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We supply blood to a helicopter service with a contract with our hospital system. We put Safe-T-Vue indicators on all of their units. They provide us a copy of their in-flight chart when they transfuse anyone not coming to our hospitals. If the patient doesn't come to us but has an account in our HIS, we create a bogus registration in our BBIS using a defined format account number. If they don't exist in our HIS, we create a complete registration manually in our BBIS using a defined format for MR# etc. Then we emergency issue the product in our BBIS and handle it just as we would those patients who expire before a specimen is drawn etc. We charge the helicopter service for the products which they include in their flat fee to the patient. We maintain the final disposition records for any lookbacks etc. If we got a market withdrawal or lookback, we would notify the helicopter company to follow up with the recipient. That duty is at least vaguely covered in our agreement with them, I believe. We tell the helicopter crew to return any unused products to us and not to leave them at the receiving hospital but this isn't perfect. We sometimes transfer products on paper to the receiving site if we can document handling sufficiently. It doesn't work easily if the receiving hospital doesn't use the same blood supplier.

Please be sure to recruit the brother as blood donor as he is a valuable donor.

The antibodies didn't read our books???

Nursing policy for blood administration should include those type of guidelines, They have references available for infusion rate, etc. The medical director of blood bank should (ideally) then review all of those polices to make sure that what they have included is good practice. In other words, a collaborative procedure. We struggle with getting blood/blood product nursing policies reviewed when written. There is a constant rotation of new nursing admin staff writing policies who never seem to know that our medical director should review those new policies and they don't understand what the lab has to do with administration. I just tell them it's an FDA requirement and TJC expects those requirements to be followed. Our nursing policies are accessible on-line so I search periodically for blood related policies to see if anything has been added. I put all of those policies in my SOP manual under blood administration. When I do biannual review, I check to see if the policy has been revised so I can upload a new version if necessary. I usually check at least annually as well. The policy format used by my facility assigns 'ownership', which is the VP of nursing, 'authorship' and also includes a line which indicates people who must review the policy. TJC requires policy review every 3 years, so that's why I include those policies in my manuals - to make sure they are reviewed often enough for CAP requirements. If I find a policy that does not have the medical director's name on it as a required reviewer, I reach out to the 'author' or the 'owner' to see about getting it added. I've also made a point of knowing who is responsible for the facility policy manuals and who is responsible for the Joint Commission compliance book. I have those 2 ladies on speed dial and they are very helpful. It can be painfully slow to deal with all the committees/councils that direct nursing policy. I tell myself that persistence and patience is key (and patience is not necessarily one of my virtues!).

Well, there always could be, but it is much more likely that she has a Partial D type, such as Partial D Type III, and she has made an anti-D. Partial D Type IIIa, IIIb and III Type V are all found in African American population, but, unless you perform molecular techniques, you would not be able to tell, as ALL monoclonal anti-D reagents so far produced react well with these types and, indeed, although they are partial D types, they actually have exulted expression of the D antigen, so you could not even detect them from weakened expression. However, beware, if her Hb drops to a level below that of her pre-transfusion level, it could be a case of hyperhaemolysis, accompanying a delayed haemolytic transfusion reaction. As she is symptomatic, it sounds like she needs a further transfusion, but this is not without danger. Firstly, the blood should be D Negative, but the clinician may also consider it wise to cover the transfusion with high-dose IVIgG (about 1g/kg body weight) and IV methylprednisolone.

I know of blood banks who have been AABB Assessed and NOT have had to have a CAP blood bank inspection. Both are CLIA deemed status. No need to have both (for Blood Bank).

Thank you, Carol

The patient is long gone. But the same method -- manual gel -- was used for both the screening cells and the panel cells. As I mentioned, the reagent cells were both all R1R1 (but from different donors)--yet only the cells from the one screening set was negative. Had to be something wrong with that particular cell and that particular patient. Scott

Agree with the comment above. While the patient is in your chopper with your blood, it's your patient. Somehow you must be be charging for the ride and any other care in flight. And like any unit transferred with a patient to another facility, you will have to follow up to finish the transfusion record. Scott

Hi Malcolm, I am a new member and just read this topic and I like to say that is honorable to be recognized for your contributions to transfusion medicine. It is exciting no need for apology Very glad I joined the society of transfusion medicine.

