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From the posts given here it seems that there is some dependency on the size of the hospital (number of beds) and the patient populations treated. There are issues of fiscal responsibility and best utilization of staff and other recourses such that dedicated staff, although ideal, may not be cost effective in all settings. A well qualified and dedicated managerial team is always needed as this factor can make a huge difference in meeting the obligations of resource management and service delivery, and staff maintenance, while maintaining fiscal responsibility. It is here that I have experienced the greatest shortage.
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- Yesterday
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ALG is anti-lymphocte globulin and ALT anti-thymocyte globulin. These are heterophile antibodies that are given to patients as treatment (or, rather, part of treatment) and, when first given, often cause a positive DAT, which disappears relatively quickly in vivo, so that blood taken immediately after dosing has a positive DAT, but blood taken a little later has a negative DAT. There may well now be other such drugs, as I came across this effect a few years ago now.
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We do the same. All group O mothers; all Rh Negative mothers; and if they had some reason to suspect a problem (i.e. a Positive DAT perhaps due to a Low Incidence Antibody that was causing the infant problems). Brenda Hutson
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We will take a Verbal Order (on an official Verbal Order Form which we keep) for the initial order for Emergent Release (4 uncrossmatched RBCs) or Massive Protocol. Since both of those require a written document of acceptance from a Physician, we attach the Verbal Order Form to that. After the initial order, we do ask that subsequent orders be requested with our official Blood Request form (as well as orders in the computer; but we can work off of an initial order in the computer for a LOT of products so we allow them to complete computer entries when time permits). Our reasoning is that after the initial order, we may be processing a number of different products on the patient. We want to send the "correct product" at the "correct time." I do not feel comfortable just sending blood based on a phone call (especially with OR as they can end up with "too many cooks in the kitchen" sometimes). If they are in a real hurry, we try to compromise (i.e. we will send up the blood product if you turn around and send the Request Form right back; or vice versa; we won't cause a delay over it). We tend to work better together as long as they see we are not trying to hold up their products, and we are willing to work "with them." This is our "policy," but when things get hectic, clearer minds do not always prevail so then we make sure they get what they need and I can follow-up on any issues once things calm down (and we can always document further on verbal order forms; but what we get from the Request Form is that we send the correct product, at the time when they are actually ready for it). That is just our Policy.... Brenda Hutson, MT(ASCP)SBB
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I have to admit that I am not familiar with the abbreviations of ALG or ATG (unless that is referring to a type of antihuman globulin)? We did not ask for the patient's medication list but a comment I just noticed that our Medical Director wrote on paperwork we are sending to Red Cross (we decided to send all of this to them in case they could find something we could not), was that other possible explanations were Dyspnea secondary to COPD or Drug Reaction. But there is still just that darned confusing DAT (I suppose could have been non-specific drug binding with the "coincidental" Anti-Lua eluted). Anyway, will definitely update you all if I hear anything different from ARC. Thanks again for your input; always invaluable. Brenda Hutson
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Our hospital IT people created a "uncrossed-emergency-MTP" order (actually just a notice) that can be entered into the hospital system that sends the patient's registration to the BB system. That way, we can order whatever on our BB system when a MTP is started. The "order" also serves to document a physician's order for using uncross-matched blood. Scott
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Thanks, Brenda! I feel the same way. No matter how good a procedure, you have to understand the process enough to open it.
- Last week
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I, for one, appreciate your further thoughts. I am still thinking myself (but, really, I am as baffled as you about Case 2 (unless the patient was given something like ALG or ATG as part of his therapy).
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Currently I do not work in such a Facility so have Generalists that rotate, but most of the Hospitals I have worked at in my career, were large Medical Centers that fit your description and they always used Blood Bank dedicated staff. I think you need that specialization to be performing high level testing. Also, it would be a lot to ask of Generalists who have to rotate between all depts. that they would be that specialized in the Blood Bank, but also be able to be knowledgeable and competent in the other areas as well. You need a certain depth of Blood Bank knowledge to be training interns; to do high complexity serology; to know how to handle difficult trauma situations. Just my thoughts.... Brenda Hutson
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Thank you all for your input. With regard to the comment that the post was long....I tend to like to explain things thoroughly so readers have all of the information I have, and know what my thoughts are up to that point. Sorry, just my style. ABsub did also occur to me, but in all honesty, I have only rarely seen this in my 30+ years (just lots of AsubB). Also not sure if it was just weak due to age so would not want to "label" them as ABsub if 6 months from now, they typed 4+ with Anti-B. So was a little nervous about coming to that "official" conclusion. So we did make the recommendation that if they really wanted to know, they could try submitting a new specimen in about 6 months. I agree that there could be a different Low Incidence Antibody that caused the transfusion reaction (we only tested what we could get from our panels). We are sending pre and post specimen plus leftover platelets to the Red Cross to see what they come up with. They may or may not elect to run a panel of some Low Incidence Antigens from their frozen inventory; but of course they can't test every Low Incidence Antigen so it would just be a "hit or miss." But I guess what is still just odd to me is that the DAT was negative before the transfusion (just that morning; was just sent because the patient was being seen by their Oncologist and has been using blood products steadily, so they wanted us to have a specimen available should they need to transfuse more RBCs in next few days); then clearly positive right after the transfusion; and there was definitely an Anti-Lua coating the cells (but also a mystery as to why the strength of the DAT would so obviously weaken in just a few hours, if no evidence of hemolysis). Also, with regard to the comment from BankerGirl about why we were calling it a hemolytic