Ensis01

Thank you all for responding to this topic. Fortunately, the patient survived probably due to bleeding at that moment. Both poly- and mono-specific DATs were done and they (i.e. poly DAT, IgG, complement and saline control) were all weakly positive. An eluate was tested against A1, A2 and B cells and reacted with A1 and B cells, not A2 cells. The reaction strength with A1 cells was stronger than B cells. The possible explanation for eluate reacting with B cells is that the anti-A,B in this O patient's plasma coated on the A donor cells got eluted and reacted with group B reagent cells. 

Those 25% that appear order abuse or CYA could just be physicians erring on the side of caution.
Alternatively many ER departments have check-list protocols; when curtain symptom boxes are ticked orders are automatically generated (or required). It may be worth while seeing if this is the case.

I would wash the red cells in saline and test the DAT (I have occasionally found stronger reactions).
You can also try washing the red cells using cold Elu-Wash as that can help bind any weak antibodies to the red cells.
In this case I would do an eluate including A1, A2 and B cells irrespective of the DAT results.
Lastly I assume you can call the transfusion reaction irrespective of DAT results if hemolysis is evident in the post sample?
The only hemolytic transfusion reaction I worked-up was clear cut and involved uncrossmatched blood given to a patient with history of an anti-Jk(a), against the BB tech’s advice. As Malcom stated above not many red cells were left, including the patient’s as the hemoglobin went from a 6 to a 3! I could not tell where the plasma ended and red cells begun. 

I would wash the red cells in saline and test the DAT (I have occasionally found stronger reactions).
You can also try washing the red cells using cold Elu-Wash as that can help bind any weak antibodies to the red cells.
In this case I would do an eluate including A1, A2 and B cells irrespective of the DAT results.
Lastly I assume you can call the transfusion reaction irrespective of DAT results if hemolysis is evident in the post sample?
The only hemolytic transfusion reaction I worked-up was clear cut and involved uncrossmatched blood given to a patient with history of an anti-Jk(a), against the BB tech’s advice. As Malcom stated above not many red cells were left, including the patient’s as the hemoglobin went from a 6 to a 3! I could not tell where the plasma ended and red cells begun. 

I would wash the red cells in saline and test the DAT (I have occasionally found stronger reactions).
You can also try washing the red cells using cold Elu-Wash as that can help bind any weak antibodies to the red cells.
In this case I would do an eluate including A1, A2 and B cells irrespective of the DAT results.
Lastly I assume you can call the transfusion reaction irrespective of DAT results if hemolysis is evident in the post sample?
The only hemolytic transfusion reaction I worked-up was clear cut and involved uncrossmatched blood given to a patient with history of an anti-Jk(a), against the BB tech’s advice. As Malcom stated above not many red cells were left, including the patient’s as the hemoglobin went from a 6 to a 3! I could not tell where the plasma ended and red cells begun. 

I am aware of the format and file type needed by Softbank.  My concern is how to extract it in the first place.  Haemonetics is being less thank helpful.  IT would like some guidance by someone with experience.  We want to make sure it is or isn't doable in house before we spend money on a third party.

I would wash the red cells in saline and test the DAT (I have occasionally found stronger reactions).
You can also try washing the red cells using cold Elu-Wash as that can help bind any weak antibodies to the red cells.
In this case I would do an eluate including A1, A2 and B cells irrespective of the DAT results.
Lastly I assume you can call the transfusion reaction irrespective of DAT results if hemolysis is evident in the post sample?
The only hemolytic transfusion reaction I worked-up was clear cut and involved uncrossmatched blood given to a patient with history of an anti-Jk(a), against the BB tech’s advice. As Malcom stated above not many red cells were left, including the patient’s as the hemoglobin went from a 6 to a 3! I could not tell where the plasma ended and red cells begun. 

I would wash the red cells in saline and test the DAT (I have occasionally found stronger reactions).
You can also try washing the red cells using cold Elu-Wash as that can help bind any weak antibodies to the red cells.
In this case I would do an eluate including A1, A2 and B cells irrespective of the DAT results.
Lastly I assume you can call the transfusion reaction irrespective of DAT results if hemolysis is evident in the post sample?
The only hemolytic transfusion reaction I worked-up was clear cut and involved uncrossmatched blood given to a patient with history of an anti-Jk(a), against the BB tech’s advice. As Malcom stated above not many red cells were left, including the patient’s as the hemoglobin went from a 6 to a 3! I could not tell where the plasma ended and red cells begun. 

I'm curious, can those 25% that appear to be "order abuse" be linked to specific docs or is it random through out the ED?  With current computer technology this should be discoverable.  Over the years of my career I realized that not all ED docs are created equal and some have a much lower threshold for CYA than others.  Just a random thought.

And we see this in surgeons as well.

Our pathologists have authorized O POS for adult males and females 56 or older without requiring permission - we have this written into our MTP and Emergency Release policies.  Younger females or pediatric patients would require a phone call.  Since we average 25 MTP monthly, this is a tremendous help in conserving O NEG.

We have the same for MTP and Emergent Release (we use 50 as the cutoff age).  For routine transfusions we still require Path approval.

You can decide how long you want to keep units in crossmatched status.  This is probably dependent on the validity of your specimen.  There is no reason you can't release after 24 hrs. 

