Ward_X

We started doing reports for each time an electronic collection was not performed correctly, and it's significantly reduced these errors. As far as requesting a necessary 2nd specimen, we tend to call the floor/OR once the first test/specimen is resulted (especially in cases when the pt needs blood). So to respond to your question, I'd call them if a 2nd is needed, or they may just start sending two tubes at a time. If the OR cannot draw it through your collection system right the first time, you'd really just need two tubes drawn at two different times -- the tubes cannot have the same time listed on the label. Whether they draw it two minutes apart is their issue, and it doesn't avoid the WBIT... whether they're "controlled" or not, they're still human and human errors can occur.

In that case, we had a bombing that happened to be at shift change, so we had two shifts worth of techs. You didn't want too* many techs at once, because then it turns into a "too many cooks in the kitchen" sort of deal, but plenty from the first shift stayed, and the second shift was arriving. They didn't call in many extraneous people because they had no idea how long it would last, and you'd need staffing for after the initial rush. That being said, there were plenty of staff, and the supervisors were helping on the floor. Our blood supplier even called and offered to ship blood. In reality you only need 2-3 people to handle an MTP if your inventory is set, but in a situation where you have dozens of bleeders and the inventory needs to be maintained, everyone has a job to do. Again, large trauma hospital here.

Just from a man-power standpoint, you don't always have the time to "extra" antigen type. I've seen pts with anti-E that receive products on a weekly basis (that happen to be cancer pts) that have yet to make the anti-c. What about the extended billing for antigen typing? It just seems like a gross assumption to believe a pt with an anti-E acquiring a unit of red blood cells will form an anti-c from it (going back to Malcolm, who initially replied that the anti-E could have been made for reasons other than transfusion). I agree with the serological science of why these are seen together, and why the anti-E can lead to the anti-c, but I have trouble justifying the cost of tech/time, reagents, and billing, to go off a hunch that the anti-c is probable.

Not all pts form antibodies each time they're transfused, and not against every antigen to which they are phenotypically negative. Futhermore, you wouldn't even know the pt is c= unless you phenotyped; otherwise, you would have only tested and found the anti-E at the time of workup, and stopped there. What prevents you from matching units that are phenotypically matched, even just the Rh group? That would require the extra resources and tech power to antigen type units. If they only have the anti-E at the date of product order, I don't see why you'd need to tack on additional testing. My lab tries to avoid extra testing if not needed

My lab (for trauma I center) does just that: our MTP prep. work includes having sets of O+ aside for male traumas, and O= aside for female traumas. For these untyped pts in emergency situations, the Rh is essentially determined by their gender. For platelets, male/women BCBY do not require Rh= receipt. You're right @Kari Reichenau in saying that giving O= to everybody really burns the inventory...

I've been in blood banking for about 15mos now, and have interests in IRL later on in my career. One thing I still have yet to wrap my brain around are adsorptions, and I've only performed a het. twice. Conceptually, they are not covered much in the MLS program at university (they barely even mentioned an eluate) and I've been told at my lab that one day the science of adsorptions will just "click." Autologous seems to make a bit more sense; it's using a pt's own cells to remove an autoAb from pt plasma, then manipulating that plasma to test for allos. However, heterologous testing is trickier, especially in the sense of picking the correct phenotypically expressed cell lines. You have R1R1, R2R2, and rr, but within each of those are an additional R1R1, R2R2, and rr tested? Even the worksheet I've seen has blocks of color all over it and just looks foreign. Are there any resources or particularly helpful explanations some fellow blood bankers can help me utilize to figure out these guys? Sometimes a peer explanation reduced to colloquialisms and less jargon help it stick. Thanks in advance!

Are there reagents currently used for Bench QC that could also be used in these cases? A set, pre-made vial that could be validated and tested (perhaps, yes, by a "panel" of people... or perhaps made by one tech, validated by another, or two)? A diluted anti-K, perhaps? Perhaps you could do this colorimetrically. Have a premade set of tittered out tubes with colored dye and a chart, and the check has to be between a certain hue/degree listed on the chart? Not sure if that is too complicated... It's unfortunate to even consider the first testing was performed incorrectly, but if it's a recurrent issue, it could also come down to training -- are people pipetting correctly? going to the first stop or second stop of the pipette? How dramatic are these discrepancies in reading -- is it between an M and 2? Or, does this actually come down to needing to verify/QC the performance of a titer? No two techs will ever pick up the exact same population of cells, no. But I'm sure you could find a standard practice to work for a few weeks at a time, or something along that lines to verify titers are legit.

I've seen after the T/S is performed, if the screen is positive it bounces to a selected cell panel that is pre-made and validated (and usually ends up being around 5, 6, or 7 cells long). An inconclusive Passive-D panel results in further workup/rule-out. Even Rh+ pts with a Passive-D due to RhIg will get Rh= products until their screen is negative. Is RhIg/WinRho not theorized to act as a previously identified antibody that can use selected rule-out? If a pt has an anti-E or anti-K for example, I've also seen pre-made mini E,K panels. Otherwise, I don't know specific regulations you can use as an argument.

~850 bed hospital here. If it's around shift change, normally the previous shift has a few techs stay to help with the need. Otherwise, you kind of deal with the traumas as they go and with the staff you have. As a safety net, if it's an off-shift, we do have a supervisor on call. We honestly seem to have at least one MTP a week, supplied by a minimum of at least 3(ish) techs.

