Sandy L

Similar to Itelchin, we have devised an Excel spreadsheet for Competency. We list the 6 CLIA elements across the top and the first column lists each reportable test. Some are listed multiple times, one for each platform such as Antibody screen Automated, Manual Gel, Manual Tube. Section 2 lists other tasks that are not reportable test such as thawing plasma, issuing blood, etc. For these we list 2 or 3 of the 6 elements that we will use for assessment of that task. It's a work in progress and we are using just a part of it this year and plan to have it fully implemented by Jan 1, 2014. The real challenge is how to accomplish the direct observation for every Clinical Lab Scientist on every shift for every test/platform. How to perform direct observation for Eluate preparation and testing when our night shift CLS's may only do two or three a year? We will probably need to combine Direct Observation of those infrequent tests with unknown testing. Still this will be our biggest challenge.

For obstetric and neonates: We call neonatal DAT if Positive greater than 1+. We call Cord Blood ABO/Rh if mother is Rh Neg and infant is Rh Pos to notify they need to order RhoGam workup on mom. If Antibody Screen is performed, we call positive antibody screen results. Other than that we do not call.

Virtually all results are recorded directly into the LIS. I would view double recording as an extra opportunity to make a clerical error. We do have downtime worksheets so that results can be recorded on paper during computer downtime. Some tech who are less comfortable with antigen typing will use the worksheet to record antigen results on paper and enter into the computer. That's about the only time we see double recording of results. Most will record antigen results directly into the LIS. We do also have an Antibody ID worksheet and a few things are recorded there, additional investigational studies, ABO typing discrepancy workup. Another exception is that antibody panel results are recorded on paper on the panel manufacturer's antigram. These are not double recorded (paper only) as we only enter the interp in the computer.

Years ago we always repeated the antigen typings performed by our blood supplier reference lab. After years of doing that and no discrepancies we decided not to repeat the typings and that was probably 10 years ago. In this day and age of billing compliance, I'm not sure if it would be correct to bill for repeat testing.

I would totally agree with albaugh who described how Cerner can be customized to your needs and then said “Maybe if you approach it from a patient safety standpoint, you could get them to fix some of these easily fixable issues.” You should not be forced to work with such a poorly constructed LIS system. It truly is a patient safety issue. I would recommend that you document it as such and then get your Medical Director involved when you present your argument to your “Corporate” folks.

We proceed as Mabel. We will not report the result on a transfused sample, but will evaluate # of units transfused and how recently. It will sometimes help unraveling multiple antibody specificities. We will just add a comment in the BB record that patient is "probable xyz neg or pos" and that the patient needs antigen typing on an untransfused specimen. This morning we had a patient who received 2 RBC's in another hosptial exactly 2 months ago (antibody screen negative at that time). Today patient has anti-c plus anti-E plus something else. We were eventually able to eliminate other clinically significant antibodies and found that all of the extra reactions were cells marked as Bg positive by Ortho. Patient is currently DAT negative. As with Mabel's patient, c and E typings were totally negative. Other antigen types were either cleanly negative or strongly positive with no mixed field reactivity. I do not believe the patient has any surviving donor cells, however we will wait 3 months post any RBC transfusions before we officially antigen type.

Because our supplier has tested the apheresis platelets already and the platelet aliquot has a 4 hour expiration once prepared, we do not test the aliquot. I do not know of any requirement to do so.

rravkin, We do the same as you for RBC's, dedicating one unit of RBC's for one infant and use for its shelf life. For platelets we do not dedicate for one infant. We do stock one AB plateletpheresis at all times for infant use. Our supplier collects only apheresis platelets, so basically our AB platelet which we get as fresh as possible from our supplier is dedicated for infant only use. We sterile dock satellite bags whenever we get an infant platelet order. The remainder is available for infant use only for any neonate that needs platelets in the next few days until the unit outdates. So if the same infant needs another platelet transfusion before unit outdates, they will automatically receive an aliquot from the same unit. On the day that the platelet outdates, if it has not been used for infants, it goes into adult stock. We have a large NICU and we frequently have multiple babies that require platelets or one baby needing more than one platelet transfusion during the dating period on one platelet unit.

Richard I would like to know if anyone actually scans the bar code on the new Typenex. What device you use to do this and does this bar code have a matching in you blood bank computer system? Richard

A platletpheresis unit must contain a minimum of 3.0 x 10^11, so I think you would need to be concerned about the residual platelet yield after you removed a portion. At the very least it seems like there should be some QC of the remaining product to be sure that it still meets the criteria. True, many units would contain considerably more than the minimum and might pass, but some may be close to that minimum and would fail after removing a portion. At our facility, we do ocassionally remove small aliquots from apheresis platelets for neonatal transfusions. We do not use the remainder for adult transfusions. For this reason and the reasons listed above I would not recommend this practice.

Our history check procedure requires a search by name if performed for a sample to be used for compatibtility testing. We review all patients with matching name and MRN to identify patients with duplicate registration. We also look for a DOB that is "close", possibly one was a typographical error. We see patients with duplicate registrations frequently and sometimes the other registration has clinically significant anitbodies, important comments or transfusion requirements.

We treat them using the same rules as policies and procedures, keep them for 5 years when superceded.