I am enormously honoured to announce that I am going to be awarded the Gold Medal of the British Blood Transfusion Society at their Annual Scientific Meeting in Brighton this year. It is awarded to an individual for their exceptional and long standing services to the Society and to the practice of blood transfusion in the UK. Sorry if this sounds egocentric, but I am very excited.

Are you using solid phase by any chance? We have seen solid phase does that, since a lot of our hospital used solid phase method. When that happened, we usually look for antibodies using PeG Tube method or by testing ficin-treated cells. We were usually able to find the suspected antibod(-ies) except for Kidd antibodies. You may be looking at some method-dependent antibody? Anti-C in your 2nd sample may be stronger than that in your first sample? What is the patient's ethinicity? Is the patient e- or e+? I am also thinking about anti-Ce like antibodies if you see this anti-C reacting stronger with e+ cells than e- cells.

Malcolm is awesome - I found my first anti-f a few years ago and he made cogent comments similar to yours. He is a great resource.

We do not recommend infusion rates. That is the purvue of the ordering MD (anyplace I have ever been). The only thing I tell nursing is to infuse plts as quickly as prudence dictates.

Thanks. That, at least, makes it even more likely. I would suggest that, at some point, she has either been transfused with blood expressing the RHCE*ce haplotype, or has been pregnant before with a foetus expressing this haplotype. The good news is that, if it proves to actually be anti-f, it has only ever been implicated in cases of mild, almost sub-clinical, HDFN.

A photograph to back up galvania's comment. IgA DAT.pptx

We give O= unxm only to females of child bearing potential (<50 yo).

We do the same for our traumas. I think its a common practice. Scott

I'm sure Malcolm can give you the hard numbers and details but keep in mind that not every D- person responds the same when given D+ RBCs. Some will develop anti-D with as little as 100 microliters of cells or less while others will never develop anti-D no matter how many units of D+ RBCs they receive. Then everyone else is scattered around in between these 2 extremes. Then throw in the males and women who are beyond child bearing and it becomes even more complicated. I fall into the category believing that try to prevent the formation of anti-D after a transfusion event, especially one of multiple units is counter productive and an effort in futility.

Congratulations! and thank you for your contributions to modern blood banking practice.

Malcolm, thanks so much for the article. It was very helpful. As it turned out, we sent mom's sample to our reference lab for MMA testing, and we also antigen typed her 2 brothers and her father. One of the brothers matched her Duffy and Kidd antigen types and was Coombs crossmatch compatible with her. He donated two units of packed red cells (at one donation) and was also confirmed to be Diego b negative. The patient's anti-Dib came back as clinically significant based on the MMA test. She did have a C-section after all and did not require any blood! The baby had a negative direct coombs so there were no issues there either!

I agree -- you have to make it hard to do the wrong thing (and thus easy to do the right thing). I've heard stories during a nearby terrorist event that coolers of blood were just going out everywhere and anywhere; whoever came down seeking blood got it. Tragedy and mistakes, unfortunately, are what drives policy adjustment. Individually assigned coolers and labels was the fix for that one, and it seems more compact and more difficult to switch pts compared to a shared fridge, but who knows. Chalking dangerous misses to "oh, that's just how humans be" seems problematic There can also be glitches and write-over problems with XM status when the doctors are attempting to assign units to their pts, especially in regards to emergency released units. We have interface problems with HCLL to EPIC -- it's fairly easy to use an UNXM record to then try to EXM.