I agree, and at this point, as long as it isn't being reduced to the nurses it should be okay to absorb onto other existing positions

As far as the specific membrane properties of each bag, I can't name specific biomedical engineering reasons. However, they are all a different size and texture for a reason. Plt bags allow optimal exchange for platelets when they're lying flat on their rotators; it comes down to clumping/aggregation cascade... But I reiterate the above comments and I would look at the manuf. directions

I agree -- you have to make it hard to do the wrong thing (and thus easy to do the right thing). I've heard stories during a nearby terrorist event that coolers of blood were just going out everywhere and anywhere; whoever came down seeking blood got it. Tragedy and mistakes, unfortunately, are what drives policy adjustment. Individually assigned coolers and labels was the fix for that one, and it seems more compact and more difficult to switch pts compared to a shared fridge, but who knows. Chalking dangerous misses to "oh, that's just how humans be" seems problematic There can also be glitches and write-over problems with XM status when the doctors are attempting to assign units to their pts, especially in regards to emergency released units. We have interface problems with HCLL to EPIC -- it's fairly easy to use an UNXM record to then try to EXM.

What's aggravating is when the pt has a historical type and you're waiting for a current sample, but you still have to give type O blood and you start running through your supply because the floor is being slow. Otherwise, what if the sample was WBIT, or some other factor that means the typing could be incorrect? In that sense, if they're asking for emergency released, the pt is still getting type O until that new T/S is completed.

Its written in AABB News, April 2019, Vol. 21 Vol. 4 They definitely are trying to highlight it as an option; not many people are aware it's a thing.

Isn't there only restrictions on the packaging for products? ____ inches of insulation, ____ type of ice pack (whether wet or dry), etc. If the products arrive as following packed guidelines, would you need to check necessarily? Reagents received usually come with those temperature validating color-changing window cards. Interesting how a similar thing doesn't come with blood products...

A quick disadvantage is the need to ABO match, so just from an inventory standpoint, you're going to have to manage the fine balance in stock without wasting products by the end of the expiration date. How long do you keep the WB before storage and preservation becomes more difficult? Towards the end, would you end up separating it into components? Would you just be ordering low titer group Os? Advantage that I've read is that the platelets contained in WB are kind of a "bonus" product compared to just issuing 1:1. Furthermore, one WB containing 3 different types of products essentially reduces donor exposure because the WB is only from one source. Whether that can therefore reduce immunological responses and antibody formation is another question. There was a review published in December of 2018 that outlines some of your bullet points: Massive transfusion of low-titer cold-stored O-positive whole blood in a civilian trauma setting. Transfusion, Epub Dec 27, 2018.

I've seen have aliquoted units on hand ready to go that are replenished when needed/expiration. Firstly, there's an emergency release prep bag with a pre-filled out emergency issue slip with irradiated units that just need a pt identifier slapped on it before send out. Secondly, there's also other aliquots that can be irradiated and issued per need.

Yeah, we're kind of the same. In terms of standard T/S testing and the cutoff for acceptability, we just throw it on our IH and if it doesn't like the sample it's just done manually. Usually the contrast distinction chromatically is the problem that triggers a rejection/difficulty in testing via machine. Only when there's hemolysis in a post-transfusion rxn specimen is another redraw requested...

It seems to me that the only time hemolysis comes with an acceptance/rejection gradient is with washing RBCs (at the institutions I've seen). At least for that there is a color hue chart to match. If the gel can't discriminate between the layers, it tends to just call it DP and it gets sent for tube testing. I've never seen a sample rejected based on hemolysis... Is there literature to dictate a cutoff?

I thought this role was being shifted specifically to TSOs (transfusion safety officers), who acted as a sort of clinical pt care/laboratory liaison? Unless this is still a relatively new position... I know they were attempting to popularize it in an article within one of the immunohematology journals of this year.

We have a male SSP historically A POS with a transfusion rxn to an AB POS platelet. The current sample was tested in gel, with cards that are DVI-. The pt also had a previous TRXN also to a plt that was Rh POS. The rxn displayed a weakly positive post-DAT, with the followup pre-DAT significantly more positive. The resultant ABORh in tube on both the post and the pre samples are A NEG rather than Rh POS. Our bench reagent is a human-derived monoclonal Anti-D. My question is, how can we have such a huge discrepancy between gel and tube for testing for D? Is this an anti-D, or is there a biochemical answer for the reactivity seen with the mechanism of bead agglutination in the column?

Even if you protect this on one end (let's say you keep one mobile device or camera in the lab at all times that does not leave the lab), you cannot guarantee it's protected on her end. What if she loses her phone, or her device gets hacked? You'd have to keep all pt identifiers out and not send it along with the photo. But then in that case, I feel like you could easily mix up pts and lose information in translation. Based on your phrasing, it seems like if you find a suspicious cell and want clarification, that you send a general picture and they could provide guidance. It does not sound like they're using it at the diagnostic level. At least, I would hope a healthcare professional of that caliber is not diagnosing over a cell line.

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What sort of protocol do you enact to test the qualifications for adherence? Different temperatures, environments? We seldom return units back to the ARC, if ever... this is mainly just a problem with our own units. However, ARC units that do get modified in a way that changes their outdate do get an updated label on top of the existing one, and that our in-house label sticks better when on an ARC label compared to an in-house stuck to an in-house (just an interesting observation).

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