AMcCord

We are considering a switch to Rhophylac.

We are a smaller facility with 1-2 in Blood Bank during AM shift and no 'assigned' blood banker the rest of the time. We used to deliver x# O negs, though assigned to a specific patient/room, and as often as not ended up throwing most of them away:cries::cries:. Some bright individual would always take them out of the cooler and drop them on a counter, gurney, table, chair, etc and that's where we found them. I never trusted them not to grab a unit for another patient, either. When we cut the cord on that practice, we agreed to provide 2 units RCs immediately whenever they wanted to hang units. They must give us the patient's emergency armband number, name, if known, and location when they call. When we deliver, a signout paper document goes with us and someone on the other end is required to sign for the blood. We have agreed with ER that this will be the 'recorder' (the person who is documenting everything - meds, treatment, status, etc.) or any nurse with that patient. We follow our normal checkout procedure as closely as is possible under the circumstances. Minimum is that the tech sees the armband number or someone reads it from the patient's arm to them. On the dayshift I can usually find a tech in another section of the main lab who can run the units, answer the phone, etc. If it's a bad day/bad trauma situation or happens evenings or nights, and we are all busy, then ER is told they must send someone. That someone is sometimes the ER director and sometimes the resource coordinator/house nursing supervisor (or whatever you call that person at your place), if there isn't anyone else free to run. The resource coordinator may also draft a nurse from somewhere else in the house to do the fetching for them. If they come to us, they have to have that emergency armband number, name if known and location - sometimes they have to call back to ER to get it. This process came about because we had data on wasted blood products and staffing numbers that we presented to the ER manager. We were able to convince them that we were just as busy as they were. We were also able to show them that they were wasting a lot of blood. Do things run smoothly with all traumas? No, but we sit down with the ER manager, and ER staff if needed, and review the things that went haywire with particular trauma cases. It's not pretty, but it does work.

We've seen patients who were given RhoGAM in the office and sent immediately to us to have an antibody screen drawn (cart before the horse). Our specimens were drawn less than 1 hour post administration and our gel reactions were 3 and 4+. We begged that office to please not do that anymore...

We also hand out a full unit (freshest, CMV neg if available tho all our stock is leukoreduced, type specific if possible).

We get requests for 'irritated blood'.

We do ABO/Rh and DAT on babies of Rh neg mothers and for O mothers from one family practice in town (no, not ordered by the older docs but one of the new ones who had a mentor who is behind the times!). If mom is O with a negative antibody screen and baby is not O, we add an antibody screen, including A and B cells. If positive with the A or B cells and negative with screen cells, we report 'Immune anti-A pos' or whatever. If mother is known (by us) to have a positive antibody screen and we can get our hands on a specimen from baby, we will do ABO/Rh, and DAT, and screen, but no elution. Mom's antibody is presumed to be the reason for the pos DAT. However, they won't necessarily collect a cord blood specimen. The docs worry a great deal about the antibody prior to birth, but once the baby is born it seems to disappear from their radar, so BB worries for them. We do an elution if the DAT is positive and we can't explain it with ABO differences or a known antibody (almost never needed). OR we do an elution if the doc orders it (never happens). This has been our policy for many many years and we don't get any grumbles.

Actually, I was almost cited during a CAP inspection for not having a mechanism in place to check types on all possible pregnant patients, whether a sample was submitted or not, especially the ER. The thing that saved me was that I asked (very sweetly, of course ), "That's a big problem for us! Can you recommend a good way to tackle it?" He hemmed and hawed and then didn't cited us. Our inspectors, you see, were from a VA hospital with a population of 95% old men :tongue:. He had never worked at a facility that had OB patients, so he had never had to worry about that item. After we talked things over, he decided it was problem he was glad to be without.

The case study was probably within the last 5- ish years and the young woman in question was in her late teens so the FFP in question could have been separated with a casual disregard, shall we say, to having a few red cells sneaking into the product. I remember my student rotation at the blood center - not saying how many years ago - and watching FFP processed. Some of those units were definitely pinkish. You don't see that anymore. I have seen a patient make anti-D after a unit of single-donor platelets, leukoreduced pheresis collection. There can't be many RBCs in those. That patient was into antibodies in a big way - the anti-D was her 4th, so she was obviously a super responder.

I read a case study somewhere (maybe Transfusion????) about a young woman with anti-D who had never been pregnant or transfused but had a nice strong anti-D. After investigation of her medical history, they discovered that she had received FFP after a tonsilectomy at age 11. This was the only exposure to 'foreign' RBC antigens they could come up with. The authors noted that it is possible to find RBC stroma in FFP units (they were not talking about pheresis collection) because red cells can sneak by during plasma separation. Since freezing would not destroy the D antigen on the RBC stroma, stimulus could occur. Seems possible but it must be quite rare - or maybe not as rare as we think...has a study been done?

We do the same as Bill. We do not cross Directed donors over into regular inventory.

