jhaig

I hereby claim victory in my battle to eliminate weak-D testing at my institution. I presented all of my research to pathology last week. My pathologist notified me today that we don't need to do any weak-D testing on pre-natal or pre-transfusion testing any more. He said it seemed superfluous and, for the amount of Rhogam we give out annually, a few extra vials would have little to no impact. Thanks to all of you that helped me in this quest. I've dropped weak-D testing on auto donor units as well. I don't want to have different results on the patient sample and their auto unit - the less confusion the better. Since we don't cross over auto units (if they don't get transfused back to the patient, they get tossed), it shouldn't be a problem.

In order to drop the weak D, I need to find the information on where and when these changes took place. I have the CAP standard, but can't find where AABB recommended this change.

We had a patient come in yesterday who recently moved up from Virginia who said she had always been told she was RH-negative. We perform weak D testing on any female of child-bearing age, and wouldn't you know that she was a 2+ weak D positive. SO...we called her RH-positive, weak D variant and notified her doctor's office that she was not a candidate for Rhogam. Needless to say, this caused mass confusion. The patient has three children and received Rhogam in the past. My guess is that either a) she's never had a weak D test performed on her or her previous care givers just called her Rh-negative and gave her Rhogam as a precaution so as to not confuse her about her blood type. Then I check the AABB standards and find standard 5.20.2 which (paraphrasing) implies that a patient shall be considered for Rhogam if the woman's test for D antigen is negative, but a test for weak D is not required. Who out there does routine weak D testing on females of child-bearing age? Has the weak D become obsolete or have I gone insane?

Gee, I thought it was only MY O.R. that was high and mighty and so versed in the ways of transfusions that they don't feel the need to follow protocols! Thanks for the tip. I do agree that crap rolls downhill and the lab is usually at the bottom. It's almost as if we have procedures in place not for the patient's protection, but for fending off attacks from other departments.

We do audits on every nursing unit, OR, ER, Dialysis, and any other department that transfuses blood products. Sometimes it's hard to get to all of them because of time constraints, so I try to stick with the units that transfuse the majority of the products. I use the same worksheet for every unit, however.

We may get lucky and have this process be just that easy, but I'm leaving that up to the technical wizards in our IT department. We haven't done a whole lot as far as actual work, but there are some preliminary steps to take. First, I registered the facility with ICCBBA to get a facility ID number. Then we coordinated with our IT dept that will be handling most of the conversion and arranged the purchase of everything needed, including barcode readers, etc. We are on version 5.5 of Meditech and I have been assured that the software is ISBT128 compatible (we'll see about that when testing starts). I've had a meeting with our local American Red Cross rep. and he seems to think we're right in line to be ready for the Nov. 1st deadline. I also received a CD from the Red Cross with the updated ISBT128 translation tables and product codes we will be using. I'm letting our computer people handle things until we're ready to parallel test in June. Overall, I'd say you'll need about 3-4 months to get everyone in line. It took ICCBBA almost two months to get us our facility ID number, and the budgetary approval from administration took awhile as well. But I started getting organized in Nov of 2006, so I had a head start. The 3-4 months is just a guess as maybe your facility is more efficient at letting go of the purse strings than mine is. But be sure your computer people have asked administration for the equipment needed and have been approved to buy it. Then register with ICCBBA, get your facility ID number, and go from there. You may also want to address the issue through your transfusion committee and get an idea of who will be affected with the changes. Have fun!:cool:

I'm also trying to change my retype procedure and also use Meditech. I also want to use a previously drawn specimen for the second type on patients with no previous history. How would you handle a patient arriving in the ER that has no prior blood bank history? Would you perform a second draw immediately? I would like to avoid a re-draw, so in cases like this I'm considering issuing only group O products to non-group O patients with no blood bank histories until a second specimen (such as the morning bloodwork) can be drawn. I'm not against doing a second draw, however. The inconvenience versus getting the right patient drawn is worth it in the end. As far as Meditech, we created a reflex test for a repeat ABO only on patients that do no have a previous blood type on file.

