Ward_X
Content Type
Store
Profiles
Forums
Blogs
Events
Frequently Asked Questions
Gallery
Downloads
Glossary
Links Directory
Questions
Jobs
Vendors
Posts posted by Ward_X
-
-
On 8/24/2019 at 9:32 AM, Malcolm Needs said:
Yes John, I was definitely talking about a mass casualty situation.
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.
-
20 hours ago, John C. Staley said:
Scott, you are kind of contradicting your self here. In one sentence you are advocating avoiding the production of anti-c which can only be accomplished by screening units and transfusing c= units. Then you say it would be nice if you did not have to screen for units. I see a conflict here. Bottom line, it's a gamble. Either you screen for c= units now to prevent anti-c or you take the chance they won't make anti-c and if they do you start screening units then. The latter was always my choice.
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
- OregonBB, Malcolm Needs, Dansket and 2 others
-
5
-
On 8/23/2019 at 6:27 PM, Dansket said:
See this large study https://www.ncbi.nlm.nih.gov/pubmed/3137672 regarding use of rh positive blood for untyped trauma recipients.
Abstract
The emergency blood needs of 449 patients were met by supplying 1,717 uncrossmatched units of either red blood cells (RBC) type specific Whole Blood or group O RBC. The RBC were all Rh positive, and 601 units were transfused to 262 untyped patients. None of the patients presented with anti-Rh antibodies. Only 20 patients who were Rh negative received group O Rh positive RBC, and most of these patients were male. There were no acute hemolytic reactions or sensitizations of young females. Group O Rh positive RBC is our first choice to support patients with trauma who cannot wait for type specific or crossmatched blood. Those who do survive the emergency conditions can be reverted to blood of their own type without problem. Acceptance of Rh positive emergency transfusions by physicians giving emergency care can prevent unbalanced shortages in a regional blood supply system.
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.
-
On 8/7/2019 at 9:05 AM, AMcCord said:
I suspect that nursing management or quality is aware of it in many places, but in smaller to mid-size facilities they are going to be looking hard at the cost to benefit ratio. At what point are there enough units transfused so that the institution feels that it can 'justify' the expense of full- or part- time employees to supervise transfusions. Transfusions happen 24/7, so it wouldn't be just one person. Until it becomes a recommendation or requirement from somebody like TJC or an excellent case can be made for cost savings, it's probably not going to happen. I think my facility would benefit from a specialized 'transfusion team' who could take on some aspects of the TSO.
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
-
On 4/21/2019 at 10:10 AM, John C. Staley said:
This is not a popular concept but at some point we have to accept there are things we can not control. Once the blood leaves the blood bank we are at the mercy of other humans and as long as the human factor is involved there will be human error be it unintentional or intentional. Attempting to complicate a process will only provide inventive humans the opportunity of coming up with creative work arounds to circumvent your best of intentions. At some point you just have to step back, do your job and hope for the best. I had a corporate transfusion QA director who could not accept that human error could not be completely eliminated with out eliminating human involvement in the process. Her directives became horribly complex solutions with multiple, redundant checks and balances only resulting in increasing problems.
Bottom line, pick your battles and fight those you have a reasonable chance of winning. Make suggestions, offer insight, provide training opportunities but at the end of the day realize that you have to accept some things are simply beyond your control and even your influence.
On that happy note I'll step off my soap box and stop my philosophical ramblings.
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
On 7/31/2019 at 1:34 PM, applejw said:As for scanning, we have Epic BPAM which does not function in the OR. OR has their own process that does allow scanning of units during massive transfusion but it isn't perfect. If they scan the units from the cooler and somehow the unit isn't transfused and is returned to the BB, there seems to be a glitch where unit status in Epic thinks the unit was transfused when it actually was not and did not update when returned to the BB. Later, when trying to scan for another patient, BPAM gives a warning "Unit not intended for this patient". This statement is an almost guaranteed nurse "freak-out."
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.
-
On 6/14/2019 at 7:34 PM, EAB81 said:
So, when releasing units for emergency release, we have always followed the policy that you give O Neg until an armbanded sample can be collected and typed regardless if the patient has history or not. I have 2 questions:
2: If the patient doesn’t have a historical ABORh, and the type is completed on the armbanded sample, can we give type specific even if the 2nd confirmatory type hasn’t been collected yet?
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.
-
On 7/15/2019 at 9:18 PM, Ward_X said:
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.
Its written in AABB News, April 2019, Vol. 21 Vol. 4
On 7/30/2019 at 8:25 AM, AMcCord said:I wonder how many facilities have a TSO. Mine doesn't. I suspect many smaller, maybe even medium size facilities don't have them.
They definitely are trying to highlight it as an option; not many people are aware it's a thing.
-
3 hours ago, SMILLER said:
Glancing at the AABB Standards (31st ed), they only state that incoming products shall be "inspected, tested as necessary" before use. In our case, we log the temp as "acceptable" for RBC products received from our supplier if they arrive on wet ice. (and labels are legible, units not leaking, etc.) Likewise, for FFP, on dry ice, and so on. This is written into our procedure for checking in blood products. I do not believe we have ever had to "validate" coolers sent from our blood supplier, although we have to do this with our own coolers used for transport.
Not sure about CAP or FDA regs, they may be more strict.
Scott
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.
-
On 7/16/2019 at 2:29 PM, Byfaith said:
There is older literature referring to the concept of hemolysis as a positive reaction interpretation. I believe this is relavant only to tube testing. There is also the fact that using EDTA samples complement does not come into play and therefore no hemolysis of test cells?
I believe our cutoff is random, going along with our chemistry laboratory cutoff.
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.
-
I just answered this question.
-
My ScorePASS
-
-
On 7/2/2019 at 8:57 AM, tcoyle said:
While not endorsing anyone, we use digitrax labels. We also have a robust pre-qualification/label adherence protocol to ensure that they will stay put in all situations. We also ensure that these labels meet the FDA regs for adhesive.
What sort of protocol do you enact to test the qualifications for adherence? Different temperatures, environments?
On 7/3/2019 at 12:17 PM, Karen knight said:Hello, we get our units from American red cross, they did not like us to place stickers on their units, when we return units to them, we may have damaged their unit info rendering them unuseable by removing our label... so we place labels on strung manila shipping tags then attach to unit of blood. , can be purchased at any office supply store. we use 4X4 isbt labels also.
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).
-
I just answered this question.
-
My ScorePASS
-
2nd ABO
in Transfusion Services
Posted
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.