An interesting case/issue. I agree with your premise: doing anything to make the saline control nonreactive (warm-washing, CDP, acid-elution) will probably make the test with anti-IgG negative, too (assuming the positive saline control is due to IgM-coating of the patient cells, causing direct agglutination).
Perhaps a DAT with an anti-IgM reagent could be arranged ? Did you try a DAT with polyspecific antiglobulin reagent or a monospecific anti-Complement reagent ? But even results from these could be "invalidated" by reactions in the so-called negative control.

I have, unfortunately, seen two ABO transfusion reactions, both of which were fatal.  In both cases, the DAT was negative, BUT, when the blood samples were put under the microscope, the reason was only too evident.  There were hardly any red cells in the samples, presumably because the complement system had haemolysed both the transfused red cells, but also the "innocent bystander" autologous red cells.

That having been said, your explanation is perfectly logical.

I like the not black or red ink logic; all other colors clearly indicate an original document and not a photocopy. As long as it is permanent and waterproof any other color or shade of ink works. I personally like weird blues

28% sounds good to me, allows units to be blood type specific and gives time for antibody identification. I remember the frustration waiting for samples.  I suggest asking the Dr how/if the question incorporates risk assessment for patient care and/or is it just financial. 

28% sounds good to me, allows units to be blood type specific and gives time for antibody identification. I remember the frustration waiting for samples.  I suggest asking the Dr how/if the question incorporates risk assessment for patient care and/or is it just financial. 

28% sounds good to me, allows units to be blood type specific and gives time for antibody identification. I remember the frustration waiting for samples.  I suggest asking the Dr how/if the question incorporates risk assessment for patient care and/or is it just financial. 

I started doing this kind of data dig before COVID, looking at appropriateness of transfusions in the ED. Similar to you, it's usually 1 unit transfusions, often in emergent settings but not MTP. I agree with @exlimey that the shotgun approach is usually what happens, and our retrospective looking is not comparable to the ED's initial read of the patient. Most often the dreaded "hypotension" is the reason for pushing products, regardless of H/H or active bleeding. We've done education to this point with our ED, and that includes our trauma patients, that a onesy-twosy red cell transfusion for low blood pressure is not appropriate. We haven't tracked the number of TYSCs ordered, but in our concurrent reviews, these are typically ordered for patients who may be pre-surgical, or to be admitted. I feel like they order TYSCs better than blood products at this point!  

We don't actually see many T&S orders from the ED. Those are usually patients who may be surgical candidates (like broken hips, bowel obstruction, etc.) and unless they are anemic, usually not transfused. There are more orders for 1 unit and transfuse, almost 100% look appropriate when reviewed. Instead we saw a pattern of ED providers ordering blood types in order to have a Blood Bank specimen available. We've persuaded them to use a BB Hold order instead of charging a patient for a blood type that was rarely needed - a specimen is collected but nothing done until they order a Prepare/T&S. We do use some discretion with the BB Hold orders. If the H&H is low or the patient is a really active GI bleed or it's a trauma case that looks bad, we put the specimen on the Echo just to get a head start. Nothing is reported until we get an order but it can definitely help the TAT. I've never actually looked at stats on ED orders, but I've wanted to (in my abundant spare time ). 
Another project I've wanted to tackle is to look at our emergency releases (especially on medical, rather than trauma, patients) and MTP orders to see what % of our patients we are actually transfusing or MTPs that only use a unit or two (or none), to see if we have any interesting provider ordering patterns. Also, how many times we ship blood with transfer patients vs how many times they are actually transfused in route or the unit(s) wasted. I would like to compare that information with the score ED assigns to the trauma patients to see if we are correlating well. 
 

Amen to the comments above. 28% is pretty good.  About 5% of our patients have antibodies detectable in the indirect antiglobulin test, so we'd rather receive more samples rather than fewer.

This is a very interesting question. I suspect that many, many, many tests requested by the ED (A & E) could be categorized as "unnecessary" during analysis in the quiet time after "The Storm", i.e., the results had no relevance to the patients' treatment. But, in the moment (especially, during trauma), the medics have very little idea of what clinical data is important at that time. A "shotgun" approach seems to be appropriate. I'm not sure there is a way to meter or control this process (other than having extremely savvy ED staff). It seems to be a necessary evil - the need for rapid turn around overweighs the concern of "over-ordering" tests.
And, as Malcolm says, a little extra time for the BB to do its work is always appreciated.

Back in the day, when I was working in a hospital laboratory (when Karl Landsteiner was a little boy, and we did all of our testing manually!), I never used to mind getting type and screen samples from the Accident and Emergency Department, even if the patient was not transfused in that department, or, indeed, we not transfused at all during that particular stay in hospital.  The reason for this was the (approximately) 2% of people who had an atypical antibody in their circulation from a previous transfusion, a pregnancy, or both.  This allowed for a bit of time to identify the specificity of any antibody/antibodies and, if necessary, ordering in a sufficient amount of antigen negative blood and blood components.

Just my opinion.

Not a Vision user, but can you use logic in your middleware/engine to remove the unwanted characters? Is there a setting in the Vision software for how the barcode is read by the analyzer?