Any advice on how often transfusion audits should be performed? I try to do as many observations as possible, but being the only person in my department I find very little free time to actually stand over nurses while they administer a blood product. I also think that if they know I'm watching, compliance will be artificially high. Should I involve nursing in the process or just keep it to myself here in the blood bank?

Did you ask your inspectors if they liked movies about gladiators?:cool:

We use a standardized form for all emergency transfusions that is used for either emergency transfusions or life-threatening situations in which an Rh-negative patient may need a transfusion of Rh-positive blood. It requires a physician signature before any release of blood is allowed. We also require that the pathologist make the final decision on whether or not to give an Rh-neg patient Rh-pos blood.

Our system is set up to charge for a retype only if a patient doesn't already have an ABO/RH on file. Any other confirmatory testing is considered QA for our purposes only and isn't charged. We do the same thing with CBC's that are run at other labs in which crossmatch orders are based. If another lab says a patient has a 24% hematocrit and orders 2 units, we confirm the hematocrit from the same specimen before transfusion, but use our own instrument to do it. This confirmatory re-check is also an internal QA and is not charged.

Our nursing service initiates any transfusion reaction workup. They are to stop the transfusion and notify the blood bank to initiate the workup, which includes a full clerical check of all paperwork and wristbands, pre- and post- ABO/RH of the patient and the unit, and a pre- and post- DAT. The nurse then calls the physician to let them know what's going on. Any suspected urticarial reactions (hives, etc.) can be continued with a physician's order without the blood bank being involved. Once the workup is complete, the nurse gives the results to the physician and the physician decides whether or not to continue the transfusion or order more testing (blood cultures, urine, gram stain, etc.) I'd be concerned about a policy which could possibly allow a transfusion reaction slip through the cracks without being addressed immediately. Sure, your docs may trust you, but see what happens if you end up in litigation regarding a transfusion reaction. You may see just how far that trust goes. You-know-what rolls downhill, and the lab is usually at the bottom. It may be worth your while to consider switching to leuko-reduced PRBC's. We've seen a drop in the number of reactions since switching over three years ago. We transfuse a large number of chemo / dialysis patients and the docs won't ever switch back. The units may cost more, but they seem to have cut down on our febrile non-hemolytics.

I've found that playing about 7 straight hours of Madden 07 de-stresses me to no end. I just picture my inspector as a recevier going over the middle and I'm the linebacker.

I should be covered with outpatient transfusions because our dialysis unit handles all outpatient infusions as well. Even though anesthesia falls under our O.R.'s jurisdiction, it probably would be a good idea to invite someone from their area specifically. They, however, are notorious for not attending meetings throughout the hospital. Must be the free food isn't enough. Oh well, it must be nice to be in your own little exclusive world.:cool:

So far, here's what I've got lined up: Blood Bank Supervisor (me) Head pathologist O.R. Director Risk Management Director Nursing Staff Development Director Dialysis Services Rep. Physician Rep. (internist) Oncology Rep. Basically I'm trying to get someone from each area that would ever issue, administer, or even touch a blood product.

We're in the process of revamping our Transfusion Committee membership and I'm trying to get some ideas of who should be on the committee. Other than representatives from pathology, blood bank, nursing, and other ancillary services (dialysis, risk management), should I include any other departments on the committee? Are there departments that should be excluded?

Rhogam should fall under the transfusion service simply because it is a transfusion issue, not pharmacological, when deciding to give Rhogam. What advantage does the pharmacy expect to gain from reviewing all Rhogam orders? The blood bank's job is to determine which patients need it or not. Rhogam is a concentrate of predominantly IgG anti-D derived from pools of human plasma, so their thinking may be that it is the same as giving something like IGIV. But it's definitely not the same as giving an antibiotic. I wonder, has your blood bank given Rhogam in the past and for how long have you done it? Why is the pharmacy suddenly insisting on this action? Our pharmacy used to handle albumin, but they couldn't keep track of it and didn't keep up the paperwork, so we took it into the blood bank. No problems since then. Most places I know of leave the issue of Rhogam to the blood bank. If it's not broke, don't fix it. I'd keep the pharmacy out of it altogether.

