BSIPHERD

Joint Commission has published its new Performance Measures for Transfusion. Here is a link to their Implement Guide (OMG - It's 180 pages long). What does it mean for each of us? I guess we have to read it first! What have others done (or will do) to implement this? http://www.jointcommission.org/assets/1/6/PBM_Implementation_Guide_20110624.pdf

We did 31 KB for Fetal Bleed last year. We have more techs than that who perform blood banking. Performing less than one a year of any manual test does not keep you competent. Plus I'm sure man of the techs who perform it would disagree with you about it being an easy test to master. We would love to pass it on to Hemo, but can't get anyone else to love (or at least not hate) the test either!

Our medical center has both trauma and OB patients. The KB's we do because of a positive Fetalscreen (rosette test) are not stat. However, all the ones ordered to determine possible fetal bleed are STAT. Most of these are traumas or OB patients when doctors are worried about a fetal bleed in a high risk OB patient. We would prefer not to do them - it's not a great test, but don't have a choice. We do testing for other hospitals - except we will NOT do KB's stat for anyone other than patient's registered at our medical center. We only have a limited number of techs trained in this (Consultation Techs who do Blood Bank problem workups), and if one is not working (middle of the night, weekend evenings), they would have to be called in.

I have to admit I've just recently had to think about LW. We had a patient (Rh positive) with a warm autoantibody that reacted stronger with Rh Pos cells than Rh Neg cells. The DAT was strongly pos and there was Warm Auto in the eluate. However, two adsorptions with ZZAP treated cells had the antibody getting a little stronger rather than weaker. The warm auto being stronger with Rh Pos cells made me consider LW specificity and I knew that LW was destroyed by DTT, and ZZAP cells are of course treated with Papain and DTT. So we did some enzyme only coated autologous cells and were able to do the adsorptions and remove the autoantibody. It was kind of a fun case.

The antibody could have LW specificity. If so, it should react with Rh Negative cord cells.

[ATTACH]410[/ATTACH]We call ours Tasklists as opposed to checklists. I tried to attach one as an example, but think I failed! bb ROUTINE Tasklist Daily.doc

The only reason that we occasionally run cells to determine if the antibody is still reacting is to determine if we can use the patient's plasma to screen units, then only antigen type the units that don't react. Particularly these days with the high cost of reagent typing serum.

Blood bankers might not find us if they do a search if the name changes. I really like it the way it is now.

Most patient with anti-f that we see are CcDEe and they would be CDe/cDE so that c and e are not together. While CCDee and ccDEE patients can form anti-f, most also have anti-c and/or anti-e and that masks the anti-f. But that's not important since patients with anti-c will get c negative blood which is also f negative and patients with anti-e will get e negative blood which is also f negative.

We do a DAT with a panel rather than an auto control. If all cells are positive on the panel and the DAT is negative, then we do an auto control, but this is very rare. Belva in Lincoln

Yes, we perform KB testing in place of the rosette test if the baby is weak D and the mother is Rh neg. And I agree with you - I really dislike the KB test! Belva in Lincoln

I assumed the Enzyme panel was Coombs phase. Since that may not be true, I would take the enzyme panel through the IgG phase.

I suggest you go back and review the enzyme panel. Remember all of the cells run by enzyme technique were negative. So you can use them to rule out antibodies to antigens that are not destroyed by enzymes (many of those are actually enhanced by enzyme treatment).

I think this would be "post manufacturing" and not part of the process overseen by the FDA. I don't think anyone disagrees that this is bad and adversely affects the safety and purity of the blood - but it happened after the process controlled by the FDA is complete, so unless it kills the patient, it would not be FDA reportable. The incident certainly deserves follow up and root cause analysis, but as part of the "practice of medicine error" rather than as an FDA Reportable event.

This is FDA Reportable. It fits into the category RT6-61-03. You can also contact the FDA and they will tell you if it is reportable or not. It is mandatory that you report - they don't give you a choice. (Although your chances of any bad thing happening to you if you don't report are low.) " RT-60-01 OtherRT-61-** Testing performed, interpreted, or documented incorrectly for: {use RT61** only if testing was performed, interpreted or documented incorrectly; use QC92** if testing positive or use QC93** if testing is not performed incompletely performed or not documented} RT-61-01 Other {includes: DAT; Hemoglobin S testing} RT-61-02 ABO RT-61-03 Rh RT-61-04 ABO & Rh

BioRad also bought DiaMed awhile back. DiaMed is the company who sells Gel reagent in the rest of the world and currently has something (?agreement, contract, license?) with Ortho that allows them the exclusive right to sell and distrubute in the U.S. until I think 2012 (maybe late 2011?). After that I believe BioRad will be able to sell DiaMed reagents in the U.S.

