John C. Staley

Same here. We don't routinely screen for C & E just because someone has an anti-D.

If work load, staffing or turn-around-time are issues IS crossmatches can be a big help without compromising safety. With your transient patient population the patient history is probably very limited. Is this where your technical supervisor is having problems? Another question I have: is IS crossmatches standard in other military hospitals or fairly uncommon? This might also help justify if other facilities have gone to IS. Bottom line is that it is standard throught much of the US and the world. Unless you can address the technical supervisors base concerns there may be little hope until they retire or move on.

Attached is our ABO Discrepancy SOP. Hope it helps. John TM0061v2s.doc

We have an SOP for this. I'll see if QA will release a copy I can attach. All of our SOPs are corporate SOPs and they are controlled fanatically and I don't readily have access to a e-copy I can attach. Look for it tomorrow.

I need to ask a question before I respond. By the term ABO discrepancy do you mean that the forward typing is not confirmed by the reverse typing or do you mean that the typing this time does not match previous history?

We don't mark the computer record as a copy. We do keep the original paper for the required time. I think when this standard was written no one gave much thought to the computer. It's not something I plan on spending much time worrying about.

I'm curious, what do you think we can do about it? Besides worry that is. Co-op and produce our own? Maybe, but in the regulatory enviroment we now live in, unlikely. The low business volume is what put the others out of business in the first place. I just hope we can keep what we have and don't get down to only 1. Apparently Olympus is trying on a very limited scale but I haven't seen much on the horrizon to indicate anyone else coming out especially with the advent of automation. Use a company's equipment you must use their reagents, why would anyone else want to get involved? If someone can see any silver linings to these clouds I sure hope they share them becasue I don't so I just try to pad my budget as best I can guess. Another thought for you is, reagents are the least of our expenses, have you looked at your blood bill lately!!

We transfused type O cells. The patient went home. It's been a couple of weeks and we've not seen them back. I "assume" the transfused cells are doing fine. No way for us to really know unless the patient comes bck for a top up earlier than expected.

Well gang it's not just Immucor rasing their prices. I just received my letter from Ortho informing me of their plan to "moderately increase pricing" as well. I must admit I'm not surprised. Actually would have been surprised if they had NOT increased their prices.

We just received an update from the reference lab. When they were doing the absorptions they used O cells. It turns out that one of the donors had a very high anti-A1 titer. Their theory is that the anti-A1 from this donor carried through all of the washing steps enough for it to show up when we performed a 45 minute albumin AHG technique. Seems like a stretch but I certainly don't have a better explanation

I've not heard anything but I have a meeting with my sales rep next week. Maybe I'll find out more then. What I'm really hoping to learn about is their new Echo (Galileo jr.). My ABS2000 is about worn out and I can't wait to get the new one.

We have a 67 yr old gentleman who types as A1 D positive. His diagnosis is pancytopenia and his medications are Glucophage and amaryl. He looks to have a warm autoantibody but the odd thing is, it appears to have A1 specificity. When crossmatching, the A units are incompatible and the O units are compatible (at least we can transfuse). His DAT is 3+ positive for both IgG and C3d. The reference lab says there are no alloantibodies hiding underneath the auto. They sent absorbed serum which was found to be incomaptible at AHG with type A units as well as A1 reagent cells but A2 cells were compatible. Anyone familiar with auto anti-A1?

Do you do either an auto control or DAT as part of your antibody ID. If so then you have addressed the package insert. A positive DAT will give you a false POSITIVE not a false negative. ( used the word false because I could not think of a better one but I do realize that it is not completely accurate. ;>)) As long as your antibody screen is negative, no worrys. I have never heard of a positive DAT masking an allo-antibody resulting in a negative antibody screen. Has anyone else? I would be surprised if you can find one other person who has interpreted the package insert in the same manner is has been at your facility. One other point. The old supervisor is just that, the old supervisor. You don't have to convince them of anything. It's the medical director you need to convince. When I arrived at my current position the "acting" supervisor stayed around for about a year and didn't like the changes I was making so she quit transfusion and became a night tech. The change that was the final straw was when I brought in automation. She couldn't accept it so she left.

