Form No number No number Annual facility survey

OMB No. 0920-0666

Exp. Date: xx-xx-20xx

Hemovigilance Module

Annual Facility Survey

*Required fields

*Tracking # / Facility ID: _____________ *Survey Year: _________

Facility Characteristics: (For all questions use past full calendar year annual statistics)

*1. Ownership: (Check one)

For profit Government Military Not for profit, including church

Veteran’s Affairs Physician-owned Managed Care Organization

*2. Is your hospital affiliated with a medical school? Yes No

If yes, type of affiliation: Major Graduate Limited

*3. Community setting of facility: Urban Suburban Rural

*4. Total beds set up and staffed: _____________

*5. Number of surgeries performed per year: Inpatient ____________ Outpatient __________

*6. At what trauma level is your facility certified? _________ N/A

Transfusion Services Characteristics:

*7. Primary classification of facility areas served by Transfusion Services: (Check all that apply)

General medical and surgical Obstetrics and gynecology Orthopedic

Cancer center Chronic disease Children’s general medical and surgical

Children’s orthopedic Children’s cancer center

Children’s chronic disease Other (specify)_______________________

*8. Is your Transfusion Services part of the facility’s core laboratory? Yes No

*9. How many dedicated Transfusion Services staff are there?

Number of technical FTEs (including supervisors): _________

Number of dedicated physician FTEs: __________

Number of MLT: ______ Number of MT: ______

Assurance of Confidentiality: The information obtained in this surveillance system that would permit identification of any individual or institution is collected with a guarantee that it will be held in strict confidence, will be used only for the purposes stated, and will not otherwise be disclosed or released without the consent of the individual, or the institution in accordance with Sections 304, 306 and 308(d) of the Public Health Service Act (42 USC 242b, 242k, and 242m(d)).

Public reporting burden of this collection of information is estimated to average 2 hours per response, including the time for reviewing instructions, searching existing data sources, gathering and maintaining the data needed, and completing and reviewing the collection of information. An agency may not conduct or sponsor, and a person is not required to respond to a collection of information unless it displays a currently valid OMB control number. Send comments regarding this burden estimate or any other aspect of this collection of information, including suggestions for reducing this burden to CDC, Reports Clearance Officer, 1600 Clifton Rd., MS D-74, Atlanta, GA 30333, ATTN: PRA (0920-0666).

CDC 57. 300 (Front)

*10. Is your Transfusion Services Laboratory Accredited? Yes No

If Yes, select all that apply: College of American Pathologists (CAP) AABB

*11. How is your hospital accredited? (Check one)

The Joint Commission Centers for Medicare and Medicaid Services

*12. Do you have a committee that reviews blood utilization? Yes No

*13. What is the total number of samples collected in the past year: ____________

*14. Products and Units Transfused: (Check all that apply)

Red Blood Cells (RBCs)

Total number of units transfused in the past year: ____________

Number of units from which aliquots were made: _________

Number of aliquots transfused: ________

Platelets

Number of units of whole blood derived platelet concentrates transfused: ________

What is your average pool size? _____

Number of units of apheresis platelets transfused: _______

Plasma Number of units transfused: _______ (Incl. FFP, thawed, etc.)

Cryoprecipitate Number of units transfused: _______

Granulocytes Number of units transfused: _______

Lymphocytes Number of units transfused: _______

*15. Are any of the following administered through Transfusion Services? (Check all that apply)

Albumin Factors (VIIa, VIII, IX, ATIII, etc) Immunoglobulin (IV)

Immunoglobulin (IM or subcutaneous) RHIg None

*16. Does your facility attempt to transfuse only leukocyte-reduced cellular components?

Yes No

17. Units Transfused by Department/Service

Department/Service	Samples Collected	Units Transfused
		Platelets		RBCs	Plasma	Cryo	Grans	Lymphs
		Apheresis	Whole Blood Derived
Emergency Room/Trauma
Hematology/Oncology (Incl. Bone marrow transplant & apheresis)
ICU
Nephrology/Dialysis
Obstetrics/Gynecology
Pediatrics/Neonatology
Surgery – cardiac
Surgery – general
Surgery – orthopedic
Surgery – other
Transplant – solid organ

*18. Are all units stored in the Transfusion Services area? Yes No

If No, indicate the location of satellite storage: (Check all that apply)

Operating room Emergency room Ambulatory care

Other: _________________

*19. To what extent does Transfusion Services modify products? (Check all that apply)

Aliquot Deglycerolizing Irradiation Leukoreduction

Plasma reduction Pooling Washing None of these

*20. Do you collect blood for transfusion at your facility? Yes No

If Yes, check all that apply: Allogeneic Autologous Directed

*21. Does your facility perform viral testing on blood for transfusion? Yes No

Transfusion Services Computerization:

*22. Is Transfusion Services computerized?

Yes No SKIP to next section

If Yes, system used: (Check all that apply) Cerner Classic® Cerner Millenium® HCLL®

Horizon BB® Hemocare® Lifeline® Meditech® Mysis®

Wingate® (Safetrace TX) Softbank® Western Star®

Other (specify) _________________________

*23. Is your system ISBT-128 compliant? Yes No

*24. Does the Transfusion Services system interface with the patient registration system?

Yes No

*25. Are Transfusion Services adverse events entered into a hospital-wide reporting computer system?

Yes Specify system used: _____________ No

*26. Do you use positive patient ID technology for transfusion services?

Yes, hospital wide Yes, certain areas Not used [SKIP to Q. 27]

If Yes, used for: (Check all that apply) Specimen collection Product administration

Indicate system used: (Check all that apply)

Mechanical barrier system (e.g., Bloodloc®)

Separate transfusion ID wristband system (e.g., Typenex®)

Radio frequency identification (RFID)

Bedside ID band barcode scanning

Other (specify) __________________________________

*27. Do you have physician on-line order entry for test requesting? Yes No

*28. Do you have physician on-line order entry for product requesting? Yes No

Transfusion Service Specimens: Handling/Testing

*29. Are the Transfusion Service specimens drawn by a dedicated phlebotomy team?

Always Sometimes, approximately ____% of the time Never

*30. What specimen labels are used at your facility? (Check all that apply)

Handwritten Addressograph Computer generated from laboratory test request

Computer generated by bedside device Other (specify) ___________________________

*31. Are phlebotomy staff allowed to correct errors in patient identification on pre-transfusion specimen labels? Yes No

*32. What items can be used to verify patient identification during specimen collection and prior to product administration at your facility? (Check all that apply)

Medical record (or other unique patient ID) number Date of birth Gender

Patient first name Patient last name Transfusion specimen ID system (e.g., Typenex®)

Patient verbal confirmation of name or date-of-birth Other (specify) ___________________

*33. How are routine type and screen done? (Check all that apply)

Manual technique % done_____ Automatic technique % done_____

Automatic and manual % done______

*34. Is the ABO group of a pre-transfusion specimen routinely confirmed?

Yes (Check one) No

All samples

If there is no laboratory record of previous determination of patient’s ABO group

If there is no laboratory record of previous determination of patient’s ABO group AND the patient is a candidate for electronic crossmatching

If Yes, is the confirmation required on a separately collected specimen before a RBC unit of Group A, B or AB is issued for transfusion? Yes No

*35. How many RBC type and crossmatch procedures were performed at your facility by any method?

RBC type: __________

Estimated % done by each method: (Check all that apply)

electronically _____ serologically _____ Don’t know

RBC crossmatch: __________

Estimated % done by each method: (Check all that apply)

electronically _____ serologically _____ Don’t know

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