jayinsat

The same phenomenon is seen if you use a spun sample for DATs.
The cells at the top can be negative and the ones from the bottom positive if recently transfused.

Well, the transfusion history was an important piece of this puzzle. I see this all the time on the ECHO Lumena. When a patient has more donor cells (group O) than autologous cells, the ECHO will often give a ? because of the mixed field reaction. When looking at the images, it looks like a clear 3+ or stronger. Tube is usually 4+ with mixed field. I should have asked transfusion history from the beginning. 

My interpretation has always been that the alarm should sound at or before the set point. The set point should be low enough to allow time to move products if necessary. But we are CAP inspected, not AABB.

I strongly suspect that you've got your answer. Echo/Lumena probes are calibrated to go to a specific depth after level sensing at the top of the plasma of the specimen and I would think that is true for other analyzers as well. Another (opposite) problem that can happen is failure to pick up a red cell sample if the Hct is extremely low. With the 'extra' plasma in the tube because of the low Hct, the probe doesn't go deep enough after level sensing the specimen to reach the red cells.

Quite concerning indeed. Luckily the mistyping is from groupA to groupO....We did contact Grifols technical support and provided all the results and lot numbers. We haven't gotten an explanation yet from their end.

Was the patient recently transfused?  We had a situation several years ago where the patient sample results were one type on the Vision and another type in tube.  I learned that the instrument samples red cells from the bottom of the patient specimen which, after centrifugation, is where the majority of the more dense transfused cells are vs. the top of the red cell layer where the less dense autologous red cells are.   This cause for a forward typing discrepancy was confirmed after communications with Ortho.
The theory was confirmed with manual gel testing where red cells were sampled from the top, middle and bottom of the red cell layer of the patient's specimen. The top layer of red cells were Group O, the middle and bottom were primarily Group A.  This patient was discovered to be Group O after receiving several Group A RBC transfusions.  The reverse typing showed reactivity only with Group B red cells at that time.

I agree with Neil above. I would challenge that deficiency and not change my process. 

That is quite concerning. Have you found a resolution? You may want to contact technical support and refer this to them. There is a significant issue going on. They will probably want samples to see if they can reproduce it on their end.

Go to www.packmasq.com, or SALES@FLYMAX.COM. They have many different sizes and applications. The cooler is reusable and can be disinfected so they are acceptable to the OR. We bought the Max+Blood Shipper--Refrigerated storage (1-6C), SKU # R12MB (5). It can hold up to 8 PRBCs  at 6C for 24 hours. We use this and a smaller (4 unit) Igloo cooler with ice blocks and refrigerated gell packs for our OR needs.

We've got a demo of the MaxQ on the way.  I'm kind of excited. 
I hate our cooler system now.

We switched f/ an in-house created/validated Igloo system to MaxQ.  We love them!  They are plastic, so we can decontaminate after each use.  When we did our validation, we maintained temp for > 24 hours in rooms @ 22, 65 (heart room), & 85 (trauma room) degrees.  The lid is hinged, so it swings closed if someone forgets.  We use a saline bag connected to a digital thermometer that sits in a pouch on the lid.  This allows someone to constantly see the internal temp.  We issue up to 6 PRBC/cooler, but it would probably hold more.  I do think that they mentioned an upcoming upgrade w/ remote temp monitoring, so you might wait for that... I attached a Word doc that we used for PCS education.  It shows pics of how the units are packed.

New Blood Coolers.docx

We just got some from MaxQ.  They are corrugated plastic and we validated them for 12 hours.  They have a handle on both sides for easier carrying and the ORs love them.  They are bright yellow so they (hopefully) will not get left behind in the OR or discarded as trash.

Hi all,
We had recently an ABO discrepancy on one of our patients (front typing  groupO; back typing  groupA) using the automated gel instrument Erytra (Grifols). When testing was done by tube method and manual gel (same manufacturer of gel cards and antisera reagents), the patient typed as straightforward group A (anti-A reacted strongly 4+ by both tube and manual gel methods). The same results were obtained again with a different sample collected from the patient. Testing on Erytra was repeated for first and second sample, again same results.  it goes without saying, all the daily QC of the gel cards on the instrument were fine and we had other patients that were typed corrected as groupA, except for the discrepant sample. The patient does not seem to have a subgroup of A (at least based on the results of tube and manual gel methods). I wonder if anyone else has had similar ABO discrepancies by gel. Thank you in advance.

Well - just to follow up - we approached our Laboratory Compliance team to see what they knew and their response was. "we don't remember, but it was a "BIG DEAL".  We then discussed with the Pathology Medical Director (he was the director when this happened) and he had some insight and suggested contacting the hospital's CLIA person (who was the same person who mad this "decision")
Our Path. Med. Dir. emailed them and - lo and behold - they were perfectly fine with it.......    Needless to say, that email has been sent to compliance and is now added as an attachment in our QP manual so no one can dispute what we all think is correct!
Thanks for letting us know that we weren't crazy in our thought process!
 

I agree with Neil above. I would challenge that deficiency and not change my process. 

