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SusieQ132 last won the day on September 8 2016

SusieQ132 had the most liked content!

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    Blood Bank Technical Specialist - Transfusion Service

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  1. Yes. I should be more specific in that the main patient population where this is an issue is for neonatal patients where the mother needs to be evaluated for Rhogam eligibility. Where treating the neonate as D negative is not enough. My question for this is when would I know to do this treatment? (Or send it out to have this performed, since we wouldn't have the resources to perform it in-house. ) Do you think I would know the Weak D was falsely negative due to other odd reactivity in the ABO/Rh typing, etc.? Or would I unknowingly result a neonate as Rh negative, and say that the mother is not eligible for Rhogam, only to later find out the mother developed Anti-D? Just trying to think about the risk of performing the Weak D in the presence of a positive DAT. I know it's more likely to cause a false positive, which is why we were thinking about performing it even if the DAT is positive, and only cancelling it as invalid if the Weak D is positive. But I don't want to cause patient harm by reporting it if it could be a false negative reaction. Hope this all makes sense. Trying to get all my thoughts into words is hard today!
  2. Our facility is evaluating making a change to our process for Weak D testing for patients with a positive DAT. For years, if we were required to do a Weak D, but the patient had a positive DAT, we used to cancel the Weak D as invalid. Another hospital in our system mentioned that they tended to perform the Weak D, but then only cancel as invalid if the Weak D is positive. We are thinking about changing to this process, as we now have to result many babies as "Rh Unknown" and give their mothers Rhogam. Per our Anti-D's package insert: "Red blood cells coated with alloantibodies or autoantibodies of the same or similar specificity as the reagent (i.e. cells that are DAT positive) may give weak reactions. This is due to decreased availability of antigen sites because of antigen blocking or steric hinderance. In extreme cases false-negative results may occur." I'm worried about the "extreme cases" where a false negative could occur, but I cannot see this being common. Also, would you think that if the cells were coated with that much antibody, that we would see any other odd reactivity in the ABO/Rh? What do other facilities do? Thank you in advance, Susan
  3. I just answered this question. My Score PASS  
  4. FYI - at our facility, we tried to validate CBCs from cord blood specimens, but the values were quite variable when compared to peripheral blood.
  5. We use cord blood specimens for pretransfusion testing for some very small birth weight babies. We ran a validation to show that the results matched the peripheral blood specimens we were getting. As long as the people collecting them know where to draw it from to get baby's blood, you should be fine. We also give only O, Rh matched blood to our neonatal patients, so it's not as high risk as some on this thread make it seem. One item to watch out for if you do proceed with this: occasionally we'll see a mixed field result in the ABO/Rh. If we do, then we confirm the blood type using a peripheral blood sample.
  6. SusieQ132

    Competency Assessment

    From what I have been told by accrediting agencies here, different tests can only be combined into one test system if there are no unique aspects in testing or in problem solving when something goes wrong. I interpret that as meaning the antibody ID, DAT, and elution are all separate test systems because the testing method is very different. Different treatments, however, I could see being grouped into 1 test system (EGA, DTT, ficin) if you can "sell" them as being similar enough. Same goes for the adsorptions, in my opinion. I would rotate which treatment and which type of adsorption you do each year, but group them each into a test system (RBC Treatments as 1 test system and Adsorptions as a separate test system). If you group multiple tests into a test system, only one of the tests in that system need to have the 6 elements of competency assessed each year. However, you have to watch what you group into a test system! It seems crazy, but by the letter of the "law," we should be doing all 6 elements of competency for every test we perform if the procedure is not exactly the same. (I have read that even if the amount of a reagent is different, it would be a different test system. Crazy! ) In practice, this doesn't work for our site; we would spend more time assessing competency than doing real work! We decided to live on the edge and combine a few things into test systems, even though they are pretty different test procedures.
  7. SusieQ132

