Sonya Martinez
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Posts posted by Sonya Martinez
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Yes we are having similar issues in San Diego. Being the only children's hospital between Mexico, Arizona boarder and Orange county we are doing a majority of all testing on children (even for Kaiser) plus we have contracts with multiple hospitals, the Navy and the county of SD and Riverside!! We are trying to hire staff but state of CA is a pain with licensure of CLS (generalist) vs molecular diagnostics (limited license that can only do human genetic testing - stupid since it exactly the same testing just on a virus). We're a small hospital lab and by Monday we're supposed to be able to run 2,000 tests per day!! Our max so far was 717 yesterday and we don't have the staff to run our high throughput assay 24/7. Plus our other 2 platforms don't have the reagent supply to keep up with demand either. It's absolutely ridiculous. We can't pull any more staff off the bench and still meet our TAT for routine and stat testing and instead of doing my office job most of the time I'm having to either cover the bench in the blood bank or do someone else in leadership's job or attend extra meetings just so others can take a day off. We have staff that have been working every single day, no day off, since March when CA shut down initially. I just don't see how we can keep up this pace.
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86644 is the CPT code we use to charge for CMV seronegative cellular products.
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We have been on Epic with HCLL (now WellSky Transfusion) since 2013. I like HCLL and they have user groups just for those of with Epic integration. We're starting our 2nd upgrade to the newest WST 2020 version next week. Do not wait too long between upgrades. We do not see much of a delay (seconds) with out interfaced orders and results. Unfortunately we are not on the Epic BPAM (Blood Producat Administration Module) with the matching so we still have paper transfusion records to document our clerical checks. I really like their analytics software and it makes my monthly reporting easier. Being a children's hospital with a large Hematology/Oncology department, Heart surgery and transplant, liver and kidney transplants, bone marrow and stem cell transplants, and multiple levels of NICU I like the safety measures built into HCLL especially for crossmatching and issuing products. There are a few glitches with dividing and modifying (irradiating, washing) and pooling but they only happen once in a while since we went live with the 2016 version. I highly recommend you purchase all the packages WellSky has to offer when it comes to build and maintenance. Oh and their customer service is top notch. I'm one of WellSky's customer resources/references so you can ask for me directly if you'd like. Or you can reach me at samartinez@rchsd.org
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Our IRL suggests we use LISS for crossmatching when we have a WAA. Most everything else we do is in gel because we don't get enough sample being a children's hospital. Also we do LISS antibody screens when we're dealing with an anti-M since kids get a lot of cold M antibodies. This way we can tell if it goes all the way through AHG and requires M neg products or if not then just LISS crossmatched red cells. When I changed to the N-HANCE it was the same time I changed our red cells for antibody screens so that made my validation simpler. We now do method to method correlation between gel and LISS but only at a qualitative level for obvious reasons although when we did our validation we matched within 1+ an all our testing.
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San Diego Blood Bank (SDBB) is our primary blood vendor an they sent out information just this morning that they are working on their process and it will require an approved eIND number for each patient and each order or an approved organizational IND which will cover all CCP requests moving forward. SDBB is starting with collections labeled with same product codes as frozen plasma products with a tie tag identifying them as CCP. I do have the CCP codes that were given to me by our software vendor, WellSky, so eventually I will build them (after I finish the added PAS platelet build and my new reagent QC for our reagent switch). ARC sent out information late last week with product codes as they will be collecting with the new codes.
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That seems over the top. What area of the country are you in?
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We require a second type no matter where the patient is. We rarely get push back even during an MTP or ECMO cannulation. We've been doing it this way for more than 15 years. We also don't require them to place an order or use Epic printed labels. We have them label with a demographics label on the lavender top and our processors know if they don't have an order they immediately bring it to the blood bank. Unfortunately working in a children's hospital we give a lot more O RBCs due to our patient population and the fact that we don't have the moms at all. We will also take a verbal second type from another hospital blood bank if we know where the patient was transferred from. Luckily most of the hospitals in San Diego county have Epic Care Everywhere and/or their NICUs and PICUs are run by my institution anyway so we can access the patient record if we know the MRN.
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I'm currently working on building the convalescent plasma product codes into our computer system in case it is needed/wanted. But I'm in a children's only hospital so the only thing we're seeing right now is the normal stuff like urgent heart, spine, cranio and orthopedic surgeries plus our chronic transfusions for the rare anemia patients. We are no longer doing non-urgent surgeries and I anticipate to slow down further but according to the news California had the first death of a child (person under 18 yo) with COVID-19 but I haven't see if that's why the patient died. It would be nice if anyone knew lab personnel in Italy, Spain, etc but I think they may be a bit busy right now!! Unfortunately for us the flu is still going strong and we have had HUS and CAHA cases from it.
