of Shipping Container form the

black box number, the date and time the box was placed in the

unit, document initials.

6.1.8 Document the date and time the black box was removed from the

unit. Perform a visual inspection of the black box upon removing

from the unit to ensure there are no cracks or leaks. Document the

results of the inspection. Document initials.

6.2 Preconditioning Requirements:

6.2.1 WINTER PROFILE: For shipments where the ambient

temperature is less than 40C, the following preconditioning

requirements must be met:

6.2.1.1 Stabilize the black box at 5-8 0C for a minimum of six

hours.

6.2.1.2 Before using, ensure internal refrigerant is liquid by

shaking. (Note: If the refrigerant is partially frozen, the

shipment time is significantly reduced and the shipping

temperature may not be acceptable. There is no need to

allow the black box to stand at room temperature.)

6.2.2 SUMMER PROFILE: For shipments where the ambient

temperature is +40C or greater, the following

preconditioning requirements must be met:

6.2.2.1 Stabilize the black box in a freezer (temperature range

between -180C and -40

0C) for a minimum of 8 hours until

frozen hard.

6.2.2.2 Remove black box from freezer and allow to rest at room

temperature for thirty (30) minutes, until surface frost

melts. Do not place lid flat to rest.

Provincial Blood



NL08.001

Version: 2.0


Page 8 of 13



Red Blood Cells

7.0 Select Units and Forms

7.1 Select the red blood cells designated for transfer. Select a maximum of four

(4) units for each shipping container.

7.2 Ensure there is a minimum of 10 days remaining on the unit of red blood

cells prior to the expiry date.

7.3 Obtain the Interhospital Transfer Form or Meditech equivalent approved

transfer form that incorporates required information. The Interhospital

transfer form will be referenced throughout this document.

7.4 Initiate documentation on the Interhospital Transfer Form, Section I.

8.0 Inspect Red Blood Cells

8.1 Red Blood cells must be inspected immediately before packing and upon

receipt.

8.2 Visually inspect red blood cells for the following:

8.2.1 Contamination – red blood cells may appear purple or black in

color

8.2.2 Discolouration – inspect supernatant or plasma for discolouration.

8.2.3 Leakage – ensure the segments and the container is not leaking.

8.2.4 Expiry Date – ensure the unit has not reached its expiry date.

8.2.5 Ensure a minimum of four segments are attached to the unit.

8.2.6 Mix the units and observe for large clots. Do not ship if large clots

are found.

8.2.7 Compare the color or the red blood cells in the segments with the

red blood cells in the container, ensuring the color is the same.

8.2.8 Ensure all ports are intact and that none of the ports are missing.

8.3 Red blood cells that do not pass visual inspection must be quarantined for

discard and the action documented.

8.4 Do not ship red blood cells that have been modified by the hospital.

Provincial Blood



NL08.001

Version: 2.0


Page 9 of 13



Red Blood Cells

9.0 Procedure for Shipping Site

9.1 Confirm the ambient temperature immediately prior to packing the red

blood cells by accessing a weather forecasting centre such as Environment

Canada at:

http://www.weatheroffice.gc.ca/forecast/canada/index_e.html?id=NL

9.2 Ensure the black box has been pre-conditioned for the appropriate shipping

profile.

9.3 Inspect the shipping container for the following:

9.3.1 Inspect the cardboard box for worn or torn cardboard outer layer.

Replace worn cardboard boxes when necessary.

9.3.2 Inspect the insulated panels to ensure the vacuum is maintained.

9.3.3 Inspect the black box and lid to ensure there are no cracks or leaks.

Do not use containers that are leaking.

9.3.4 Inspect the Velcro strap and ensure that it is still effective to close

the black box.

9.4 Obtain units of red blood cells that have been stored at 1-60C.

9.5 Inspect unit(s) of red blood cells as per Section 8.0.

9.6 Document that the inspection has been performed on the Interhospital

Transfer Form in Section I.

9.7 Document total number of unit(s) shipped on the Interhospital Transfer form

in Section I.

9.8 Place a maximum of four (4) units in a plastic bag and fold over plastic bag.

9.9 Press START on the Log Tag. Place Log Tag temperature monitoring

device outside the bag, within the folds of the bag. Do not place Log Tag in

direct contact with the units. Do not place Log Tag in direct contact with the

shipping container.

9.10 Place the units in the shipping container.

Provincial Blood



NL08.001

Version: 2.0


Page 10 of 13



Red Blood Cells

9.11 Close the black box by placing the lid on top of the container.

9.12 Secure the lid tightly in place using the Velcro straps.

9.13 Place the black box into the insulated shipping container.

9.14 Complete Section II of the Interhospital Transfer form. The shipping time

(24 hours maximum) is measured from the time the container is closed.