If your blood bank administers the tissue bank as well, watch out. My FDA inspector spent nearly twice as much time going through the tissue bank than she did with the rest of the entire department.

We, of course, have the usual litany of food (pizza party and subs from sales reps, lab luncheon by pathologists), but I've been put in charge of games yet again. I work with our church's youth group and we specialize in messy games such as "Spew", where you put an Alka-Seltzer under your tongue, then take a sip of soda. Then you try to hold it in as long as you can - most people only last a few seconds. Just don't swallow...And, of course, all of the action is videotaped for future blackmailings. I'm adding a Fear Factor - like eating contest between the techs and phlebotomists. No pig's intestine or monkey brains, more stuff like spoonfuls of mayonnaise, dill pickle juice, etc. The crowning event this year is Human Bowling - ten real bowling pins set up at the end of a long hallway, put someone on a skateboard wearing a football helmet, and give them a push. I also want to broaden my employee's minds, so I put together a list of 20 words taken directly from the dictionary that sound offensive or vulgar, but really aren't. You have four definitions of that word and have to guess the right one. The winner gets a week's worth of lunches from the cafeteria (insert hospital food jokes here). Let's hope our workload allows all of this to actually happen

Our donors are considered for deferral if they haven't eaten yet during the day of donation. It is up to the patient - if they want to donate, they need to have eaten or will have to go get a snack in the cafeteria before a needle gets anywhere near their arm. The patients almost always comply, and our post-donation reaction rate has decreased.

37C and room temp (20-24C) for Yersinia

I wouldn't say that the doctor is going overboard, but it does seem like some education is in order. It's always best to give ABO and Rh specific products, but in cases with platelets it is sometimes necessary to give what you can get when it is available. It depends on the clinical situation. Does the patient have a history of not responding (refractory) to platelet transfusions? Is the patient a female of child-bearing age? Is the patient actively bleeding? Obviously a count of 14,000 warrants a transfusion. But what the physician needs to know is that unless the pheresis unit you have is grossly bloody, there is little risk in giving an Rh pos unit of platelets to an Rh neg patient. And giving a full dose injection of Rhogam should protect against Rh-positive transfused RBC's in a minimum of 30 units of Rh-positive platelets or 7 units of pheresis platelets. Our policy is to administer Rhogam to any patient, male or female, when an Rh negative patient receives Rh positive platelets. If the doctor feels the patient is clinically stable and the doctor is willing to wait for ABO/Rh compatible products, then that's their call. But the doctor also needs to know that giving Rh pos platelets to an Rh neg patient is not unheard of and is sometimes necessary.

I recently finished some correlation studies and found no real significant differences. The new cells showed some slightly stronger reaction strength (3+ vs. 2+) on some patient samples of Anti-K and Anti-M and there were some weaker reactions seen with a couple of Anti-E patients (1+ vs. 2+). Some of the patients I used had been aliquotted and frozen so some of the variability may have been due to the plasma being frozen, but I have no way to tell. On the fresh patient specimens I used (approx. 25 specimens) there was virtually no difference. I have yet to do any eluates, but as far as antibody screening and antibody ID, the new Ortho cells worked just fine. :cool:

Alarm testing must be performed 'regularly and frequently enough to achieve and maintain personnel competency and to detect malfunctions' according to AABB and CAP regulations. I'd say checking an alarm's ability to be heard daily would satisfy that requirement since not being able to hear it would qualify as a malfunction. The way you're doing seems fine.

I'm curious to know where these guidelines regarding Anti-D levels of less than 2+ came from. Is this AABB, CAP, etc? I've had this happen as well, and in these cases I've given Rh negative units if at all possible if only for the fact that a person on chemo probably shouldn't be exposed to any more RBC antigens than they need to be. If my inventory allows me to give immunocompromised patient RH negative blood, then I'll give it. However, these patients are still producing a detectable level of Anti-D so it would seem like Rh pos blood should be fine. We have a patient we've been transfusing for years that has a type of myeloproliferative disorder in which she now had no Anti-D titer. She started off as a B Positive, but for all intents and purposes she is now a B Negative and we give her Rh negative units. So I guess it all depends on the patient's situation, but we've done it both ways.