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On 12/28/2019 at 8:10 AM, John C. Staley said:
I have to ask, did you do this for every antigen listed on the panel?
Hi John, No we did not do every antigen. Hemo Bioscience makes a validation kit that contains 8 positives and 2 negative specimens plus they make MedTEK kits that contain vials with a single antibody in them including D, C, c, E, K, Fya and S. I'm using both to validated our new Bio Rad IH manual gel this quarter
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Since it's the same vendor I don't think you need a validation. When I changed from Immucor to BioRad for our tube panels I did performance validation covering avidity (strength of reaction), accuracy and precision (predictability). The FDA liked it and that's my plan now that I'm changing over to BioRad's gel reagents as well.
- David Saikin and AMcCord
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If you filter the syringe the nurse does not need to filter again at transfusion. Our nurses uses a syringe pump for all transfusion 60cc or less which doesn't allow for a filter set.
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Per AABB 31st edition of BB/TS standards:
3.5.1Calibration of Equipment: Calibrations and/or adjustments shall be performed using equipment and materials that have adequate accuracy and precision. At a minimum, calibrations and/or adjustments shall be performed as described below unless otherwise indicated by the manufacturer:1) Before use.
2) After activities that may affect the calibration.
3) At prescribed intervals.
However,it further specifies:
3.5.1.2Calibration procedures shall follow the MANUFACTURER'S WRITTEN INSTRUCTIONS and shall include:
1) Instructions for performing calibrations.
2) Acceptance criteria.
3) Actions to be taken when unsatisfactory results are obtained.
We currently do calibrations once per year with bi-annual RPM checks on our Serofuges but quarterly on our CW2+ cell washer (both per manufacturer recommendations). However, we are getting new Bio-Rad IH-centrifuges next month so I'm sure this will change. I think you should probably determine your own prescribed interval for completing the calibrations if the manufacturer doesn't specify. Maybe before use, after repair and if results are not satisfactory as opposed to annually?
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I work in a children's hospital and we do aliquots on 95% of our products. We either fold the 4x4 label at the bottom or we write the sticker around the other side of the aliquot bag. We primarily fold the label for the syringe units. I don't think the 4x2 label you are showing is in compliance with ICCBBA standards since it doesn't have a DIN and no Product code plus how would you differentiate the parts of the product (i.e. Aa, Ab, Ac, etc.) if you don't have the product code? Besides its cheaper to have one label stock.
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The only test I know of is PGD (Pan Genera Detection) test by Verax. We have not completed our validation yet because the logistics of implementing the test are extensive because I work in a children's hospital and we split our apheresis platelets into really small syringe aliquots for our NICU and CVICU so we use our platelets for the full 5 days. The test takes about a 1.5 mL of platelets per test per 24 hours. We have not implemented PAS platelets yet due to the fact that our primary vendor doesn't collect them yet and I have to build and validate them in our computer system (I am the only one who can build in our computer system and I am the manager and technical specialist as well). I hope to build them into our next computer upgrade next year. So the only plus I see from using the PGD is the potential to extend the expiration date of the apheresis platelets to 7 days but I haven't even looked at what that validation is going to require. Verax is very good at providing all the information you need, however.
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We are also a free standing children's hospital with a level 1 trauma. Last year we changed our MTP to weight based because there was way too much wastage for the smaller patients. We are currently in the process of switching from CPDA to AS3 for all our neonates and transfusion >20cc/kg on patients < 1 year old. We will be 100% AS3 (but can still use CPD, CP2D and CPDA1 if available) by mid December (if everything works out as planned). I attached a couple of abstracts and a really nice Power Point we used to get neonatology to agree to the switch. Hope this helps.
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We switched from Safe-T-Vues to BT10s earlier this year and they are much better. With the safe-t-vues we had problems with both nursing and blood bank staff placing their thumb or finger over the indicator and making it turn when in actuality the blood temp didn't change. The BT10s are room temp storage, stick better, and don't have the issue with activating if someone puts there finger over it. We've also found during our validation the BT10s are a lot more accurate and turn right at 10C where the safe-t-vues were activating at 11 or 12C. Plus the BT10s are cheaper for us.
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We had a Terumo SCD 312 a few years back that never gave us any problems until one day it just flat stopped working and couldn't be fixed. I had been talking to Fresenius about the ComboDock but we have limited space and it was too big for our area. We ended up with the Terumo TSCDII because they were the only ones to get us a same day quote and had the equipment to us in 2 days plus they let us return the 6 boxes of wafers we had from the previous version and gave us out money back (minus 25% stocking fee). Working at a children's hospital we have to have a sterile docker so for us fast was what we needed.