One of our near (hospital) neighbors had a Group O mom and an AB dad. Baby turned out to be AB. They also suspected all kinds of dumb things happening in delivery, they asked about a GIFT ovum (nurses didn't have a clue why they would ask), retyped and retyped and retyped. Redrew mom and dad, then collected a cap sample on baby. The doctor thought the lab had a major problem with their ability to determine a simple blood type. Finally sent it out to the ARC reference lab in Philadelphia to see what kind of weirdness was going on. The reference folks requested some family study samples from dad's family. Lo and Behold!, dad was sharing cis-AB, not A or B, with his child, just as his daddy had shared with him. Dad's family members, in the relative few they tested, had several instances of cis-AB, but it was not discovered until this cord blood sample was typed. The funny part was that the story ended up on the front page of the local newspaper - the story was actually pretty accurate, though how the editor or reporter (non-science people) grasped enough to find it interesting enough to publish, is a mystery. That's a patient that will be talked about for years in that lab.

My hospital does not have an institutional membership, but does pay for my individual membership. I agree that the membership is well worth the expense for education, book discounts and the information available on the member only section of their website. I use the website frequently when I'm working on procedures or implementing new processes.

Does the manufacturer of your refrigerator specify what to use? They should presumably be able to provide references for their recommendation.

We don't require the comma but do require that the names on the tube label appear in the same order as the test request/patient ID band. The computer generated test request and ID band label are supposed to be 'Last name, First name middle initial'. (Frank, Robert E). Of course , that depends on admitting getting the name right (which is a whole 'nother problem!).

I'll bet all of us have been bitten on the posterior by anti-H. I tell my techs that cold reactive antibodies were put on earth to keep us blood bankers humble. Just when you think you've got them all figured out, one of them will sneak up and get you! :mad:

We use a StatSpin for gel specimens that spins 7200 rpm for 2 minutes 10 sec and were still getting fuzzies until we started diluting our own cells. Maybe a few more RPMs forces them into submission.

Based on the wrangling we've done here to get the tissue issue under control, I would bet large amounts of money that there are all kinds of things going on in ORs across the country in regards to tissues that would make give the FDA fits if they only knew. There are salesmen (who are clueless about tissue handling regs) who tell surgeon customers (who are cluelees about tissue handling regs and don't care, either) that they can provide products on consignment and other little services to make life easy....just do business with ME. When you ask OR if the vendor is qualified, they don't know what you are talking about. When you ask the OR where the tissues come from, they don't have a clue. But that salesman has the best stuff and can get anything! so he says, so they do business. I don't really want the responsibility of tissues, but OR won't take care of a freezer so we are involved.

I don't incubate for 5' for QC of the reagent. If I can't get a good reaction with QC straigt up, then I would consider my reagent to have a problem (deterioration, contamination, whatever), though that hasn't happened so far...knock on wood. All patient tests (and my negative reagent control) get the 5' incubation.

We were having quite a few non-specific reactions, fuzzy, hazy etc. also. Pregnant ladies and Onc patients were the worst (and the majority of our patients! inconvenient to say the least). We started diluting up our 3-4% undiluted screen cells fresh each morning to 0.8% with MTS diluent 2 and using those for our antibody screens. That greatly reduced the problems we were having. We switched to Echo/solid phase in January and do not see many non-specific reactions in that same patient population. I had a conversation middle of last year with the supervisor of the reference lab we use about the 'gel problem'. She said that they have been receiving a significant number of samples that behave this way - funky in gel and negative with other methods. She also feels that the non-specifics could be 'formerly known as' HTLAs and/or white cell related antibodies. The problem seemed to get worse after Ortho's last reformulation of their prediluted cells. They were addressing complaints that the method was not sensitive enough. Now the method seems to be picking up stuff we'd all rather not see. My recommendation is to dilute up your own cells. The hassle of doing that is small for the reward of many fewer problem antibody screens.

I do agree with you Malcolm, "shaking" is the problem. I was taught to tip, observe for sheeting, tremble with your dainty fingertips, repeat the tip.... The first thing I do with a new tech or a student in Blood Bank for their clinicals is to correct their bad "shaking' habits. Most of them arrive with a lot of wrist action. It's also amazing how many of my long term Blood Bankers pick up that bad habit over time.

Complement Control Cells are 'designed' to react 1-2+ according to the insert, so they aren't going to be really strong reactors. I find that your shaking technique can make a huge difference in what your reaction strengths are with these cells. When I have a tech who consistently gets a 1+ at best (or less), I watch their technique and often they are pretty enthusiastic shakers. I have them ease up and they usually get better results. I also use Comp Control Cells to educate students about shaking out tubes properly. If the control cells are really fresh, I can almost always get a 2+, sometimes a 3+ (unless the cells were shipped on a HOT summer day - takes the stuffing right out of them!). I tend to open the new lot when it comes in, rather than waiting for the previous lot to outdate before switching lots. I think that helps quite a bit, too. I do incubate patient tubes for 5 minutes with anti-C3 prior to reading, but I don't incubate for 5 minutes with the control cells.

Cider!...I am jealous. Love that stuff. And the scones and clotted cream and spotted ****.

We use EDTA and do not pour off. Too risky with the possiblity of mislabeling the tube.

I also think it's worth the price to order prepooled cryo. When you are thinking about cost, remember to factor in the price of the bag you pool into, any other supplies used and tech time. Makes the extra amount the prepool costs look better. It is a very efficient way for us to provide the product with minimal staffing.

We'll have physician ordering in about 6 months. Nursing service thinks it will be great. We think it will be veeeeeeeeeery interesting. I agree that a good unit clerk is a major asset.