transfusion reaction. We had called the Red Cross Medical Director right after we discovered the Positive DAT and he instructed us to do that; however, our Medical Director did not state that on the Transfusion Reaction Report; but in fact, stated that the reaction may not have even been related to the transfusion; could have been coincidental timing (but that still doesn't explain a Negative DAT becoming Positive from Pre to Post). So is the suggestion then that while we eluted the Lua.....that had we performed an eluate on the negative DAT cells from the morning, we may also have eluted it then but it is just that it is not present on enough cells to have resulted in the Positive DAT (i.e. as an explanation as to why the DAT changed but no Anti-Lua was identified in the platelet plasma)? I am still trying to make sense of that part; that if it was not the cause of the reaction and was not in the platelets, the assumption would have to be that it was already present and coating the cells prior to the transfusion; just not enough to cause a positive DAT; but enough to come off in a concentrated eluate? The patient had received numerous red cell transfusions over a long period of time; so there certainly could have been a small population of transfused cells that were Lua POS to which the patient's Anti-Lua attached? Also, Antibody Screen Negative, so no "free" Anti-Lua (unless low titer). If Red Cross comes up with anything more concrete, I will pass that along; but I really appreciate your input on this mystery! Brenda Hutson
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CAP TRM.31450 Comparability of Instrument/Method
tbostock replied to Ardele Hanson's topic in Accrediting Agencies
For the list of tests that I correlate (see above), we do 5 of each (at least one pos and one neg in the set of 5). -
We We got shamed once for the same people doing qc... Aka midnights. So we had to mix it up so more people did qc. Now we do midnight techs on weekends and holidays and day shift during the week.
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One of our issues is that our patients are not always in our blood bank system if nothing has been ordered during this stay. To issue to that person would require the blood bank to place an order in the HIS (Epic). We keep a "dummy" patient in the BB system so that we can issue to traumas that aren't registered yet, but that's not a great option when we know a name/MRN. All of your replies are helping me work through a plan, though. Thank you 😊
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Do you place the order under LAB under "enter requisitions" or under "Order Entry"?
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We also accept verbal orders for MTP and Trauma patients, then reconcile when the event is over.
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We are able in the blood bank to receive verbal orders and to place them into our LIS system which is Meditech. We realized this could cause issues so there is a field in Meditech when you place an order that defines whether the order is written or verbal. Up until this time it was set to default as Written. We requested a change from our IT department and now we have the option of selecting Verbal with the default setting of Written. When we select Verbal the ordering physician is electronically prompted to sign orders. It worked much the same way verbal physician orders to the nursing units worked at our institution. It seems to be working well.
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Well said.
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It does not seem like there would be a problem in just looking at a specimen. The problem would be in billing for that review as PPMP (if that is going to be done), and then having another billing submitted by your path lab. I would suggest you get advice from your Path Lab for starters. Other than that, I guess I would see what CMMS has to say about it. Scott
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Whether you call yourselves Lean (or Six Sigma or some other facetious productivity name) or not, the reality for many labs these days is that generalists are more and more necessary to keep things going in light of personnel shortages, We are a 250 bed level 2 trauma hospital, with a fair amount of Lab work on the type of patient population we see, including BB. The only real "dedicated" techs we have are in Micro (and of course, Histology). About a quarter of the techs on first shift are generalists that can work on a regular basis in BB (in addition to the main Lab area). On second and third shift, virtually all of the techs work BB in addition to the main lab area. Whether one has BB with all dedicated staff or no, the key is to have adequate training and competency, along with extensive references, including having good P&Ps available. This is true for all areas of the Lab (and in health care in general!). It requires a sharp and dedicated management model and staff. Scott
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Manual differential correlation between technologists
nziegler replied to milesd3's topic in Accrediting Agencies
that spreadsheet looks great! I'm definitely going to give it a try. the only thing I see that I don't like is that it seems to use the manual count as the "reference" method to do the math... with today's technology, I would consider the automated count more accurate than manual (obviously excluding leukemic/dysplastic scenarios) -
There is a very good reason why "generalists" avoid Blood Bank and transfusion medicine - it's complicated and you need a lot of specific training to do it well. Even today, with a significant level of automation, a warm body is often needed to interpret results and give recommendations. And then add the fact that there is a seemingly endless list of "exceptions", "equivocal", "indeterminate", and other levels of results that confound even a trained (SBB) person, let alone an "every other weekend, third shift" employee. Cross-training is a must for very small, low volume facilities. No question. However, once work gets to a certain level of complexity and volume, institutions should seriously consider having dedicated staff. I don't know how "generalists" manage to maintain their legally-required competency levels.
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I think this is highly dangerous, and I also think that your Pathologist should tell your "LEAN" department to butt out, if you will excuse the language.
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Rh neg moms and those with clinically significant antibodies. A physician may request one if they feel it's indicated for other reasons (a mom had a previously affected infant), but that's fairly uncommon. If a baby develops jaundice, we have a separate orderable for a venous or capillary ABO/Rh/DAT
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Our "LEAN" department makes us use everyone. In my opinion-this has cost us quality. Not a good idea to have a casually trained tech working-no SBB in charge for reviews.
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Another one for hospital transfusion services: For those of you in complex blood banks (multiple ABID's, adsorptions, elutions, irradiation, neonatal aliquots, titers, student interns, Trauma, etc...), do you maintain a dedicated blood bank staff or are they all cross-trained in other areas of the laboratory? Thanks!
