Ensis01

I was taught that testing titers in parallel with the previous specimen is primarily done so that any change in titer can be objectively compared; you are using the same cell of the same age with both specimens at the same time with the same tech. The secondary reason was to monitor and so minimize tech variability i.e. plus or minus one titer from the last techs results.

Well, think about this... the indicator cells are rosetting any cell with IgM coating it  - test uses a monoclonal IgM anti-D.  But anything else that's IgM coating the cells may give you pos test. 
You cannot tell with certainty using this test the Rh of the baby.  Certainly it's not the test of record.  If you ever had to defend your result, you'd have difficulty. 
Picture this:  you've presumed the baby is Rh neg based on the FMH screen.  No RhIG for mom.  Baby is really Rh pos (variant?), and mom goes on to develop an anti-D.  Next baby is at risk.  Mom sues.  You have no defense, as this is not standard practice. 
In the case of a pos DAT with an inconclusive Du, we do a KB and presume the baby is Rh pos.  RhIG dose based on the KB.

I agree, BUT, if the antibody identified in the previous sample has, for example, a specificity of anti-E, and you titrate using r"r red cells and get a titre of, for example, 64, and then the next sample gives a titre of 4, what do you do?  At this stage, you have no idea whether the original titre of 64, or this titre of 4, is correct.  It could be that there is a second specificity present (say an anti-Swa) and it just so happened that the original r"r red cells also expressed the Swa antigen.  Now, I will readily admit that both anti-Swa and the antigen Swa are exceedingly rare, so these were probably not a great example, but, supposing it was an anti-E and an anti-Kpa?

Suggestion...drop the routine autocontrol. There is no requirement to run it with the antibody screen. If your patient has a positive antibody screen or incompatible crossmatch, then do the auto as part of the antibody ID workup. If the auto is positive, do the DAT. If the DAT is positive, do the differential DAT.
If the auto is positive, but the screen is negative and the crossmatch compatible, what do you do differently to transfuse the patient? Anything? If you aren't changing the transfusion protocol in that case, is there value in performing the test routinely?

I composed an answer to this yesterday and must have gotten 'sideswiped' before I posted it!
 
Anyway, here's what I have to add to this conversation ...
You cannot compare gel to tube testing.  Aside from the 'sensitivity' issue (DAT could be positive in gel, negative in tube), gel has a totally different premise that needs to be taken into consideration.
Gel: Slippery RBCs will make it all the way to the bottom of the gel column during a given period of time at a given centrifugal force. Tube: Cells must be agglutinated. 1. Therefore, gel results are affected not only by coating of RBCs with antibodies, but also coating (roughening) with just about anything (proteins, medications).  In addition, changes in shape (e.g. sickling, acanthrocytosis, fragmentation) will cause a slower migration to the bottom. 
 
2. You cannot expect an auto control to give the same results as a DAT because the autocontrol has plasma in it.  (It's like all ladies are women but not all women are ladies.) Certain properties of the plasma will affect this downward migration (e.g. artifact, fibrin, TP ratio leading to rouleaux, cold agglutinins).
 
3. You cannot even expect the same 'DAT grade' with an auto vs DAT.  The autocontrol contains the same enhancement medium as the tests.  The presence of an enhancement medium will, ummm, enhance the antigen-antibody reaction.
 
Suggestion:  Don't mix your media.  If Auto Control is positive in gel, don't bother running DAT with tube method; run it using same method as the Auto Control (gel) and be sure to include a 'negative' control using a buffer card with patient's cells.
If the buffer control is positive: You cannot determine if DAT is pos or neg because the 'positive result' may be due to steric interferrence rather than 'coated with antibody'; check hemo smear for sickling, acanthrocytes, etc. If the gel DAT is positive and the control is negative, your patient cells have a positive DAT. If the gel DAT is negative, the positive auto could be a result of plasma abnormalities, check protein analysis, cold agglutin, etc. Hope I haven't overstayed my welcome ...

I'm not sure I understand the question...
In order to perform a fetal screen (rosette test), you must know the infant's Rh type as it is not valid on a weak D infant.  This is rarely known in an early loss.  For a loss/bleeding up to 20 weeks gestation, we do an antibody screen to make certain that the mother is not previously sensitized to D, and give one full dose.  After 20 weeks, we would perform a Kleihauer-Betke for a loss/bleed if the infant's type is unknown to determine if > one vial is needed.
 