I have had this conversation numerous times with Anesthesia manager - do we really have to have 2 people verify? Yes. Stop asking. As for scanning, we have Epic BPAM which does not function in the OR. OR has their own process that does allow scanning of units during massive transfusion but it isn't perfect. If they scan the units from the cooler and somehow the unit isn't transfused and is returned to the BB, there seems to be a glitch where unit status in Epic thinks the unit was transfused when it actually was not and did not update when returned to the BB. Later, when trying to scan for another patient, BPAM gives a warning "Unit not intended for this patient". This statement is an almost guaranteed nurse "freak-out."

We just recently initiated scanning for blood products in the OR (Epic). Because blood products are not often transfused in the OR here, I foresee that the problem will be that anesthesia will get 'rusty' and find it difficult to utilize scanning. Too easy to forget details for something you rarely use. The first place everyone calls for assistance with BPAM is the lab and we generally can't help them - not something we've been trained to do, though we've learned some basics in self-defense. BPAM looks different in the OR version, so the tricks we know are probably not going to be very helpful. If blood is given frequently in the OR, I think it would work fairly well, The OR version of BPAM is clunky, but workable. In a mass transfusion situation, it may not be useable because it could slow things down to much. No refrigerators or coolers in use here. We issue units as requested, with positive patient ID provided by the runner. For routine situations, we have a specific document that prints for Epic for each unit. In urgent/emergent situations, they bring us a chart sticker. No patient ID, no blood. We will hand deliver units to the OR for emergent situations, if we have enough staffing to do it. Sign out would be performed by two blood bankers in that situation.

My own questions would be, firstly, what on Earth are you doing identifying the RCI Laboratory concerned (poor form) and, secondly, what on Earth are they doing wasting public money by proving the presence of an anti-G in a 92-year-old patient, when knowing the exact specificity of the Rh antibody/antibodies in the patient's plasma will make no difference to what blood she will be given, should she require a transfusion?

Your post suggests that patients who initially type group O should be tested a second time for not only ABO, but also Rh and Antibody Screen. I assume you would include the same testing (ABO, Rh and Antibody Screen) for non-Group O patients. I disagree. Does anyone (US and UK) in this forum repeat the Antibody screen on the same sample or a newly collected blood sample? Repeat the Rh? The concept of a second ABO typing did not emerge until after the "Computer Crossmatch" became an alternative method (to the serological crossmatch) approved by the FDA in the late 1990’s. Repeat testing of the same sample or a newly collected blood sample for Rh and Antibody screen was not required by the FDA, AABB or the CAP. A second ABO typing is intended to be a serological alternative to the Immediate-spin Crossmatch to confirm the patient's ABO determination when a "Computer Crossmatch" is done. This creates a process that is similar to that done for donor units, i.e., blood type determination by donor center and blood type confirmation by the Transfusion Service. In the absence of a "Computer Crossmatch", a serological Immediate-spin Crossmatch is required to detect ABO incompatibility between donor and recipient and most patients are transfused based on a single ABO determination without any repeat testing for Rh or Antibody Screen.

In the US, all accrediting agencies must satisfy CLIA, and Blood Bank regs are based on AABB standards. So AABB standards are already in use by JCAHO, CAP, etc. Scott

Years ago we discussed dropping out of AABB but the corporate Transfusion Service medical director could not let it go. She had no rational argument for maintaining the accreditation while still having CAP and JCHO. She just could not part with what she perceived as a great status symbol. Then in the next breath she would declare how much we needed to reduce our budgets. It didn't make much sense to me.

I'd love to be able to get these cards in the USA. However, they are not available for us at this time.

This is true Mabel, but it is far from fail-safe. We have had numerous cases in the UK (where treatment under the NHS is free) of identity theft, where a person not entitled to free treatment has come in to hospital having learned all the details of a person who is entitled to free treatment, and we have detected the fraud by them having different ABO groups and/or D types to the person entitled to treatment, or no longer have an antibody that normally remains in the circulation for decades.

A number of years ago the President made a visit to our area. His advance team visited our hospital and the blood bank. They asked if we were AABB accredited which we regrettably answered no. We are accredited by the Joint Commission Consequently our blood bank was told we could not provide blood product in the event of a medical emergency!