carolyn swickard

The best we were able to manage on a recent OB Massive transfusion episode, was that they settled down on only 1 communication person with the Blood Bank so we weren't overwhelmed with calls ("Is it ready yet?!?") as we have been in the past. The sole tech in Blood Bank (most common staffing level now) was barely able to keep up. There was no one to spare to go to the event. It went well even though she was Rh neg - they knew enough not to worry about the plts and we were even able to keep her on Rh neg blood so we didn't have to go through that change. Yes - the pathologist on call did help them some with a few questions and using them in that way needs to be done more frequently than we sometimes think to use them. The best part of the whole thing was that the senior anthesiologist in the hopsital was called in and he was a ROCK of knowledge and skill. Two days after the event, he also called for a Review and ran a 2 1/2 hour review of the case that went over everything - everone learned a lot from that. Staff turnover is one of the hardest things to cope with. Even though everyone learned a lot from the case and the review - that crew may not be there next time around and the newbies may again, not have a clue.

That is a nice little doable cold screen - it even makes sense. Our heart surgeons have been worried about cold agglutinins some too as the surgical procedures call for some real cooling of the patients. I really didn't know what we could do for them that even reflected reality. We only detect cold "somethings" if they occur in the I.S XM, otherwise we don't even see most colds anymore. They once wanted us to do incubations at several different temps, gradually lowering them until we reached the standard heart surgery procedure temperature they wanted to use. They wanted to use the lowest temp that did not show the cold aglutinin. We declined.

I had never thought of this either - tough sell to get more heelstick specimens though. And it has been a long time since I have seen Wharton's jelly in a specimen - but we did see it occasionally (different collection techniques, I think) and still teach the newbies to watch out for it. We do not use cord blood for crossmatching at all - labeling is wrong and we use a unique armband for Blood Bank. Most of the time, it is quite a while after birth too (usually days) before they start asking for blood. Pretty rare we get a request early on except for the occasional "Exchange Transfusion" scare that almost always gets cancelled with the aggressive hyperbilirubin lowering treatments they manage now.

I find checking tubes under the scope still quite useful and will just continue with it until I retire. DATs, Fetal Screens (are SUPPOSED to be read under the scope) and weak reacting tube tests (especially when Capture is showing something and tube reactions are SO much weaker) are very useful, I find. We do not read rare reagents under the scope as that can lead to mis-interpretation of the test results. Rouleaus vs. agglutination is usually only detectable under a scope. Not to mention (but I will anyway!) my eyes are not as sharp as they used to be and the concave mirror just doesn't always do enough for me. Just like to see the reaction as MERRYPATH does. Sorry, Malcolm!

Letters (A, B, C...) and/or numerics (1, 2, 3...) would take less space than the ONE, TWO, THREE you currently propose - just a thought. If the numbers are buried a little deeper (STEPHANIE1) they won't bother most computer systems.

If you are Joint Commission accredited in your lab, this is no longer a problem. Joint has a standard QSA.05.18.01 that states specifically "The requirement that suspected transfusion related adverse events are reported immendiately to the lab, whether or not the the physician responsible for the patient deems it necessary to report the event." This changed what we do to: if we hear about it - it gets worked up. (that's if my team member remembers the change!!!) I have attached our old paperwork for the Transfusion Reaction Workup Request and the Transfusion Reaction Workup. Feel free to use what might help you. We are still struggling to get this in Meditech - tried to make it too fancy and have finally decided to back down to simple T-Tests, but now don't have the time to build them with my IT Coor. (Oh well!) Suspected Transfusion Reaction Workup 742-002.pdf Suspected Transfusion Reaction Workup Request 742-001.pdf

Yes Cliff - thanks for asking and posting - BUT - I still find this answer ambiguous and hard to interpret. I know what they THINK they want - but what will they accept that is more doable (because frankly, rescreening an entire panel is just not doable). From the sounds of that QSA standard - QSA.05.06.01 EP 2 - I will now have to go back to QCing both of my reagent racks everyday instead of rotating the QC between the racks after making sure that both racks have matching lot#s, as we have done for several years now with no problems from the inspectors. Joint Comm gets more citations from their QSA standards than any other section, I think. I only received the ImmunoHematology section from my boss - obviously I need to go find the rest of the Standards they could get us on. Thanks for the links too, that is not an easy site to navigate from my limited experience.

Just a question - what does a Perpetual worksheet look like? Would you be willing to post yours? May just be semantics, but that one threw me.