Our basic post-transfusion work up includes clerical check, hemolysis check (pre & post), icterus check (pre & post), post ABO/Rh, post DAT, pre DAT if post was +, elution if the post DAT is stronger than pre. Additional testing is ordered if any of these results dictate.  A blood culture of the bag is requested if there is unexplained hemolysis in the recipient, or when a fever greater than or equal to 39 degrees C. or an increase in temperature of at least 2 degrees C over pre-transfusion temperature is reported.
We encourage and constantly educate nurses to identify and call transfusion reactions.  We have found that physicians tend to be dismissive, and want the unit continued.  An area hospital actually transfused the entirety of a contaminated platelet because the physician paused, gave Tylenol, and continued the unit.  The patient died.
Hives/urticarial only requires clerical check.  We require pathologist OK prior to issuing another unit. The only time we will allow a transfusion to continue is if hive/urticaria are the only symptoms. 
We continue using the original specimen for crossmatch.

Sending a prelabeled tube for nursing to collect would make me really nervous

I'm curious which standard was referenced in your non-conformance and did your response/corrective actions address that specific standard or just the examples listed as objective evidence supporting the non-conformance?
Just taking a guess here but for example, if the non-conformance cited was to 1.3 Policies, Processes, and Procedures--"Quality and operational policies, processes, and procedures shall be developed and implemented to ensure that the requirements of these BB/TS Standards are satisfied. All such policies, processes....." and the objective evidence included some examples of procedures/policies/processes that did not meet standards, simply modifying the specific procedures listed as examples supporting the non-conformance would not address the non-conformance of having a process to meet the Standards in the first place. If 1.3 was the non-conformance, it's highly unlikely you would have been able to effectively identify the root cause during the course of the assessment, let alone develop a corrective action plan.
As for suggestions to identify the root cause in the above example, perhaps you could start by using the 5 Whys......(the responses may obviously be different and would take you down a different path of follow-up questions so are just examples, but)
Why was standard A not included in procedure X and standard B not addressed in procedure Y?

Because the author/reviewer did not know the Standards had changed.
Why did the author/reviewer not know the Standards had changed?

Because the Medical Director received the new Standards but the individual(s) writing/reviewing the procedure did not receive a copy.
Why do the individuals writing/reviewing procedures not have access to the Standards?

etc., etc.
Once you run out of "whys" you've likely identified the root cause(s) and can start with the corrective actions to "fix" those causes.

We report it as a quality issue - which gets the attention of people who can sink some teeth into the problems on the other end. As a result, we have very few cases of these kinds of issues over the course of a year.
We don't charge patient care units for the wasted/destroyed products - my lab director points out that the money all comes from the same pot in the end, i.e. the hospital budget, so he's not interested in taking that route. From a practical standpoint, the person who did something dumb to waste the product or the doctor who cancelled the order would never know about or care about the charge, so it doesn't address cause and prevention. The money is small in the overall scheme of things, so pushing a charge through does not provide much of motivator for nursing management to fix problems or educate staff. (If you need to bill for enough wasted products that it IS a financial issue, you've got major problems.) That's why we choose to use the quality route. That's something that management notices here.
 

Technically, its not "necessary" to do either....
But to answer your question: No.  
A patient who has developed anti-E has a high chance a having been exposed to the c antigen.  That is why "some practitioners" recommend typing for c, and if the patient is negative, giving c- and E- units even if the anti-c is not present.  This practice is not a requirement!  
The same is not true for a patient who has anti-c; the chance of being exposed to the E antigen are less, so this situation is not treated in the same manner.

If I understand it correctly, the lab tested an eluate that they had made against reagent A1 and B cells and it was negative; and the reference cetre tested the donor cells - with an eluate that they had made or with the eluate that the lab had made?  I suspect they made their own eluate....Could be down to a difference in method for the elution.  Also - from the same sample or a different sample? 

We accept verbal orders in emergent situations, however we recently configured our LIS system so we could record the order as verbal.  In the background the computer system generates a physician order and a notification that he or she must sign the order.  It solves the issue of policing up physicians and getting them to enter the orders after the fact.  So far it is working great.

It happens to us all!   - but it is ALWAYS better when it isn't me!!!!!!!!!!!!!!!!!!!!!!!!!

So fun story, one of our supervisors thought the Quality systems stuff for AABB was BS.  So she made a BS manual and every procedure in there is  named BS...

It's a pretty interesting phenomenon. It sometimes seems like the entire hospital is run by a nursing council/committee, which can only be overruled by medical staff and even then, physicians don't always get the last word depending on the topic (though sometimes that's probably a good thing!). That is why it is absolutely essential to cultivate some key relationships with nurses in various disciplines. The team approach is preached but I think we - the lab - have to work very hard to be included in the team in a truly meaningful way. Always a work in progress.
The current thinking at my facility is that everything has to be focused on easing the life of the nurse so that they have the time to best care for their patients. I have no problem with doing what we can to improve patient care, but sometimes it puts us in some interesting job responsibilities as we 'ease their workload'. There also seems to be a mindset of 'Mother Knows Best' and of course Mother is a nurse. Often Mother does know best, but sometimes she needs to listen to advice.
Another issue is that many nurses do not truly know what the lab does and how, do not understand that we are tightly regulated and that we are actually well educated people. We often bump into issues where we have to say (very sweetly, of course) - I don't tell you how to do your job because I'm not educated to do your job (unless you are messing with my blood products!), so please do not tell me how to do mine.