We are a large blood bank in an academic medical center.  Our blood bank does just about everything in the lines of testing with exception of testing related to donors (we don't collect donors).  That being said - we get quite a few CAP proficiency testing surveys.  YEARS ago (>10) the individual samples in the PT Kits would get divided up amongst the staff where each "sample" was tested by a different tech.  In comes CLIA for an inspection of the entire Clin. Path department and they say that ONE individual must perform ALL the testing associated with the kit.  Meaning if the kit comes with 5 samples, one tech must complete ALL the testing on ALL 5 samples.  We are now under new management and are curious if other Blood Banks have experienced the same thing?  Our AABB inspector told us we were asking for trouble, and also eluded to the fact that we could get cited by CAP for doing it the way CLIA says we have to......  We have yet to find another lab that follows these CLIA "rules".
Just searching for a little "clarification"

Interesting.  I've never read anything on that and couldn't find a reference to it either.  I've always divided my samples up so I can also use them for annual competency for the techs.
Here's the CLIA/FDA piece: https://www.ecfr.gov/current/title-42/chapter-IV/subchapter-G/part-493/subpart-H
And from the CLIA PT booklet it says: https://www.cms.gov/Regulations-and-Guidance/Legislation/CLIA/downloads/cliabrochure8.pdf

I'd go up the food chain ladder and consult with this inspector's supervisor. 
Clearly if the lab receives five samples, giving them all to one technologist does not in any way mirror clinical practice, and thus violates the regulations. Thus my initial take on this is that is another extremely bad idea from an inspector who has no idea what they are doing. Sort of the old joke about some physicians:  "Occasionally wrong, but never in doubt."

Has anyone seen a specimen where the red cells were above the plasma after it was centrifuged?  The patient was in cath lab and then went for a CABG.  I asked our Pharmacy intern to research what meds he got that were more dense than red cells and they said, "the only two agents that are denser than RBCs on the patient's MAR are Calcium chloride (100 mg/mL) and Isovue".  The Isovue contrast material is not charted for before the specimen was drawn but later during the CABG.  I suspect that is the culprit. His Hct here looks to be about 25% but the redrawn specimen had a Hct of about 45 so I think there was very dense IV fluid in this specimen.   Does anyone have similar experience?  BTW, this plasma created very junky reactions in gel and interfered with the tube reverse type.
  

I would argue that the DCLS program is probably your best route. Here in Texas, UTHSCSA (University of Texas Health Science Center San Antonio) has a PhD Clinical Laboratory Sciences program but it is residential only. The tricky part to any of these programs is how they will fit into clinical laboratory practice. It is unlikely that hospitals will want to pay laboratory experts to consult with physicians on appropriate lab orders, which is the main described goal of the DCLS program. However, perhaps both the DCLS and PhD CLS candidate could fill the role of Medical Director for a clinical laboratory? That is another goal of these programs. DCLS, like MD, is a practical doctorate. An argument could be made that either of these professional degrees could qualify the individual for the Medical Director role.
Just a few thoughts of mine. I am finishing up my PhD dissertation in Biblical Studies. I have been contemplating doing the DCLS or PhD CLS afterward. I love both lab and ministry. 

Thank you Jayinsat. This was very helpful and I wish you the best of luck with your PhD dissertation.
I hope we can see in the near future a more substantial change in the scope of practice of DCLS or PhD CLS graduates in the clinical laboratory. But I'm sure the path won't be without resistance as pathologist's interest will be at stake.

We have an active pre-hospital emergency service with both ground and air transport that carry blood products. If the patient doesn't come to a facility within our system, we don't have a specimen or even a system-generated ID, so the blood is issued in our LIS with a comment describing what happened in case of collection facility lookback.
An alternate scenario is where the patient expires prior to specimen collection - if you don't have the specimen, you can't test it and we document that the units were issued emergency release and cancel the system generated crossmatch with a comment that no specimen was received.

First, blood given pre-hospital is quite routine these days. Both ambulances and helicopters are carrying Low Titer O Positive whole blood that they transfuse on scene in response to traumas and hemorrhagic shock. In South Texas, the ambulances and helicopters receive their blood directly from our blood supplier. Who will be stocking your helicopter? Will it be your facility? If so, you have a lot of work to do. If your supplier, you have nothing to fear.
Second, when a unit is given pre-hospital, our EMS techs give the empty blood bag and a record of transfusion to the receiving nurse in the Emergency room, who then sends them to the blood bank (theoretically, practically we seldom get them right away). Our emergency room physician orders a type and screen upon arrival. Only if an antibody is detected (or we have a history of a clinically significant antibody) will we perform any crossmatching with the unit. 
I would suggest you google the topic Low Titer Whole Blood. It will help you answer your question.

I would argue that the DCLS program is probably your best route. Here in Texas, UTHSCSA (University of Texas Health Science Center San Antonio) has a PhD Clinical Laboratory Sciences program but it is residential only. The tricky part to any of these programs is how they will fit into clinical laboratory practice. It is unlikely that hospitals will want to pay laboratory experts to consult with physicians on appropriate lab orders, which is the main described goal of the DCLS program. However, perhaps both the DCLS and PhD CLS candidate could fill the role of Medical Director for a clinical laboratory? That is another goal of these programs. DCLS, like MD, is a practical doctorate. An argument could be made that either of these professional degrees could qualify the individual for the Medical Director role.
Just a few thoughts of mine. I am finishing up my PhD dissertation in Biblical Studies. I have been contemplating doing the DCLS or PhD CLS afterward. I love both lab and ministry. 

Cerner allows us to extend the date of the Preassess sample. If no pregnancy or transfusions, and a prior history or second sample drawn for confirmation of ABO/Rh, sample good for 4 days with OR day being day one. Not to surpass 30 days sample date. EXM still applies when sample date is extended.