AMcCord

Remember that the gel method will really ramp up reactions of warm autos, just as PeG and solid phase will. You can see warm autos with gel that you wouldn't have even detected if your standard method was tube/LISS. (Same holds true if you use PeG, instead of gel.) If you used standard tube/LISS you would have transfused antigen negative units that crossmatched with LISS, probably with no greater risk to the patient. All transfusions to patients with warm autos are a risk and should be avoided whenever possible. Crossmatching antigen neg units with Peg or Gel or solid phase instead of LISS and calling them compatible doesn't necessarily make transfusion any safer with the warm auto. Sometimes sensitivity can get in the way of specificity. When working with warm autos it is sometime helpful to take a step back to LISS to crossmatch antigen negative units, thus avoiding the warm auto, to see if there are any other dangers present (alloantibodies that have gone undetected because they were hiding behind the warm auto). Your reference lab is not following an unusual process.

We have very few draws that are not done by one of our phelbotomists and they are specifically checked off for Blood Bank draws by me or the phelbotomy supervisor (a tech), who is well versed in Blood Bank collections. If the specimen is a line draw (ER, ICU, NSY, ONC etc) then the phleb has to be present to ID the patient and observe the collection. The phleb receives the specimen and labels the tube (remember that they ID'd the patient prior to collection and were present throughout the process). We have only a few specimens drawn in SURG by anesthesia. We require that the tubes come out of the OR labeled, though we sometimes have to get pretty pushy. We may not get EXACTLY what we require of phleb drawn specimens, but we get enough (name, MR#, time, who drew) or they are rejected. We tell them the patient gets uncrossmatched type O that the surgeon has to sign for until we are happy with the sample. That usually makes things happen. I have met with the anesthia department to explain our requirements and when they understood that these were based on standards, not my whims, they were cooperative. They forget requirements sometimes because they draw so few and there are always new people coming in, but they make aneffort. Our phlebs go into delivery rooms and draw any specimens needed there, but this is not often. All of the OB patients are supposed to be drawn for Blood Bank when a CBC is drawn prior to their spinal.

Working in one of those community hospitals, far from the blood center, I can also tell you that's exactly how it will work. And they will ask for O neg on every baby, 'cause that's what I was taught' so there must be a really good (mandatory) reason for that. (Usually the really good reason is because that was what their teacher was taught and his/her teacher before them, with no reference to references.) Heaven help you if you have a baby who needs c negative red cells! Good reference material is a must when you have to win these kinds of arguments.

You are doing pretty much what we do. We have the nursing staff from the floors pretty well trained and they bring back units pronto. ER...forget it! OR...sometimes. Our waste rate has gone down because we have policed this issue strongly. Violators of our policy get a hospital occurence report written which includes dollars lost, the first viewer of which is one of the hospital vice-presidents. Tends to be quite effective.

You should do the automation survey in addition.

We had a mixture before 'THE LAST STRAW'. Most of them were very professional, the majority of them were knowledgible, a few of them were very helpful to us and, unfortunately, a notable few were anything but knowledgable and helpful. I do believe that a complaint is important when an inspector is not doing their job professionally and with good knowledge of Blood Bank. The inspection process won't work if we can't interact in a positive way with the inspectors and FDA management has to know that. As a side note...in phone and email contacts with various individuals, I've gotten nothing but cordial, professional assistance.

We use an electronic/digital thermometer with a nice thin probe. We have used an infrared, but if the temp is within 1 degree of 10C a recheck with the digital is required (accuracy) by SOP. So most of the techs prefer to just use the digital to start with.

We give them 15 minutes and take the temp when the unit is returned. We found that anything over 15 minutes guaranteed a temp > 10C and even less time in some areas. The nursing staff has gotten very careful about checking out products only when they are absolutely ready to hang the unit. They are also very diligent, for the most part, about getting products back to us quickly (exceptions: surgery and ER, what a surprise!). We have very few wasted units with returns.

Be sure that your Medical Director sends the FDA a letter stating that you are withdrawing your registration/licensure because you are no longer doing anything that requires registration/licensure (irradiating product). They should reply to you. Keep that letter on file. If the inspector shows up again anyway, show them the letter (trying not to smile too broadly :tongue:). He/she may still insist on inspecting, but it probably won't be as intensive - hopefully. Technically the FDA can check you out at any time because you are holding a blood supply and transfusing patients, but they are so understaffed that they probably won't bother coming anymore if you are not having any problems that call attention to yourself. The final year of our FDA registration, we irradiated about 20 units of blood and drew approx 40 autologous units. Our last-straw inspector was an English major I swear:mad:! She knew nothing nothing nothing about science, much less Blood Banking. She was on the phone constantly to her supervisor and citing us for stuff we had been specifically told by our previous inspector ( who did have some knowledge of Blood Banking) to do. While she was still picking nits in our records, my Medical Director marched to the CEOs office and told him 'effective immediately' that we were drawing no more autos and irradiating no more blood. When he returned to the lab, he told the inspector the same thing. She immediately started telling us that we were doing a fine job, we shouldn't cut those services, she was in no way implying that there were any large problems at our facility, etc, etc. The Medical Director stuck to his guns, though we did give the medical staff 30 days before we actually cut the cord. When our inspection report finally came from that inspector, you couldn't recognize our facility in it. She had more than half of the information wrong. Even though we withdrew our registration, we got a visit the following year. We showed the man the FDA response to our letter. He blustered a bit, did a cursory inspection because "you still have blood don't you" and left. We never saw a report from that visit and we have never been visited again. The same inspector showed up at the Red Cross depot near us outside of the normal inspection process and several other facilities in our area complained about his behavior and he got fired. So, a complaint might be worth filing.