Since we have started using Gel, we have lots more problems with Bg antibodies than we had with any tube technique. And with tube techniques, the reactions tended to be pretty weak. With Gel, in addition to seeing more Bg reactions, they tend to be quite a bit stronger than we experience with other techniques. One of the down sides of Gel. Belva in Lincoln

I think you may be talking about us (Lincoln, NE)! Yes, it has been very successful for us and very economical considering both the cost of a separate BB armband and the phlebo time to initiate a new armband. Because we do this, we realize how frequently hospital armbands can be changed. You may think the same admission armband stays on during the whole hospital stay. But I think most of us find it just gets replaced and you don't have a way to know that. So you may have lost your link between armband and specimen and not know it. We have had several instances where the BB No. has been key in catching mislabeling and even Wrong Blood in Tube. Belva in Lincoln

For Rh negative patients with passive Anti-D secondary to RhIG administration, we do not consider it clinically signficant and don't require AHG crossmatches. We do I.S. only. However, when Rh Positive patient get RhIG for ITP treatment, we do consider this clinically significant. We give Rh Neg blood and do both I.S. and AHG crossmatches. We don't do electronic crossmatching. Belva in Lincoln

I think you mean an antibody to a rare or low incidence antigen. This could occur when such antigens are not on the screening cells used for the antibody screen. In our experience, antibodies to Kp(a) and Cw most frequently fall into this category. You could also have Bg antibodies, particuarly with Gel that are not rare, but Gel is very good at picking them up. These aren't the only ones but are some of the most frequent. The risk of this is present even if the patient has not been transfused or pregnant recently. Oh, just another thought. When we went to I.S. Crossmatches, we changed our requirements for the cells we use for antibody screening. We require that at least one of the screening cells have double dose Jk(a), Fy(a), c, and E. All of us that do Immediate Spin or electronic crossmatches (probably most of us) have made the decision that even though we know these situations exist, we know that significant clinical harm based on this is very rare. Hope that helps. Belva in Lincoln

Our absolute on this is that the two identifiers on the armband must match the specimen must match the Blood Tag on the unit. If the name is truncated on the armband, it must be truncated exactly the same on the specimen and Blood Tag. The specimen must be labeled directly from the armband. (And armbands always have the last name,first name so we don't accept specimens that are labeled first name last name because they couldn't have been copied directly from the armband.) If the patient's name is Jones, Robert but the armband says Jones, Bobby, then the specimen and the Blood Tag must also say Jones, Bobby. And we are also very strict on the rules being followed for Blood Bank specimens. I read a study once quite a while ago that pointed out that even specimens with minor errors (letters reversed, wrong vowel, etc) had a much greater risk of being Wrong Blood in Tube than correctly labeled specimens. Belva in Lincoln

Our transfusion procedure requires that both the Transfusionist and a Witness verify that information on the patient's armband matches information on the unit label and unit tag. Even if the 2nd nurse was an inch away and wasn't verifying information from the armband, we would consider it a deficiency. So depending on how your procedures are written, I'm with your inspector!

Were you using serum rather than plasma? Serum may contain unusually potent anti-B that binds complement and interferes with agglutination. Try tube testing using plasma, or diluted patient plasma. Weak Anti-B due to some reason (immunocomprised, bone marrow transplant, etc.). Get history. Do tube testing with 4 drops plasma rather than 2 and longer incubation. If you go below room temperature, make sure to include patient control. Chimera - was she a twin? Could be a very small portion of B cells that prevented her from making anti-B. Get history, try adsorbing and eluting with Anti-B from group A donor. Or maybe she has lived in sterile environment (bubble girl) all her life and not been exposed bacteria, etc to form ABO antibodies. Okay, some of these are pretty far fetched! Belva in Lincoln

One of my favorite sayings comes from my long time beloved boss and mentor, Dr. Larry Toalson. "Just because you guessed right doesn't make it right to guess." Dr. Toalson said this came from his mentor, Dr. Zeman. Belva Sipherd

There is plenty of published information available (and I'm not going to cite it) to indicate that giving c negative blood to CCDee patients who have developed Anti-E is a good idea and improves patient safety. I don't think it's just a matter of preventing the development of Anti-c. We see, not infrequently, that when patients develop new antibodies, particularly Anti-K or additional Rh antibodies, that they may also develop autoantibodies. Some of these autoantibodies may not not be clinically significant but finding blood when you have to do differential adsorptions is a real pain. So for me and mine, please always give c negative blood if we are CCDee and have developed Anti-E. Belva