We went live with one instrument in 2005 and added the 2nd in 2011. Our workload had increased substantially between '05 and 2011. We were constantly emergency stopping to add samples as soon as the previous batch had finished pipetting. With only one instrument we were forced to do quite a bit of our STAT workload manually. We still do emergency stop and add samples but are able to accomodate most of our STAT as well as routine workload on the instruments. We are looking forward to the replacement for ProVue.

1. Community Hospital 500+ beds with active trauma, transplant, large OB service, 800 deliveries/month plus 75 bed NICU. We transfuse ~1000 RBC/month. We perform 1800 ABO/Rh, 1000 Antibody screens, 1400 Electonic Crossmatches, 200 serologic extended crossmatches per month. 2. Stat TAT is published at 60 minutes. 3. Receipt to verify. Blood Bank spins samples upon receipt 4. Primary method: ProVue (2 insturments). Backup manual tube ABO/Rh and Gel ABSC. We try to do as much testing as possible on ProVue but even with 2 instruments, they get backed up with routine testing and slow down the STAT’s. 5. TAT is very difficult to monitor in our LIS. We cannot monitor for Corssmatch as samples stay “open” for 3 days (pre-op up to 10 days). The best we can do is monitor STAT antibody screen as a marker for the Type and Screen TAT, and even that is very difficult to do without a lot of manual data mining. We do not regularly monitor, but we know we miss our 60 minute TAT due to the issues mentioned in #4.

We do ABO/Rh and DAT if the Mom is Rh Neg. If Mom is group O Rh Pos we do ABO only on the cord. When resulted the Cord ABO will reflex order a DAT if the result is other than O (even though the DAT has a low predictive value). Any other mom blood type, we do no testing.

We have always used a separate BB Armband (Typenex bar code BB Band). We will be implementing a bedside barcode ID scanning system to print specimen labels at the bedside within the next year; however we are not planning to give up our BB armband when it is implemented, at least not in the foreseeable future. We use the one band/visit method and require BB Band for all blood products. Outpatients/pre-op patients are required to keep the band on until they return or will have to be redrawn and retested if they don’t. Sharp HealthCare (6 hospital system), San Diego area, California.

We use Digitrax (Hematrax interface to Cerner Millennium) to print our ISBT labels when we modify. The labels we purchase from Digitrax are perforated along the 4 quadrants. We print full face 4X4 inch labels for all modifications. The labels are easily separated along the perforation lines (and we like them a lot). If we are changing the product E code and expiration, we use the bottom 2 quadrants only to label. The rule is NEVER cover up the DIN and ABO/Rh when just changing product and expiration. We would not want to print only the bottom 2 quadrants in this situation. We might be modifying multiple units at the same time (e.g. 4 units of thawed plasma) and they might have different E codes and volumes. You need to have the DIN number to match the correct thawed plasma label to the correct unit, and then tear off the bottom 2 quadrants and label. If preparing a product in a new container (syringe aliquot or pooled product) then the full face label is used. Products must go through a Label Verify application following labeling.

We have Cerner Millennium Blood Bank and have a custom “Unit Tag”. With Cerner Classic we printed a Transfusion Record (8.5 X 11 inch) that had a peel-off label that went on the unit and also all of the patient and product compatibility info printed on the Transfusion Record as well. The down side of the old system is that it had to be printed on a dot matrix printer that had frequent jamming issues. When we moved to Cerner Millennium in 2011 we decided that we could achieve the same thing by printing (Zebra style laser label printer) onto a label. The label prints multiple copies so that one copy affixes to the transfusion label and one copy affixes to the unit. The standard label stock we use is not an “FDA-approved” label adhesive, so it goes onto a tie tag that is affixed to the unit with plastic cable tie fasteners. Cerner has a “standard” compatibility tag that is not very desirable. Most Cerner users go the custom route. We had our custom “tag” (label) designed for us by Cerner.

Oh sorry, I was suggesting Laurie contact him.

I have also heard this described, either by John Judd or George Garratty, pehaps both. They were aware of multiple cases where the patient apparently had an antibody in the Rh system (e.g. anti-c, anti-C, etc) and the patient was negative for the corresponding antigen. The patient experienced repeated hemolytic transfusion reactions until it was determined that Rh phenotypically matched RBC's survived just fine. The antibodies could not be demostrated by any standard technique, but I believe they were able to detect the antibody by special techniques (MMA, antiglobulin consumption assay? ... not sure what?). You might want to contact George Garratty.

We dropped antibody screens on post natal samples for RhIg workup many years ago. All OB patient's get ABO/Rh on admission. Infant's of Rh neg mothers get ABO/Rh and DAT. Any time the infant is DAT pos and ABO compatible with mother or anytime DAT is greater than than expected for ABO incompatibility (greater than 2+) we would perform antibody screen on mother.

We require a blood type on every obstetric patient on admission. We see discrepancies with transcribed prenatal results with some frequency and would never rely on outside results.

I believe it was Cliff or someone form this site reaching out in an email, and yes it was "back in the day" when it was Donor Limits.

I agree with Scott, we require ABO/Rh on each admission, and yes we do occassionally see patients using someone else's insurance ID.

We also test unwashed cord blood samples on ProVue with no problems.