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If it's positive in gel, we consider them positive. It's been that way at this facility since we went to gel in 2004. We haven't see any complications because of it, but then with our volumes we probably wouldn't. Probably the majority of our daily testing is prenatal type and screen testing from our doctors office. We don't have a huge daily volume though. A dozen separate patients would be about as busy as we'd get. I would say most of our patients are pretty healthy with strong antigen expression. I don't see many below 2+ on them. We only weak D test cord bloods. Isn't it the general statistic that 16% of Rh neg mothers will develop anti-D without RhIgG? You can probably run the numbers on how many you have that test at 1+ and 2+ and then check their results against any DNA testing you've done. You might find that the low the percentage may not be worth the extra fuss. I believe I heard the number of people having just one child is increasing. Huge world of statistics to consider!

So, we just got hit on this by JC and they recommended us to use guidelines established by the CDC on the hemovigilance program. This is located on the following website: https://www.cdc.gov/nhsn/acute-care-hospital/bio-hemo/index.html There are over 10 different categories for an adverse reaction and they have 4 sections to it: Case Definition, Severity, Imputability, and Other. From what I gather, if the investigation falls under Doubtful or Ruled out (both options under Other), then it is not considered and adverse reaction or safety concern. The Case Definition gives physicians and pathologists a criteria they can use to rule out that specific Adverse Reaction. For example, TACO would need to meet the following to be considered Definitive: New onset or exacerbation of 3 or more of the following within 6 hours of cessation of transfusion:  Acute respiratory distress (dyspnea, orthopnea, cough)  Elevated brain natriuretic peptide (BNP)  Elevated central venous pressure (CVP)  Evidence of left heart failure  Evidence of positive fluid balance  Radiographic evidence of pulmonary edema It is a great guide for physicians and pathologist to use once and adverse event is reported to them. The problem I struggle with here is that all of these with the exception of Acute respiratory distress are procedures that are ordered after you suspect an event. We want to make sure the nurse is calling it a transfusion adverse event under the right circumstance. For example, if a patient was hypotensive 90/40 and received ended with a BP of 125/75 while receiving a second unit. Does this require the physician to order those diagnostics tests to rule out TACO? I think this is where each facility has to come together and develop a policy to rule out adverse events before having to order all those diagnostic tests. For example, if the patient does jump in BP, but has no respiratory distress, pulse oxygen has not decrease greater than "X", and lungs sounds have not worsen or present crackles and rales; then no workup should be initiated. All this should be documented and the physician and blood bank pathologist should still be notified, since techs and nurses are not allowed to make that call. Transfusions can be stopped momentarily while the initial investigation is taken place and resumed if no adverse effect is determined.

So, we just got hit on this by JC and they recommended us to use guidelines established by the CDC on the hemovigilance program. This is located on the following website: https://www.cdc.gov/nhsn/acute-care-hospital/bio-hemo/index.html There are over 10 different categories for an adverse reaction and they have 4 sections to it: Case Definition, Severity, Imputability, and Other. From what I gather, if the investigation falls under Doubtful or Ruled out (both options under Other), then it is not considered and adverse reaction or safety concern. The Case Definition gives physicians and pathologists a criteria they can use to rule out that specific Adverse Reaction. For example, TACO would need to meet the following to be considered Definitive: New onset or exacerbation of 3 or more of the following within 6 hours of cessation of transfusion:  Acute respiratory distress (dyspnea, orthopnea, cough)  Elevated brain natriuretic peptide (BNP)  Elevated central venous pressure (CVP)  Evidence of left heart failure  Evidence of positive fluid balance  Radiographic evidence of pulmonary edema It is a great guide for physicians and pathologist to use once and adverse event is reported to them. The problem I struggle with here is that all of these with the exception of Acute respiratory distress are procedures that are ordered after you suspect an event. We want to make sure the nurse is calling it a transfusion adverse event under the right circumstance. For example, if a patient was hypotensive 90/40 and received ended with a BP of 125/75 while receiving a second unit. Does this require the physician to order those diagnostics tests to rule out TACO? I think this is where each facility has to come together and develop a policy to rule out adverse events before having to order all those diagnostic tests. For example, if the patient does jump in BP, but has no respiratory distress, pulse oxygen has not decrease greater than "X", and lungs sounds have not worsen or present crackles and rales; then no workup should be initiated. All this should be documented and the physician and blood bank pathologist should still be notified, since techs and nurses are not allowed to make that call. Transfusions can be stopped momentarily while the initial investigation is taken place and resumed if no adverse effect is determined.

I just answered this question. My Score PASS

I like this as a rise in temperature can be due to the temperatures being taken by different methods or locations (oral, rectal or armpit). SMILLER's phrase ensures this is incorporated into the evaluation process.

We have had similar problems with providers and nurses. The last statement is something we wrestled with when the policy was presented to us and my medical director is still not quite fully satisfied with it. Scott - I'm going to show him your suggestion to see what he thinks.

At the end of the quoted policy above is this caveat: "Increase in temperature alone should not always constitute justification for a transfusion reaction work up. Nursing judgment should be used in evaluating symptoms and notification of physician." Here, we occasionally have problems with workups not being done, or direction from the blood bank to stop transfusions, against hospital policy. This is because there is sometimes a tendency to excuse reactions, such as a temp increase, to something other than an acute reaction to the transfusion. Now, every facility has to go by their own policy, but I would rephrase this as: "A significant increase in temperature, that may be attributable to some other cause, shall not constitute justification for ignoring what may be a life-threatening acute transfusion reaction. Nursing judgment should be used in evaluating symptoms only after consultation with the Laboratory Blood Bank, and attending physician." Scott

Fantastic list - now all they need is TACO (Transfusion Related Circulatory Overload) and it's differential diagnosis from TRALI and they are set to go with current recommendations. Seems like there is an increased interest in TACO with regulatory agencies lately.

In the US we have been doing what you say is going to be the new policy for many years, except we only would do a DAT if the autocontrol was positive. I think that approach is pretty common. Orthos' panel A is for the ijnitial assessment. Most of the time, you will have a pretty good idea what you are dealing with with those results. Then, going by the 3 x 3 rule, w use other panels for rule-outs / rule-ins. Also, if there is no history, we antigen-type the patient for those antibodies that are being made. Scott

No previous history on patient then do immediate spin crossmatch with type "O" blood until type is confirmed on 2nd specimen drawn at a different time form the original BB specimen. Once type is confirmed then electronic crossmatch with type specific units