I think we are dealing with different definitons of "validation" here. I fully agree that you should thoroughly review the package insert to see if there are any significant variations from the current SOP you are using. I don't consider that validation, I consider that common sense. What I take exception to is when there is no significant changes in SOP based on package insert information and still expecting people to test in duplicate, triplicate etc in large numbers with no obvious reason other than to say you validated. I validate when I am bringing a new test or procedure on-line that we have never done before and I don't know if we can make it work here or when we are changing from one technique to a completely different one. Example; if someone were to come out with a new elution technique/kit I certainly would perform an adequate amount of validation to confirm that it was as good or better than the current one we are using and that my staff could use it successfully.

David, I couldn't agree with you more. I waited to see if anyone else would make this statement and was glad to see you did. It never ceases to amaze me the lengths we seem to go because we fear not doing enough.

Morning Cathy, (I always visit my websites first thing in the morning before the day gets crazy). Our blood issue policy simply states that if the required patient identification is not available blood can not be released. If the situation is urgent then it indicates we follow the emergency release procedure for issuing uncrossmatched type O or type specific RBCs. We do not use a blood bank specific identification for patients. They wear one armband and it takes care of everything. It has two Unique Identifiers, Patient Name and Unit Record (UR#) number. The theory is that when the patient enters the systm they are assigned the UR# and it stays with them for ever. When requesting blood the nurse must provide both the patient's name and UR#, without those we go into emergency issue mode if needed.

Morning Cathy, Does your blood issue protocol address what to do in the event required patient identification is not available? If not it should. Based on the information you provided I, for one, certainly could not fault you for your actions. It sounds as if the transfusion was not delayed to any extent. If the nurse knew that the BB Band identification was required to issue crossmatched blood then they should have crawled under the bed in the first place. I know that things go crazy in ICUs but that is the most important time to follow protocols. I cringe everytime I hear an ER or ICU nurse screaming, "We don't have time to do it right!!" They certainly don't have time to do it twice or have to treat a hemolytic transfusion rxn along with everything else. Don't beat your self up over this. I think you did fine.

Despite all my heroic efforts we (our corporation) will continue performing wD testing on everyone. Sometimes reason and DATA do not prevail while inertia and fear of changes does. I probably should stop now before I get my self in more trouble.

It's the same thing with infection control. Ever see a Microbiologist/MT in hospital infection control? Nurses have the high profile. I'll bet that one of the top positions in your hospital is the CNO (chief nursing officer) or something similar. It should not be a surprise that nurses have a much taller ladder to climb.

We're just glad to have platelets most days. We don't hesitate to give an Rh pos plt pheresis to an Rh neg patient becasue that's probably all we have. On the other hand we always "suggest" to the physician of a woman of child bearing potential that they should consider ordering RhIG. Most do.

I'm feeling a little left out here. Our shifts overlap by a couple of hours and we just talk. Notes are made specific to patients in the computer for all to see. We aren't very large, maybe that's how we get away with it.

The only time we require a control during the wD test is if the result is positive. The control can be either repeating the wD test with control sera or do a DAT. As long as the wD test is negative no control is needed as indicated in the package insert from the anti-D reagents we use.

We just went through a JCAHO inspection and no one mentioned it but it would not surprise me if some one, some where dosen't come up with such a foolish idea. I'm lucky when I can keep pencils out of the department let alone regulate the color ink they are using.

We also give leukoreduced to everyone because it's easier to manage one inventory than two and trying to figure out who really needs it and who dosen't, as noted by Gloria's question, can really be a pain. Our blood supplier currently supplies every thing leukoreduced and will actually charge us more if we were to request non-leukoreduced RBCs. My suggestion for Gloria would be to go all leukoreduced if it is an option. Then you don't have to worry about who gets it and who dosen't.

Antenatal RhIG orders get an antibody screen. Post partum does not if we have a record of a negative screen at antenatal testing.