    Transfusion Reaction - Positive DAT, Negative Eluate

    New information: The patient's post-RXN plasma reacts 1+ with the patient's pre-RXN red cells. (So whatever it is, it is in the plasma, too!) We performed an antibody screen on the plasma from the platelet unit, and that was negative. We have ruled out Anti-Jsa, -Kpa, -V, -Cw, and -Lua in the eluate. The eluate was performed using the Elu-Kit (acid elution). I know this isn't the best for picking up Anti-A, but we have picked it up using this kit in the past, so it was surprising not to see it this time. At this point, the patient doesn't show any signs of hemolysis, and the significance of this positive DAT is unclear. We are going to crossmatch at AHG for future RBC needs as a precaution, but we aren't going to pursue it further. My wild theory: The patient had received Zosyn (Tazobactam-Piperacillin) and Vancomycin, which have both been reported to cause drug-induced hemolytic anemia. These were given a few weeks prior to the transfusion reaction, and theoretically, the patient could have formed Anti-Piperacillin (or another drug antibody) that only reacts in the presence of the drug. Then, the platelet or RBC donor took the medication, and it was passively administered to the patient with the blood component. Then, the drug was introduced back into the patient's system and caused a positive DAT. Or maybe the donor has Anti-Piperacillin (or another drug antibody). Not very likely. But you never know!
  8. SusieQ132

    Competency Assessment

    That's what I think, too! It is a crazy task for our 40 staff members, so I really hope this goes okay. It is daunting to look at right now!
  9. SusieQ132

    Competency Assessment

    Thank you for the input! So I'm thinking that for anything that is not a test, we can put "N/A" for the other items that do not apply. That makes more sense now.
  10. SusieQ132

    Competency Assessment

    Yes, it was a CMS/CLIA regulation. This is the Q and A session that I was forwarded that goes over the details: If you have a tech that floats between 2 different hospital labs within the same health system do you need to perform competencies (6 mo. and annual) in both labs or just one and share documentation? Per CMS, each CLIA laboratory must complete training and competency assessment for all employees at each facility. Laboratories may not share training and competency assessment documentation, even if laboratories are related and share the same instrumentation, LIS and procedures. Must waived testing competency be repeated for all CLIA sites? Including CLIA waived? Yes, a competency must be assessed at the site where the staff is responsible for testing. Each site must be separately assessed and waived is included (remembering all six elements are not mandated for waived testing). Please clarify again competency documentations between sites that have different CLIA#, but are under the same system with the same test methods and instruments. Yes, a competency must be assessed at the site where the staff is responsible for testing. Each site must be separately assessed and waived is included (remembering all six elements are not mandated for waived testing). All permutations at each site need to be taken into consideration as part of competency at that site. Does the issue of not sharing competencies across hospitals within the same system, with different CLIA numbers also apply to Waived Testing? Yes, competencies for both waived and non-waived testing must be performed and kept at each site (under each separate CLIA number). If employees rotate between different CLIA numbers but are performing the same testing, does competency need to be assessed at each CLIA location? Per CMS, each CLIA laboratory must complete training and competency assessment for all employees at each facility. Laboratories may not share training and competency assessment documentation, even if laboratories are related and share the same instrumentation, LIS and procedures. If an employee is shared between 2 hospitals in the same system (different lab CLIA numbers) but the same instrument, same SOP, and same standardized competency is used at both sites, does the entire competency need to be performed at both sites? Per CMS, the entire competency assessment must be performed at each CLIA site. Or is it permissible to provide a copy of the entire competency packet to the 2nd site for them to review and keep? Per CMS, it is not acceptable to use a copy of a competency performed at a different CLIA site instead of performing training and competency assessment at the current CLIA site. Or is it permissible to use perhaps some pieces (like the Direct Observation, evaluation of knowledge, PT or blind samples) and maybe just use record reviews from the 2nd site? All six elements of competency assessment must be performed at each CLIA site the nonwaived laboratory testing is performed at.
  11. Sorry for the novel! I have an odd case that I wanted some input on. Patient History: 66 year old female with CMML. A Pos, with a negative antibody screen, no history of clinically significant antibodies. Has HLA antibodies that have never been detected in our IgG antibody screen testing, but cause her to be refractory to random platelet transfusions. Has been getting HLA-matched platelets. She has received 9 RBCs and 24 apheresis PLTs over the month of September. Transfusion Reaction: The patient received 1 O Pos HLA-matched apheresis platelet (Anti-A titer <1:200) on 8/29/16 at 1100, and 1 electronically compatible A Pos PCLR right after the platelet was done infusing. After the RBC infusion, the patient developed chills/rigors, flushing, and felt tired and "out of it" according to the RN. Her temperature had increased >2 degrees F, so a transfusion reaction investigation was initiated. BB Testing: Clerical Check OK Gram stain on both the RBC and PLT were negative. Cultures from both are still pending. Post-Rxn Sample: ABO/Rh = A Pos Poly (IgG/C3) DAT = 1+ Positive Mono IgG DAT = 2+ Positive Mono C3 DAT = 1+ Positive Aby Screen = Negative Plasma color = slightly darker than Pre-Rxn sample, but not visably hemolyzed Pre-Rxn Sample: Poly (IgG/C3) DAT = Negative Aby Screen = Negative Gel/AHG XM of transfused RBC with Pre- and Post-Rxn samples = Negative/Compatible RBC unit DAT = Negative So, we obviously decided to perform an eluate on the post-reaction sample. The eluate was tested against screen cells, A1 cells, B cells, and panel cells, and showed no reactivity. Questioning the original eluate, we performed an eluate on a new post-reaction sample the next morning (8/30), and got the same results. We decided to try running both eluates against the transfused RBC and the patient's own cells from the pre-reaction (DAT negative) sample. The eluate did not react with the transfused RBC, but reacted 1+ with the patient's Pre-Rxn sample. How the heck do I explain this!? ~Susan
  12. SusieQ132