This is getting a little ridiculous. With good controls showing the antigen is still reactive (either the pt or antigen reagents), expired panels should be OK to use for additional ruleouts only, as we have done for decades. You don't use them for the initial work, but ruleouts surely are OK? Haven't we recently had several discussions on how to do controls on these older panels just for this use - and now we can't use them at all??? I am only able to keep one panel on site at a time - that is not always going to allow for all ruleouts. We keep our panels for up to 3 months only and run a positive control on the panel to show the antigen being tested for is still detectable. CAP did have a specific standard that allowed an exception for the use of RARE antigen typing reagents only (the really expensive ones) that passed controls on day of use. TJC does not have that same exemption and I have wondered what they would do with Blood Bank reagents. Doesn't sound encouraging. We will be inspected by TJC this year (our 2nd time), so I guess I will find out. None of the rest of our routine reagents are expired and we do not use expired RBC reagents either for routine testing.

We are on Lot# R632 - no problems here, but we have seen this cell #2 problem in the past. Changed out everything with no real resolution until we got a new Lot# of WBcorQC, since in our case, it was mostly the QC that was failing, patients were better. If you are also seeing patient failures, my best recommendation would be to get Service out to look the instrument over well (mini-tuneup) and get the newest lot# of RS3 strips Immucor can give you. Best wishes.

Just remember that you can not do comparison testing on CAP/API/etc proficiency materials until after the due date of the survey (or the date after which you can no longer change the answers). Doing comparison testing before that will put you in violation of " treat the survey the same as the pt specimens", since you will be doing multiple testing on the specimen and might get a different answer. Hopefully not as that would mean your methods were not correlating either! Record the due date of the survey on your correlation form and then the date (a later one) that you do the correlation studies. Some might recommended waiting until the survey answers come back, but the automated and manual BB surveys don't last as well as some of the other survey materials, so that might lead to some problems too. Good luck and welcome to the FUN!

Yes - it seems like the phones are even worse than the food problem now. But how are you going to know if they stop in the cafeteria on their way back upstairs unless you just happen to run into them there? Hummmm - maybe that explains that slow start time on some of those units when we get the unit review back.....!!!

Hi - just happened to run into this again. We are now a 190 bed, community hospital and we belong to the Lifepoint Healthcare system, headquartered in Tenn.

Very interesting procedure. How come they don't just leave the units together WITH their gel paks while putting them in the refrigerator, I wonder? The units today are small enough that they change temp very fast, especially if someone is handling them. This seems like a good answer to help with that problem.. Has this procedure been through an inspection yet?

Each relabel will depend upon which product is being thawed. Most distribution centers send several products to their hospitals. Check with your distribution center as it is very unlikely that a single roll of labels will do this job for you. Most of these emails refer to computerized systems where the produst label is assigned (or chosen) from a huge list of possible available products that correspond to your original frozen unit and then is printed out by a special label printer. The 2 systems most likely to work with your computer system, if you have one, are Hematrax and Computype. If you do not have a Blood Bank computer system, all labeling will depend on your techs picking the correct labels from a stack of several label choices. UAL, Shamrock and St John's (now PDC Healthcare) have a lot of choices that can be bought in roll form. Best of luck - the SOP is the smallest part of this job.

If your Lab changes to Joint Comm accreditation too, you might have much more cooperation from Nursing on these standards, because they understand Joint and they respond to Joint inspectors better than they ever did to CAP inspectors. We changed to Joint Comm accreditation for the Lab too (for corporate financial reasons) and FINALLY got yearly documentation of nursing training and competency. Many hospitals have changed Lab accreditation to Joint in the last few years both for the financial reasons and because they don't have to answer to both Joint and Cap/AABB for Lab operations. Even if you are not accrediated by Joint in your Lab now, the Joint inspectors can and sometimes do, come to the Lab while following their tracers, making the Lab essentially responsible for 2 sets of standards. Administrators refer to that as double jeopardy.

