AMcCord

We have a Sorval. Unfortunately, I think they don't make those anymore.

Every few years, our blood supplier takes a look at what we order and use over a period of a year or so, then calculates an average number for each red cell type for weekly orders. I think they add a fudge factor of a few percent to account for heavier use. Then they send us the list as a proposed standing order. If we don't like their list, we can ask them to change the numbers a bit to suit us. There's a little give and take on both sides and the numbers seem to work well for us. We do have to order special needs through the week ( antigen neg, irradiated, etc.) and if we are using heavy amounts, we have to order midweek, but not frequently. We return very few red cells - only Rh negs as a rule, if our supplier needs them and outdate very few. If your supplier won't/can't supply those numbers, can you pull your own numbers and check your average use over a year or two? We are 150 miles from our supplier, so this is an important thing for us, too.

It would also depend on the bylaws for your medical staff at your facility. We get orders from both PA's and nurse practitioners. Cerified nurse midwives, too.

I've just started training techs, mostly generalists, for the switch from gel to Echo and solid phase. My facility is a bit smaller than yours. What I tell them about positive and negative reactions is this: "In gel, the cells are all in a button in the bottom of the column if the reaction is negative. In solid phase, the cells are all in a button in the bottom of the well if the reaction is negative. In gel, the cells are scattered somewhere through the column if positive. In solid phase, the cells are scattered somewhere through the well if positive." They get it immediately and once they've seen a few camera shots with interpretations, it's no big deal. As was said earlier, Echo is reading the reactions. You just review them. I think Ortho must be training their sales staff to really push the big fear factor for intrepretation of results. I got that spiel also, as did the folks at a neighboring facility. But it's really a minor thing. Don't worry about that when you are deciding whether or not the instrument is right for you.

I monitored 100% of transfusions when we were on paper (avg 165 RBCs per month). I started out sending incomplete forms to the guilty party with a note asking for completion of the record - and don't forget the chart copy! I also had a spread sheet to make note of the type of error (omitted vitals, incorrect unit #, etc) plus the nursing unit involved. If a flow sheet was missing, we called the unit to speak to the nurse or leave a message - x 2 if necessary. Then we sent a written notice to the nurse. If a second written notice was needed, it went to the unit manager. The spread sheet information when to staff development. Compliance improved dramatically when folks started getting "nastygrams' from us. Nurse management backed us, which was very important. From there we looked for a pattern - was one individual consistently making the same errors, was one nursing unit responsible for a particular problem(s), was it a time period of unusually heavy workload vs staff, etc? At that point, copies of the actual incomplete records went to the unit manager for action. And we got action! I don't know what was said or done, but we got improvement. After about 18 months, we were looking good. It was a lot of work at first, but it paid off. Make a friend in the nursing management hierarchy who can help you and then keep barking up that tree!

I ask for the scope here. I have too many rotators who don't work many hours in the Blood Bank. They were missing some clinically significant antibodies by shaking too hard and/or not looking closely enough with the mirror. Gel is our primary method, however. (Switching to automation soon !) We use tube only for those antibodies/problems that are too puny for gel to give nice reactions or for special methods. That means we know we may be looking for weak reactions going into the tube test. So, we aren't using the scope a lot.

A well maintained cell washer can be a very reliable device. Some models work better than others, so that would be a consideration when purchasing. Do you have to have a cell washer?...no, a good manual wash will work just fine. Would I give up my very reliable cell washer?...No Way!!! It's value is in the time it saves me. When I'm doing tube testing for antibody IDs, etc., I usually have plenty of other things I can do while the cell washer is doing its business.

We've used gel for 7 years and our followup for your scenarios is very similar to David's, though I don't routinely use enzyme.

I had asked about this and was told that once the patient is out the door for transfer, he/she has been discharged from the institution and what comes after that is not our problem. However, we all know that any transfusion reaction, no matter who gives it and where, would come back to haunt us. I've never been able to come up with a good answer nor has anyone I've asked about it been overly concerned.

Different transplant programs have different rules about who gets irradiated blood products and who doesn't. Most of our patients post-kidney transplant don't get irradiated but one program insists upon it. Perhaps the physician should discuss the issue with the patient's coordinator/transplant surgeon.

We installed ECHO the same week as bpkelly. So far, so good!

Both worked for me and I run the 'old' stuff.

If you have access to AABB member info, they have a section on best practices that includes Quality plans from several institutions of different sizes.