    Competency Assessment

    I just joined the site, and have some questions about competency assessments. We have staff that rotate between two different campuses of the same hospital, but the labs have different CLIA numbers. So we were recently informed that we have to demonstrate competency at each site where our staff works. (Even though we use the same procedures, follow the same standard work, and have standardized things completely.) So I am trying to put this into practice without overwhelming our staff, but I still want to make sure we are doing a thorough check. We have a high percentage of new staff right now, so I don't want to half-a$$ it. Question 1: Competency must be assessed for every "test system," but what are the Blood Bank test systems you assess? Do we need to assess competency for every method of testing we use every year? Or would I be able to assess IAT as a test system and rotate yearly on what method we use? I cannot seem to find any Blood Bank-specific listing of test systems that require annual competencies! It seems pretty clear for other areas, but I am getting a bit stressed out trying to make sure we are fulfilling the requirements for CAP/AABB. And I also don't want to overwhelm our staff with 17 yearly competencies. In my lab, we perform the following tests: ABO/Rh - automated gel and tube testing Antibody screens - automated gel, manual gel, and tube testing DATs - manual gel and tube testing Antibody titration - manual gel and tube testing Antibody identification Antigen typing Elutions Fetal bleed screens Question 2: How do you handle items that you want to do a competency assessment on that are not tests? For example, we do quite a bit of component preparation, so we generally try to do an annual competency assessment and direct observation of our staff splitting a platelet into a pediatric dose. I am familiar with the 6 elements of competency assessment (show below), but I struggle with how to apply these to processes. "The following six (6) procedures are the minimal regulatory requirements for assessment of competency for all personnel performing laboratory testing: Direct observations of routine patient test performance, including patient preparation, if applicable, specimen handling, processing and testing; Monitoring the recording and reporting of test results; Review of intermediate test results or worksheets, quality control records, proficiency testing results, and preventive maintenance records; Direct observations of performance of instrument maintenance and function checks; Assessment of test performance through testing previously analyzed specimens, internal blind testing samples or external proficiency testing samples; and Assessment of problem solving skills." Thank you in advance! Susan

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