I order the elution survey but dropped the titer survey and started sending all titers out. Makes me real sad to pass up doing titers...Boo Hoo!

I agree 100% with conwaysbb. That is our billing philosophy - capure everything, accurately, for the big picture.

Echo will not report a mixed field, but you should be able to see it when you review the camera image for the test well. We document visual inspection results of the well when visual and Echo interps vary. We look at historic type, if available, and use tube testing as a 2nd type for all new patients.

We charge for the antigen typing. Irraditation and CMV neg are charged with the product, if infused.

Received an invitation some time ago.

True random access like the chemists have on their analyzers.

Same as tbostock.

We occasionally give a unit or 2 of platelets to the patient post-op for hip or knee replacement, if there is oozing. The ortho surgeons used to want those plts available preop but have discovered that they rarely need them pre or post. Now they just request platelets on standby at our local blood center's satellite depot. (They are teachable!) Anesthesia, on the other hand is very nervous and they want 2 units in house. If they are doing a spinal, I don't argue with them, except to suggest we give one and keep the 2nd one at the satellite depot. That has cut our waste rate for plts quite a bit. Our surgical case load is mostly ortho, gynecological and colon resections, so we don't have nearly as much fun with this as a lot of you do. The cardiologists here are adamant that the patient does not come off Plavis preop, so I'm sure they would veto an antidote, if there was one. Our biggest nightmares are the folks who come in with a GI bleed on Plavix (and the cardiologist won't take them off it). You can suck down a lot of blood in a hurry.

I am not allowed to see the daily surgical schedule - I don't have a "need to know"! Yet I have to pull a rabbit (instant crossmatched blood) out of a hat...Voila!...on a fairly regular basis. I can't change the relevant minds, so we just do the best we can do. Never have been able to figure this one out.

We are using one with the fixed (serology type) rotor to spin EDTA specimens for testing on Galileo Echo. Our validation studies for solid phase/Echo were spun that way. It is working fine. I resorted to using it that way cause I couldn't get my boss to buy me anything else suitable to replace the fixed speed (high speed) centrifuge we had been using for specimen processing.

Asking maternal weight is not universal, but is a desirable practice and not uncommon in the US.

I'm saving it in case somebody I know might need it in an emergency.

How about 'overkill' or decision making by people who are not well informed/incorrectly informed/past good sense or who are looking at what happened in Mexico and don't want to be sued if a death or deaths should occur here. The deaths in Mexico loom large when decisions are made here. According to the interviews with experts from the CDC, infectious disease specialists, etc, there are a number of decisions being made that are extreme, including some school closings. Keeping kids away from one another for several days is a good, time tested way to stop a flu breakout in schools in it's tracks when dealing with the 'normal' flu. I don't know if anyone knows whether or not this would be helpful with this bug. At times like this, I wonder about the children's fable about the boy who called wolf too many times. We react so very cautiously, things turn out to be not so bad after all (thank heavens!), then people are lulled into complacency and will not respond when they need too. Time will tell which kind of event this is - wolf or not.

Ditto! except our check is done by 2 RNs at bedside.

We also follow the tech manual with anti-A,B for group O units and no weak D for the Rh check on Rh neg units. You definitely should have the approval of your medical director to change policy.

These kind of patients always make you pray that they'll move far far away so you don't have to deal with the problems, don't they!? I think I'd consider trying phenotypically similar red cells for her next transfusion, running that first 25-50 mls sloooowly to see if anything is going to happen, then continue infusing the rest of the unit slooowly, if all seems OK. Let one unit sit and circulate for awhile, check DAT, check for hemolysis, rise in Hgb, etc. If she is doing well, try another unit, slow, slow, slow. If she had an undetectable antibody (in spite of everyone's best efforts) like the anti-C or anti-K1 previously mentioned, a phenotype matched unit MIGHT work if her antibody is directed at one of the antigens we can routinely screen for. The literature discusses in vivo red cell survival studies with 51Cr tags for cases of mystery hemolysis, but that sure isn't practical for those of us in smaller facilities. Is she is hemolyzing ALL the transfused red cells rapidly?? then her DAT is going to be negative, because she's destroyed anything coated with antibody. That would sound like an antibody to a high incidence antigen - scary to think a patient could have that and not be able to detect the antibody. Does she have siblings? A sibling can sometimes be compatible in difficult cases. Have you asked the large hospital's blood bank what they transfused and if anything they tried worked better than anything else? Have you consulted with the medical director of your blood supplier or reference lab to see if they can recommend anything? Just throwing out ideas here............I wish you and your patient luck!