John C. Staley

Just out of curiosity, how has this been working out for you? Any significant problems or negative patient outcomes do to this practice? What caused you to pose this question? Also, how big and/or busy is your facility? Is your testing manual or automated? On the surface I would have to answer your question with a NO but a little more info would help. I've always been a "if it ain't broke..." kind of guy. If your system is simple and works well for you why seek to complicate it.

Just a side note, my wife's anti-K would show up at immediate spin, go away at 37oC and then come back strong at AHG. Her anti-D was detectable only at AHG. Her anti-S disappeared completely after about 1 year. She's a nurse, you can't expect her antibodies to be normal!!

I always considered antibody identification both art and science with a little magic thrown in for good measure.

People can be quite creative when it comes to finding an "easier" way to do their job. That is one of the reasons I have always been a firm believer that complicating a process never makes it better or safer. I know the rational behind the 2 types being required but I personally never bought into it being a practical solution the potential problems it is trying to solve because of the many more problems is has seemed to cause for the staff resulting in all the work arounds they manage to come up with. For it to really work you would have to have 2 separate draws performed by two different people at different times. (Both phlebotomists in the room drawing one immediately after the other defeats the purpose.) Then you need to have two different techs perform the testing, one for each sample. This would be impossible in many smaller facilities, especially on evening and night shifts. Of course the requirement came from people based in large, well staffed facilities. I'm starting to ramble so I'll stop here for now. I have one question, in the past the AABB rule was written that you had to have 2 sets of test results, the one you are currently performing and one on file to compare the current one to and if you did not have one on file then you needed the second test performed prior to issuing RBCs. It that still the case?

I always used the time the unit was issued to start the clock with the assumption that it had been removed from the refrigerator only moments prior to being issued and that was the documented time. No where did we specifically document the time it was removed from the refrigerator. Our process was, remove the unit, issue it on the computer, place it in the pneumatic tube, push the send button.

I think the more important question would be, how many facilities not doing this are seeing significant negative outcomes because they failed to detect those antibodies this technique would have potentially identified?

If I remember correctly AABB has a book on the validation of pneumatic tube systems for the transport of blood products. It was very thorough and in MY opinion overly and unnecessarily complex. We validated ours before it was available by simply timing the transport and checking the temp on arrival. If I remember correctly we may have even let the units used settle out to see if there was any excessive hemolysis visible but I'm not sure on that since is was 16 years and 3 jobs ago. Since we were transporting to every nursing unit in the facility we were most concerned with those farthest from the blood bank. We were fortunate to be able to do this prior to moving into the new facility which made life much simpler.

About 10 years ago I was having a deep philosophical discussion with the best blood bank medical director I ever worked with. During that discussion I told her that I thought the decline of the American Healthcare started when physicians stopped being hospital administrators and they started hiring MBAs to run the "business". She completely agreed with me.

I found it amazing that one of the corporations I worked for loved hiring consultants and on any given subject they would hire one after another until they found one that would tell them what they wanted to hear. It just never made sense to me to spend that kind of money only to search until they found someone who would confirm their chosen course of action was a good idea no matter how many others told them it was a bad idea. One place actually fired me because I told them the CEO's idea was a bad one when a consultant was blowing the expectations all out of proportion. Five years later they are still trying how to figure out how to make it work and it never will.

Pneumatic tube delivery solved all of our transport problems.

That would be like back when everything was manual and we had multiple racks of reagents out being used by more than one tech. Every rack had to be QC'd.

Not sure if it has changed but most daily QC was generally implied by the regulation statement of "day of use". Obviously we did most tests every day so it became daily. Other testing that was performed only on as as needed basis was QC'd on the day we did the testing. So, based on this I would say your manual screens only needed QC'd on the day you tested. This may have all changed but that's what I remember.

You may want to post this under Transfusion Service. I think more people will see it there. I'm afraid I won't be able to help you. We did not do pediatric cardiac surgery at either of the hospitals I was in. There was a large pediatric hospital nearby that took care of that. Prior to my retirement washing red cells had gone out of vogue and most places had gotten rid of their IBM 2991 cell washers but I've read recently that it might be coming back. It's a shame the surgeon would not try to educate by explaining himself but not surprising.

Is this request specific for a certain patient or by a specific physician? Is this a "universal" order for all pediatric cardiac surgeries?

Our only difference was that we cut off 2 segments. We stopped getting bags back over 25 years ago. Hated the mess and getting them back served no real purpose.

Just to make sure I understand, this was done as comparison between 2 methods in use and you do this every 6 months. How many samples do you compare?

I'm just curious, why are you doing both tube and gel on the same patient/donor? Do you do it on every patient/donor or was this a special case for some reason?

Just as a side note, most of the hemolysis I saw was in tubes that were collected by a nurse when they started an IV. Not sure what the exact correlation was but that was the case more often than not.

Just to clarify, at this point in the discussion I was referring to a positive DAT obviously (most likely) due to an ABO incompatibility between mom and baby.

My question is when was the most current antibody screen performed, just prior to the RhIG injection or just prior to the delivery, or after the delivery? Also, as I think about it, was an elution performed at the time of the positive DAT? One more thought, if the antibody screen was performed just prior to or just after delivery most of the available antibody could be attached to the babies cells resulting in a negative antibody screen.

Cliff, I'm glad to hear things have improved since the last time I submitted anything to them many years ago. I remember my first FDA inspector had just came from a meat packing plant and the only thing he knew about blood banks was his check list. The last one I had was actually an SBB. I was excited to see they were making an effort to do it right.

Ann, on the flip side I bet there is a lot that gets reported that doesn't need to be reported for fear of getting caught not reporting something. Unless the FDA has improved their information in the past few years, a lot of what they say leaves a great deal of room for interpretation.

Well Neil, it looks like a lot of folks may be dragging their old IBM 2991 cell washers out and dusting them off. Great information, thanks.

Malcolm, you make me laugh. Just like a bull dog, once you get hold of something you just can't let go. I think the moto from a place I once worked is appropriate. "An exercise in futility is better than no exercise at all!"

Good luck with the exchange. The worst case of HDN I ever saw was caused by anti-c.