Carrie Easley

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

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

I'd like to see the standard that says QC needs to be done at the same time every day, esp for BB and Micro.  I can see in Hem/Coag and Chem a "reasonable" about the same time.  Sounds like an individualized interp of a standard.  Folks need to not take inspectors at verbatim . . . ask to see the documentation. 

We are very small (one tech for BB) - day shift does QC every day either prior to or along with any BB orders.  There is no set time frame.  Just as an aside, I've never seen blood bank reagents that did not work as expected.

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.

So we have had 2 patient mysteries in the past week.  One of them probably has a simple solution....but is just not something I have ever seen in over 30 years.  The other one is more of a mystery.
1st case:  We received a Cord Specimen on the baby from an A NEG mom to evaluate for Rhogam.  The baby typed 4+ with Anti-A, but 1+ with Anti-B.  We did wash the cells many times.  We also obtained a heelstick but obtained the same results.  I am used to seeing weak A typing on newborns; but not used to seeing it with Anti-B (but then statistically, I have seen many more A's over the years than B's); especially when it was so strong with the Anti-A.  Have any of you seen that weak of typing with Anti-B on newborns, or are there any other thoughts on what is occurring here?
 
2nd case:  62 year old male with diagnosis of COPD, Dyspnea, GI Bleed, Chemo (as recently as yesterday).  So ongoing problems.  He has had MANY transfusions of RBCs and Platelets over the past year; including past 3 months.  The patient is A POS.  Yesterday, he was transfused with an O POS Platelet (we only keep 2-3 in-house at any given time so just have to give what we have, and do so by outdate).  Anyway, after receiving only 151 cc's of Platelets, he had Chest Pain, Respiratory Distress and Vomiting.  He was transferred by ambulance the 1 block to the Hospital ER.  All of our clerical check was fine.  Our Policy for giving Platelets is that we just have to have a historical type on the patient; it does not have to be a current type.  However, the Cancer Center had drawn a HOLD specimen that morning so as it turned out, we did have a pre-transfusion specimen (just had not been tested yet).  Upon testing both the pre- and post- specimens, the only issue we came across was that the pre-transfusion IgG DAT was Negative, but the post-transfusion IgG DAT was 3+.  When we spoke to the Medical Director of our Donor Facility, he said to report it as a hemolytic transfusion reaction.  Problems with that are:  After whatever treatment they gave patient in ER, he was sitting up and feeling just fine.  Also, no indications of it being TRALI.  So we became concerned that perhaps we had a platelet with a high-titer Anti-A,B.  We performed an Eluate on the post specimen and tested it against screening cells plus A1 and B cells.  All testing was NEG.  Now we were really stumped.  We had the patient re-drawn and now, several hours later, the IgG DAT had dropped to 1+.  Not a dramatic drop in Hgb.....from 7.4 before transfusion, to 7.1 after transfusion, to 6.9 this morning.  So my last "guess" was that perhaps he was just really unlucky and the donor of the platelets had an Antibody to a Low Incidence Antigen, and the patient just happened to be Positive for that Low Antigen??  So we are testing just the Lows that are on our panels (Cw, Kpa, Jsa and Lua).  Of course there are a lot more Low Incidence Antigens that it "could" be if that is what caused this.  But that decrease in strength of the DAT, in light of not really seeing evidence of hemolysis, is very confusing.  And if it is an Antibody to a Low Incidence, due to his many transfusions of RBCs, is the Antibody attaching to his own cells, or to donor cells he previously received which may have been Positive for a Low Incidence Antigen?  Any thoughts/ suggestions.
Also, as I am completing this, my Tech. just brought me a gel card with the results from 2 of the Low Incidence Antigens.  It looks like the card spun at an angle so I want it repeated, but it appears that the eluate is reacting with the Lua+ panel cell.  But I wouldn't expect an Anti-Lua to cause a severe reaction in a patient like that.
Anyway, will keep you posted on our serological results.....but if you have any other ideas/ thoughts, would love to hear them.
Thanks in advance for your input,
Brenda Hutson, MT(ASCP)SBB

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.
 

We transfuse febrile patients regularly. The nurses look for an elevation in temperature (1.5 C) above the starting temp to call a febrile reaction. I don't feel that we are doing a large number of workups simply because the patient transfusion started with an elevated temp.

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.

Our Lab has a 'Documentation of Verbal Orders' - policy and form (available as Log Books), which the blood bank techs follow as needed.  Like most labs we strongly encourage transfusion orders to be placed by the provider, nurse or trained patient services personnel, but we will accept and order as necessary.