With the Terumo TSCD you have a clear catch bin for the used wafers so it's easy to tell when you need to empty it. I was watching a youtube video on the Genesis TCD and it looks more complicated than the Terumo. You have to load a wafer every time and your tubing has to be longer. Here's the link to the video:
The only problem we've had is during a emergency generator load test one night it revered back to the LED screen being in German instead of English but the user's guide has a really good troubleshooting guide and I was able to fix it in about 5 minutes. I don't like the way you change cassettes though. It's not as easy to change them as the older SCD 312 model. Here's a video on the Terumo:
Hope this helps!
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Our policy is if the patient is transfused they get a new ABID every 3 days but if the patient is not transfused we will only do the ABID if they are going to be transfused or every 7 days which ever comes first. Being at a children's hospital we don't get a lot of antibodies and most of them are WAA from our oncology/hematology kids. Plus we don't have the staff to complete the WAA workups ourselves and they get sent to a reference lab. So if they are just keeping a current TSCR but are not planning on transfusing (usually they give medication instead of transfusing these WAA kids) we only send out the ABID if they want blood for a procedure or something. We also keep the kids on the same unit and/or donor as long as possible. That's the nice thing about kids. For those kids with other than WAA we do a new ABID with every sample. For neonates (passive antibodies) we do a new ABID when we run out of specimen to crossmatch new units which happens rarely.
- AMcCord and Malcolm Needs
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No you charge for the product, then each process. So the HCPCS for leukoreduced platelets, washed is P9035 just like non-washed but you have 2 procedures codes in your CDM to include a larger charge for the washing then you add the irradiation using CPT 86945. For example a regular platelet unit is procedure code 63877 and is priced at $450 but when it's washed the procedure code is 68309 and you charge $611. We have our computer system built so that if the product code is washed then it charges the procedure code for the $611 but if it's not washed it charges $450. Unfortunately there's only a P code for washed RBCs.
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Along with anti-P1 you might want to look at the possibility of polyagglutination (if you are using human derived antisera not monoclonal) especially if the patient has bacterial infection which can cause T, Tk, Th, Tx, acquired B, and/or VA polyagglutination. There are also inherited and nonmicrobial associated polyagglutination as well. I would try testing with washed patient cells and donor plasma. The Blood Bank Guy has a good blog on it: http://bbguy.blogspot.com/2011/03/perils-of-polyagglutination.html
Either way you will most likely have to send this testing out if you are not in an immunohematology reference lab.
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The Circular of Information (9/22/16) states "no medications or solutions may be added to or infused through the same tubing simultaneously with blood or blood components with the exception of 0.9% sodium chloride." When you transfusion whole blood or reconstituted whole blood for exchange you are creating a new product or medication. Since blood and blood products are considered biologic medication our hospital only transfuses one unit at time. However, if the patient has multiple lines which our traumas usually do then you can infuse multiple products just not through the same line. The other problem is if the patient has a reaction how are you going to tell which product is being transfused at the time of the reaction? Of course this is the same problem we see when patient's are placed on ECMO and both the RBC and FFP are placed in the circuit together.
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If you are using internet explorer 11 you must have it in compatibility mode for it to work for the CAP website. Also I have found that Mozilla Foxfire works better than IE11 for this website.
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FDA has this scheduled in their talks this month to move from guidance to regulation. This is the first topic on their agenda. But there is rumor out there that because this will raise the price for both the patient and the hospitals they may leave it at guidance until the healthcare issues are resolved. (Trying very hard to be PC). However, since it's a patient care issue no one really knows. We are moving forward to bring testing in house. All whole blood derived and apheresis platelets (including PAS) will be required to be tested once every 24 hours at a minimum on days 4 and 5. You can also use the PGD testing to extend the outdates to 6 and 7 days (with new product codes). Verax is the only FDA approved kit for doing PGD testing. We will be getting in our supplies and equipment by the end of March for validation in April-ish.
Newborn with naturally occurring anti-M?
in Transfusion Services
Posted
We have a newborn (2 hour old when the sample was collected from the patient) term infant who's mom is confirmed to have anti-E and anti-c. Being a children's hospital we have specimens collected on all our patients and do not use the mother's sample. Our workup shows the anti-E but instead of the anti-c we have a confirmed cold anti-M that reacts in gel and only at RT in LISS (tube method) and shows dosage. We do 3 homozygous cells to rule in and out each antibody. We completed a back type on the patient just to see and the patient has a 4+ reaction with A cells and negative with B cells (he's type O). DAT IgG by gel is 2+ (not surprising). We will be giving the baby E negative and c negative (since mom has it) crossmatch compatible units. Has anyone else ever seen a newborn with a naturally occurring cold anti-M?