I have MT students and this is what I use for them: You can use 4 D negative donor segments and 1 D positive donor segment + 3-5 drops anti-D. Incubate 1 hr at 37C, mixing occasionally. Trial and error will tell you how many drops to use to get the strength of reaction you want with your DAT - "jump out and slap them" strong or a little more subtle. 10 drops of Coombs control cells + 3 D negative donor segments also works well. If you want something else, try 1 Jk(a) positive donor segment + 3 Jk(a) negative segments + 8 or 9 drops of anti-Jk(a). This works for Fy(a), Fy( and Jk(. Use outdated antisera or a patient sample that reacts strongly (you will have to incubate, check your DAT and maybe add more patient serum to make the patient antibody work well). Incubate the same as with anti-D. Anti-e works well also and I usually have some that has outdated. Any Rh neg patient or donor sample will give you red cells. Use 3-5 drops antisera. You can add the anti-e (5 drops to 2 mL serum) and provide 1-2 mL e positive red cells to fake a warm auto absorption. Incubate the same as above. For red cells, grab some extra segments when you check out blood to get segments to work with or retrieve some empty bags. You could also use some agreeable lab employees for red cell samples - do some antigen types on them and keep a list of who is good for the sample you want to make. I usually make a double batch for students as they often need more sample to work with until they refine their technique. I also usually wash once with saline to remove some of the excess antibody before I hand it over. These samples work better if they are used the same day or the next day at the latest.

My new baby is SP brand, oval shaped, about the size of the palm of my hand, attached to a lanyard. It has one button to push with a simple digital readout. It's slick!

Be my guest to clarify...my brain and my fingers get all disorderly sometimes. I can tell already that I'm going to love ours! It would have saved me a 2 AM phone call this morning.

What we preach to MT/MLT students about control cells (either IgG or complement coated) is that it's all about... did we add it, did we wash it (and we aren't neutralizing our AHG by not washing well enough), and did it work. Complement control cells are a part of the QC for DATs. There is no requirement to detect C3 activity for screens, IDs or AHG crossmatches and our life is easier if we avoid finding it there . I hate cold agglutinins! There could be a rare case where it become important, but I haven't seen one of those yet (did I just jinx myself?).

This is directed to those folks who are using infrared thermometers to check unit temps. How did you validate the thermometer? Thanks for your assistance!

Look closer at TRM.40200. It says IgG coated cells must be used for testing that has 'anti-IgG reactivity', which poly does (and so does anti-IgG). TRM.40210 says complement-coated red blood cells should be used to confirm all negative results when testing has 'anti-C-3 reactivity, which poly also does. Set up 2 tubes with poly AHG. The first tube is read at immediate spin for IgG reactivity with negatives checked with IgG coated cells. The second tube can be read at immediate spin, but it is recommended to incubate at RT for 5 minutes to increase sensitivity for C-3 activity. If the second tube is negative (no C-3 reactivity), control it with complement coated cells. Both IgG and C-3 reactivity are covered for your patient and QC is done for both types of reactivity.

My transfusion investigation worksheet is awful!!! - if it was good I would be happy to share. We had a Medical Director for years who declined to change anything and insisted that we do an absolutely full blown investigation for everything, including a rash. He retired a year again, so I am in the process of rethinking and redoing just about everything. Just haven't gotten to that yet. I have found some good examples of a variety of things by searching the web. There are a number of big hospitals/organizations who have policies and procedures on line and available without password. You can get some good ideas that way.

Methods in Immunohematology 2nd edition. Published by Montgomery Scientific Publications 1994. Even though its old, it still has lots of good information. Try Amazon, Powells.com. It's not exactly a New York Times best seller, so there probably aren't many copies circulating. Worth it if you can get it, though. Another oldie but goodie is Applied Blood Group Serology, Issit and Anstee. Same publisher and also out of print.

The note for TRM.40210 says "Complement-coated red blood cells should be used to confirm all negative antiglobulin tests when the antiglobulin reagent used for testing has anti-C3 reactivity." Poly has anti-C3 reactivity. If you are doing DAT screens and you report a negative poly, is it negative because there is no IgG and/or C3 on your patient red cells? Or is it negative because your poly AHG failed to detect the C3 on the patient red cells because it has lost some of its reactivity? Without using C3 coated red cells, you can't answer that question. If you have a false negative DAT, it won't be sent to the reference lab. It is true that a majority of WAIHA cases are due to IgG. Don't forget, however, that there are cases of severe AIHA due to C3 and they are not rare - think cephalosporin induced. The cephalsporin family is a commonly prescribed antibiotic. Even though we are a smaller facility, we have seen several cases like this, 2 extremely severe. The presence of C3 on the patient's cells and a medication history gave the presumptive diagnosis. We have also seen several very severe cases of idiopathic WAIHA due to C3. Leukemia and lymphoma patients with C3 coated cells have a worse prognosis than those patients with IgG coated cells. Treatments are modified based on what is reported. The treatment for cold agglutinin disease is affected by whether or not we report a positive DAT w/ C3. So, it can be crucial, even if not as common. Email or phone CAP with this question. Their technical people are very helpful and respond quickly.

The mention at lab meetings is an excellent suggestion. It might help with the calls I get from nurses who say "we called about a reaction and the lab tech didn't know what to do"!

We don't often use blood warmers here and not for years for the reasons you listed. Our blood bank medical director would recommend the use of the warmer, not techs. If the patient's physician requested infusion with a warmer, that would be his/her call, we don't worry about the reason.

How do you know that your poly is detecting C3 activity if you don't QC it with complement coated cells?