Our method here is as A McCord's - If the ECHO solid phase is positive with all 3 cells, we run a Capture R Ready ID (to check for high frequency or multiple ABs) and a Solid phase DAT. (We want to see what solid phase is trying to tell us 1st, before dropping the sensitivity of the test system.) If that is all positive too, we set up 3 trios in tubes, 1 - in PEG, 1 - in LISS (N-Hance) and 1 - no enhancement media/ 1 hour incubation (saline). We will do all furthur work and crossmatching in the 1st of these test systems that comes up negative. If they are all still positive - off it goes to the reference lab. PEG is the best tube enhancement media to back up solid phase testing - it is the only one close to solid phase sensitivity. But, it can still be sensitive to warms and colds. You still need to have LISS and 1 hr/no enhancement to see under some of these problems. If you already have tube testing as one of your formats, it doesn't take much to keep some LISS around too. With PEG, it is very important to emphasize with all generalist training that you DO NOT read PEG after the 37C incubation - you wash it 1st and read only with IgG. If you have problems getting them to remeber that - eliminate the 37C read in LISS too and just read everything at coombs phase only. This system works pretty well, we have seen underlying antibodies a few times. It also saves a lot of shipments to the refence labs. Good Luck

Yeeessss - #47 got me too!

I think it is coming from the Joint Commission standards. Our Chem and Heme depts have been struggling with that one since we changed to Joint accreditation. Blood Bank has not been roped into the standard yet that I know of (perhaps a surprise awaits!). Currently I am struggling with trying to share the daily QC with all shifts. Blood Bank and Micro have always done QC once daily on dayshift, now all techs on all shifts are required to participate at lease once or twice a year - go figure.

There was a query on here a couple a years ago that said one of the Joint inspectors was using an infection control standard to cite the Blood Bank for not placing the blood in an extra outside bag before tranport to the floors. They wanted the blood contained in case the unit was dropped (they do occasionally break that way). We have had a little trouble introducing an extra bag here. There are already so many plastic bags being thrown out that everyone objected to yet another unrecycled waste product. We could't find anything that would both contain the product and conceal the product. We will wind up with a clear plastic bag and the visitors will just have to avert their eyes, I guess. Though I have heard of folks passing out and falling at the mere sight of a bag of blood.......

We have a long standing policy of up to seven days in advance for outpt surgeries with a negative history. The history is recorded on the tube by the RN drawing the preop work after questioning the pt. (Understandable that that information source may not always be perfect, but it has done well for years. If they were transfused here, we catch it on prior records.) If used, the specimen still has 7 days storage post transfusion because I have room for 18 days of storage racks.) We also occasionally extend inpts too, we ask the RN if the pt is "awake and aware" and is capable of answering transfusion history questions before extending. The answer is documented on the pt's records. If the information comes from the pt in both instances, it should be equally valid. Though we did just have a case where we had a newly developed anti-E and when pheontyping the pt, showed a mixed field phenotyping for E. The pt and the family both said he had not been transfused with RBCs (we did have a history of Plts and FFP), but I have not yet figured out how he could have a mixed field phenotyping and a new antibody without getting units somewhere - anybody else know? Sometimes the RN forgets why they are asking for history and we get a request for an extended specimen with a positive history recorded - on those we run the specimen anyway, but do not charge for it and then redraw date of surgery, at least knowing about possible problems and having units on site if needed. This whole procedure is getting a little harder to maintain as the RNs and the Physicians turnover more and more and we have almost all rotating generalists in the Blood Bank here. It is hard for them to keep perfect track of the usable specimens and the specimens that need redrawing. That need is in fact, the only reason we still have a card file, we have not yet figured out how to get all of the "negative hx, surg date, ok to use until such a date data" in an easiley accessable place in our Meditech 5.6.6 system. If anybody has a nicely functional system going in their Meditech system, could you share it?

This is essentially what we do too, except our backup is PEG in tubes. We have always treated these as Solid-Phase Warm Autos. Sometimes they are very strong and react in tubes also, sometimes not. I also would appreciate any flowcharts anyone might be able to share.

AHA! Another from the Land Of Enchantment and clear blue skies and open spaces! One of our 50 is NOT missing! Wish I could come to the meeting too - would be fun!

How do you search this file now? I used to use the death index and search by SS#, but you can't do that anymore and you can't get far on Ancestry.com without joining it - something I am not going to pay for! The lists that are generated now are too generic, they don't even give you the whole birthdate, and if you don't know the date of death (because, after all, that is what you are looking for!) you get too many candidates. If you have a workable trick, I would love to know about it. Thanks.

Mine is a small, plastic Nativity that has been in my family as long as I can remember. I have fixed it over time and even "re-glittered" it once and the original box is still hanging in there too. It goes up somewhere each year, helping me still feel close to my parents. Merry Christmas everyone and may you all have a healthy and prosperous New Year.