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Posts posted by BSIPHERD
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BSIPHERD,
Why are there only a limitted number of techs trained in a procedure that your facility offers 24/7 for traumas? It would make sense to train all of your BB staff to perform this procedure. The primary problem with K/B staining is the lack of use of the procedure; when it is used more readily it is not that difficult. I have turned around K/B staining results within an hour to two hours; and I thought two hours was too long at times. The K/B stain procedure is not difficult you just have to practice it like any manual procedure.
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!
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Unless these other hospitals are sending in their specimens close to the 72 hour mark (which is their fault), what is their justification for requiring a 4 hour TAT???
:confuse::confuse: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.
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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.
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The antibody could have LW specificity. If so, it should react with Rh Negative cord cells.
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[ATTACH]410[/ATTACH]We call ours Tasklists as opposed to checklists. I tried to attach one as an example, but think I failed!
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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.
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Blood bankers might not find us if they do a search if the name changes. I really like it the way it is now.
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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.
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Currently we perform a DAT with all of our ABID's as well as an auto control, and were wondering if the DAT is clinically significant?? We are looking at eliminating the DAT unless we have a positive auto control and/or pan agglutination in the panel cells. Could you please let me know what the practice is at your facility. Any information would be appreciated.
Thanks,
Barbara
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
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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
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I assumed the Enzyme panel was Coombs phase. Since that may not be true, I would take the enzyme panel through the IgG phase.
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ok - have pondered and deliberated over this for long enough and whilst i may just be demonstrating the SS part of KISS, this is what I have come up with and I am not very confident about it!!
ok the antibodies which i have positively identified is anti-M reactive at 37c by IAT and depressed by enzyme as expected. Patients M- phenotype also confirms this.
Other antibody specificities which ? positively identified as according to BCSH guidelines for assigning specificity include; anti-C, anti-S, anti-Fya and anti-Jkb. I have excluded anti-Cw and Kpa due to the fact that they are rarely clinically significant and are often not expressed on antibody screening cells. ? anti-Le(a) as this would only require to be IAT cross-match compatible.
This process which I used for achieve this result is the 'crossing out' method and excluding specificities base on non-reactivity with the serum and this allowed tentative exclusion of antibodies to antigens expressed on non-reactive cells.
Additional test which i would perform would be to include an auto-control as a way of excluding an underlying auto-antibody. I would then use an additional panel ( Diamed ID) as a way of further excluding specificities ie would use a reagent cell which is R1R1 M- as a way of excluding anti-C ( would have expected this to have reacted by enzyme) . I would select reagent cells and sytematically try to eliminate each of the potential specificities present.
I would also crossmatch by IAT blood which is antigen negative for each of the probable antibodies present as a way of demonstrating comaptibility to the blood and providing additional confirmation of antibody specificity.
I really feel that this is not correct but have been racking my brains and it is the best i can come up with!!
thanks
tricia
? also deliberated the point of a room temperature panel???
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).
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I don't like to disagree with my learned members, but the dextrose is probably in Y-tubing mixing with the blood prior to entering the patient. This, to me, comes under the realm of manufacturing and since the dextrose will hemolyze the blood (making it useless), it does affect purity etc which makes it reportable. My understanding is that the FDA wants actions reported that make the product unhealthy --this action makes the blood unhealthy
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.
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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 ABORT-61-03 RhRT-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.
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... Upon calling Ortho, they said that Bg was on that cell. I'm not sure I am convinced that is what this is (I don't tend to see them that strong); but could be. ...
Brenda Hutson, CLS(ASCP)SBB
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
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I know of a facility that uses a small sticker with a Blood Bank ID# on it that is placed on the patient's hospital ID band. The sticker also says that it is not to be removed.
We copied their idea and used it successfully until the 'powers that be' decided to change the armband format here. The barcode on the band become bigger and there was no room left for our stickers. We found about the change when a phleb came back from preop saying they couldn't figure out where to put the BB ID#. (You ever notice that folks in one area never imagine that something they change can affect other areas?? Usually in a bad way!) Anyway, we started putting the same sticker on another blank hospital band and have continued using the separate ID#.
I know that the hospital we copied from is still using the same small sticker on the hospital ID band - I saw one 2 weeks ago. It's been working for them for > than 10 years.
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
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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
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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
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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
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In my facility we require all blood bank specimens to be hand-written. The main reason is because long names will not print on the Sunquest label. Yes, we do require a full name. We also require the MR number, DOB, location ,date / time. We place an additional blood bank armband on the patient as another identification system. I have had many heated discussions about collection of specimens and other collection areas are not allowed to collect specimens for blood bank because they just don't get it. I also tell them we are the only facility in our area that has not had a near-miss. We do not accept names that are not perfect, no exceptions, they must be re-collected. Are your phlebotomy managers lab or nursing trained? One of the things we do when we train new phlebotomist is bring them into blood bank and show them what we check when we get our specimen. It shows them how good handwriting is a must. We also show them a unit issued and then I go with nursing to the bedside to check and hang the unit. Sometimes its hard to know the whole picture. Now if you issue blood thru the pneumatic tube this might be an issue.
Another point...we had Joint Commission watch a transfusion. When the nurses checked the unit one was at the patients armbands and the other nurse was checking on a bedside table. The patient was in a private room. The inspector threw a fit because the 2nd nurse wasn't "at the bedside". She was maybe a foot away. :mad:
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!
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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
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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
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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
:confuse:
Joint Commision Blood Performance Measures 2011
in Accrediting Agencies
Posted
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