In some patient events its hard to know going into a situation how its going to play out. Some waste is inevitable, but keeping it to a minimum is vital. It really pains me to have to toss O negative red cells and AB plasma.
We are currently engaged in a lengthy project/process to try to fix those kinds of problems - and others. We have a new poster of a process map for Emergency Release and Mass Transfusion for the patient care areas plus a similar version that allows the entry of information for use at the bedside. We are educating everyone. Lab is focusing on faster/more efficient. Nursing is focusing on what they are actually supposed to do, communication (don't bug the lab with multiple phone calls from multiple people about the same things!) and what the lab is actually doing for the patient (and how long it takes). The physicians are being educated on the fact that there actually is a protocol (seems to be a surprise to many of them) and how it works, plus education of what products might be used and when. We have pushed ourselves into the debrief sessions following the mass transfusion/emergency release events - it had apparently never occurred to nursing that we might have something to contribute or problems that they need to help us fix. We are working on notification - when does lab need to know something is going on so we can prepare for the possibility of mass transfusion, how should they notify us, and what phrases should they use for activation so that we are all on the same page.
Lab turnaround time has improved dramatically. and we are starting to see some promising results from nursing. We are planning cross-disciplinary table top drills, then live drills for later in the year to see how things are going. We are cautiously optimistic.

I have been accused of looking for unicorns when I hear hoofbeats!
We once had a patient that got blood every month. She had anti-K and anti-Kpa. After several years her anti-Kpa was no longer detectable--hence an antiglobulin xm would be useless to detect a Kpa pos unit. We ended up just hoping for the best with gel xms and she moved away before we ever gave her another Kpa pos unit.
Does everyone find this an acceptable risk also?

I would give the group A, D Positive platelets.  The amount of anti-B in the plasma will not affect the patient, and platelets do not express the D antigen.  However, the danger with this is that there may be a few group A, D Positive red cells in the plasma and, as the patient has already been sensitised to the D and the E antigen, these may boost the antibodies (as a secondary response can be stimulated with very few red cells).  It is a slight danger, unless the platelets "look red".
If the patient can wait for the group O, D Negative platelets, then this "danger" would disappear completely, and any danger from the anti-A, anti-B and anti-A,B in the plasma in which the platelets are suspended would be minimal.

I wouldn't suggest that with all non-specific reactions. Just if you get an impression that there might be a kidd, it's better to error on the side of caution. I've certainly called my fair share of unknown/non-specific reactions. I've seen several antibodies who don't react even with all of the homozygous expressions. Honestly, sometimes its not much more than your blood bank "spidey-sense" that leads you to the antibody ID, when you would have been completely correct (per SOPs) to call something unknown.

It is actually quite easy to do this Mabel, as long as you have the right cells available.  You split the patient's plasma sample into two, and adsorb one of these with r'r red cells (which will remove anti-C and anti-G, but leave anti-D) and test this adsorbed plasma with Ro red cells to see if there is an anti-D present.  You adsorb the other one with Ro red cells (which will remove anti-D and anti-G, but will leave anti-C) and test this adsorbed plasma with r'r red cells to see if anti-C is present.  If both adsorbed plasma samples give negative results, it is a monospecific anti-G.  If both adsorbed plasma samples give positive results, you have an anti-D and anti-C +/- an anti-G - but, in this case, the anti-G is fairly irrelevant, as the clinical advice, both for the pregnancy and for any transfusions the mother or baby may require would be the same, whether there is an anti-G present or not.

Coming from a reference lab perspective, we couldn't do our job if we didn't use some expired reagents.  We have 2 LN2 tanks that hold our library of rare cells.  It has taken our lab over 40 years to accumulate these resources.  In some cases, our cells are from the propositus the antibody/antigen was named after and the donor is no longer alive.  You can't get most of these cells commercially.
In some instances, it appears that regulating groups try to control something just for the sake of control.  Control of a service/technique doesn't necessarily make it better quality, it just makes it more expensive or prohibitive to provide.  Immunohematology isn't like chemistry, hematology, urinalysis, etc.  It's not as easy to put this part of the lab in a box.  At least, that's my opinion.
And there is no such thing as a "mere generalist".  There is much to keep track of when you are working in several different departments; that's no "mere" feat.

I could not agree more.