First, you have a discrepancy between the Mom's Rh type on the pre- vs. post-delivery specimen. That needs to be resolved just as you would need to resolve an ABO discrepancy.
I would suggest that a new specimen be collected from the Mom and tested.
If the new specimen's Rh type agrees with the pre- specimen, then it would indicate there was a problem with your post specimen either misidentification or contamination. Repeat the rosette test on the newly collected post specimen.
If the new specimen's Rh type agrees with the original post- specimen then you have your answer that the rosette test is false positive due to the Mom having a weak expression of D which interferes with rosette testing. You are not detecting Rh + fetal cells, instead you are detecting Rh + (weak) maternal cells which would explain why the rosette test is positive but the KB stain is negative. You would also then need to follow up as to the pre- sample and whether it was misidentified at collection, etc.

Our Massive Transfusion Protocol states that blood bank/lab staff will place orders for subsequent products needed.  Other than that, we have a "Written verification of Verbal Order" sheet that we complete and send to the patient location for the physician to sign.  This is used in those circumstances where the nurses are too busy to order so blood bank puts in the orders.  For Emergency Issue products, we have the physician sign a release for the use of the emergency products.

Simular to AMcCord, above, except that once something like a massive transfusion protocol starts, we follow a documented P&P to get further units ready until the MTP is called off.  We do the ordering during that time ourselves.
Scott

We also allow for verbal orders in exceptional cases (i.e. massive transfusion, patient bleeding in the OR).  We document the call on the Verbal Order Log Sheet - includes the physician requesting, hospital number of patient, first/last name of patient, person phoning, type/number of products.  it also includes a check box for the MLT to document the issue checks before either handing off a crate of blood components or shooting the component off in the pneumatic tube system.

For Mass Transfusion and Emergency Release - Yes, we accept verbal orders for products for immediate transfusion and blood bank staff will place orders for what we need to carry through with the product requested. Once the dire emergency phase is past, nursing staff is asked to take care of the additional orders. My medical director and I feel that our #1 priority is to focus on what is best for the patient, not the paperwork.
If the request is STAT but less urgent than a MTP or emergency release, we ask the person who called to take care of the order. We will start doing what is necessary to get product ready for release, but release comes after we receive an order.

We do as Baby Banker does, create a selected cell panel to rule out everything else.  The game we play is how few cells can we run and have a valid rule out panel   We have had several patients that we do every 3 days until delivery.  One of our patients had Anti-c and Anti-E.

I would be very worried about any extension, for exactly the reason you have given (i.e. that she is pregnant) and has already shown herself to be a responder.

I work at a level 1 trauma center. During trauma/MTP the Belmont Rapid Infuser is frequently used.  Up to 3 units at a time (any combination of RBC/FFP) are hooked up to large diameter tubing that drains into a large reservoir. The products mix together in the reservoir rand then are rapidly infused in about 1 minute.  
I also agree with David's comments about making WB. 

Yes.  We do not allow platelets and cryo to be transfused using the Belmont Rapid Infuser.   

Bio-Rad has one that is just a 5 minute RT, spin and read. 

My opinion:  Why are we recording vital signs?  The person recording them has to be able to interpret them in regards to the transfusion taking place.  They must be trained to recognize changes that are indicative of a reaction regardless if they are an RN or not.

We switched from a Raycell to a Rad Source 3400 X-ray irradiator about a year ago.  We're very happy with it as it does not require plumbing...it has an internal water tank for cooling.  The company is based in Georgia, USA and is very responsive.

Better make certain you validate the heck out of Epic, esp if you are using  Beaker.  My most recent experience with Epic/Beaker and HCLL made me want to call the FDA.  I'd run my own validation protocols rather than the Epic ones.  Not enough training for staff , though this could have been a vagary of the institution rather than the system. 

If I have no history I get an ABORh.  I also prefer one if a new admission even if I have a history.  It just helps to verify the patient.  I am not averse to transfusing either based on a historical type in my file.

We've been extremely happy with the Rad Source.  Service and extended downtimes on the Raycell were an issue since parts had to make it through Customs from Canada.  Rad Source offers 24/7 phone support, if needed.  We have had minimal problems.  They are based in Georgia, and respond quickly if there is a issue.  There is also a syringe adapter for neo aliquots.  
I don't know anything about disposal of a cesium device, but Rad Source did take care of of Raycell.