9.15 Copy the Interhospital Transfer form and retain copy at shipping site.

9.16 Place original Interhospital Transfer Form on top of the insulated shipping

container.

9.17 Close the cardboard box.

9.18 Remove old shipping/address labels attached to shipping container, if

present.

9.19 Secure with tamperproof device where indicated on the cardboard box.

9.20 Affix the shipping label to the shipping container.

9.20.1 The shipping label must include the following information:

a) The shipping site address

b) The receiving site address

c) A statement that it contains human blood components

d) Any caution or description required under provincial or federal

transport regulations

9.21 Place packed shipping container in courier pick up area for delivery.

Complete Courier Log Sheet if applicable.

10.0 Notification to Receiving Site

10.1 The shipping site is responsible to notify the receiving site by phone and

fax, when sending a shipment

10.2 Obtain the Interhospital Transfer Notification form.

10.3 Complete the applicable information.

10.4 Phone the receiving site with the shipping details.

Provincial Blood



NL08.001

Version: 2.0


Page 11 of 13



Red Blood Cells

10.5 Fax completed form to designated receiving site.

10.6 Attach fax confirmation to Interhospital Transfer Notification form and the

hospital copy of the Interhospital Transfer Form.

11.0 Procedure for Receiving Site

11.1 Retrieve the fax notification of Interhospital Transfer.

11.2 Receive incoming shipping container.

11.3 Inspect shipping container for the following:

11.3.1 Inspect the shipping container for worn or torn cardboard outer

layer. 11.3.2 Ensure tamperproof device is intact.

11.4 Remove Interhospital Transfer Form from shipping container.

11.5 Complete applicable documentation in Section I and Section III on the

Interhospital Transfer Form. 11.6 Remove Log Tag from the folds of the plastic bag and press the START

button. (This places a marker on the data.) 11.7 Place Log Tag in Log Tag interface cradle to download data from Log Tag.

11.8 Print data and attach to Interhospital Transfer form. 11.9 Remove units of red blood cells from the plastic bag.

11.10 Confirm documentation on the Interhospital Transfer form matches the

labelling on the unit(s) of red blood cells.

11.11 Ensure that the total number of units shipped is the same as that indicated on

the Interhospital Transfer form.

11.12 Perform the visual inspection upon receipt of the red blood cells as per

Section 8.0. 11.13 Document in the applicable columns, the results of the visual inspection and

initials in Section I on the Interhospital Transfer form.

Provincial Blood



NL08.001

Version: 2.0


Page 12 of 13



Red Blood Cells

11.14 Review downloaded data chart to determine if the temperature during

shipment was within the acceptable temperature range of 1 to 100C.

11.14.1 If temperature was not acceptable, place red blood cells in

quarantine for destruction following facility protocols.

11.15 Document temperature upon receipt and time in transit in Section III on the

Interhospital Transfer Form.

11.16 Place the units of red blood cells into general inventory for use following the

transfusion service policies and procedures.

11.17 Review all documentation for completeness. Failure to complete the

required documentation may result in the products being discarded

according to hospital policy.

12.0 Records Management

12.1 The shipping site must keep a copy of the Interhospital Transfer form

(release vouchers) indefinitely.

12.2 The receiving site must keep the original of the Interhospital Transfer form

indefinitely.

12.3 Temperature monitoring records for blood products must be kept a

minimum of five years.

12.4 Records of blood components inspection prior to release must be kept for a

minimum of five years.

12.5 Documentation of staff training and competency must be kept for a

minimum of ten years.

Provincial Blood



NL08.001

Version: 2.0


Page 13 of 13



Red Blood Cells

13.0 References

13.1 American Association of Blood Banks. Standards for blood bank and

transfusion services, 26th

ed. Bethesda, Maryland: American Association of

Blood Banks; 2009

13.2 Becher M. Technical manual. 15th

ed. Bethesda, Maryland:

American Association of Blood Banks; 2005.

13.3 Canadian Standards Association. Blood and blood components Z902-10.

Mississauga (ON): Canadian Standards Association; 2010.

13.4 Canadian Standards for Transfusion Medicine. CSTM standards for hospital

transfusion services Version 2.0. Ottawa: Canadian Society for Transfusion

Medicine; 2007.

13.5 Provincial Blood Coordinating Office. British Columbia provincial blood

coordinating program interregional blood redistribution resource manual.

Vancouver (BC): Provincial Blood Coordinating Office; Jan.2005.

Documents

TRANSFER RED BLOOD CELL