Dr. Pepper

I have not looked at a CAP checklist since last summer (and may never do it again as Ibegone2016 at the end of the month), but it sounds like an overzealous inspector transposing his opinions into the CAP standards. Happens a lot. Follow Goodchild's advice.

I'm interpreting the <3 days to mean your specimen is still within the usability window but a day or two down the road from the original type and screen. We have never had a billing issue with inpatients, I think mainly because they're DRGs and no one pays on a per item basis anyway. I think the biggest issue might be getting the charges for the blood posted on the correct patient account. If your specimen was from, say, an outpatient preop PAT and then they get admitted (could be > 3 days), or an outpatient draw for an outpatient transfusion the next day, the blood charges unfortunately will follow the original specimen and get posted on the wrong day of service and the wrong patient account. We used to do the crossmatches on paper ahead of time in these situations, then put them in the LIS on the day of service when the new account was created, a awkward system just asking for a secretarial error to happen. Now we can do them on the original type and screen and Fiscal happily (I guess, it was their idea) transfers the charges to the proper account behind the scenes. Keep in mind you don't have to tack the units/crossmatches onto a type and screen; they can be ordered on another specimen just by themselves. We create a new specimen on the desired account and date and order the units, along with a nonreportable informational test "SPEC USED" so we can record the old specimen we actually used for the crossmatches. Our Meditech trainer told most customers do it like that. I would not want to do another type and screen if there was a valid specimen that was still within your time limits. Extra work, expense, and a stick to the patient. I also agree with Scott - get everyone on the same page with a system that works for you and your fiscal dept. Trust me, the third party payers will let them know if something is amiss with your blood charges.

One of the more useless of CAP surveys, since you know perfectly well what should happen if you try to give an unscreened A Pos to an O Pos with anti-E, particularly since you probably did the hundred pages of validation for your system. (I know, you still have to check and do the survey, but.........) We have 2 hospitals and use the mock patients in our test area in the LIS. Each site has different product mnemonics so there's no confusion (or peeking). So what you could do is: Use different names/mnemonics for the products (1st or second donations) for each site. Use different numbers as suggested above. You are not testing your system's ability to read a bar code, but rather its ability to prevent the issue of an inappropriate unit of blood. If you can't do that, have different fake patients and take turns using the same units. Release the units and let the next facility have at them. Don't peek at the other guys results. Why would you even be tempted to, when, unlike other CAP surveys, you know what the answers to this one should be!

Ditto to Malcolm's comment. I don't think you have much to worry about. And remember the worst that can happen is that the CAP/AABB representative will find something, you correct it, your process gets improved, and life goes on. Also keep in mind that if you disagree with the ding from the inspector, you can always appeal it. You win, you win. You lose, you're back to "And remember...". Good luck. I am in my AABB window myself. My window closes 3/31 and I'm retiring 4/1 - something tells me I could have timed this a little better! Phil

StephenB, please forgive me if I was unclear in my post , (although I can't seem to find anywhere in it where I advocated using the prewarm technique wantonly to eliminate "stray" reactions), as well as for taking the careless but convenient path of using "stray" instead of "occasional weak reactions whose pattern of reactivity does not suggest an apparent specificity". I agree wholeheartedly with everything you say regarding the potential pitfalls of prewarmed testing. (I am the slightly off-key bass in the back of the choir singing "Please don't prewarm that anti-E awayyyyyyyyy...........")

StephenB, since the inherent danger of a prewarmed technique is that you could miss a weak significant antibody, if you still get a positive reaction, then you haven't missed anything. I was just offering a laundry list of tools that might help you figure out why you have a cell or two reacting weakly with no discernible pattern.

Glad I took it the same year as David (1986). Good luck! I guess I'm somewhat comforted that a fish, thought to be extinct for millennia, was actually plentiful enough to tin up. Hopefully, that is still the case 41 years after Patricia and Phyllis pointed them in line to the anti-B factory.

If we get a stray reaction with, say, a Bga positive cell that doesn't seem to be due to anything else, we will try to find another cell or two listed by the manufacturer as Bga-positive, and if they react report the antibody as anti-Bga as we would with any other antibody identified. We also have a "probable HLA antibody" as a reportable choice. In which case we would look for one or two stray reactions, usually weak, that again don't add up to anything else, eliminate all other choices by standard techniques, no significant difference in reactivity with LISS and PeG, doesn't prewarm away, and hopefully a good titer (although they don't have to be high titered).

I had told this story years ago but it might be worth a revisit. We had a Bombay patient who was a frequent flier for decades. She was the propositus in Levine's seminal study back in 1955. After he had pretty much figured out how the blood bank universe operated by studying her and her family, he made the tactical error of telling her that her blood was so precious that people should pay her whenever they took it. So she gave everyone grief for the morning CBC. You could forget about autologous donation. Eventually she realized that if she needed blood, there were not a lot of options, and started to donate her own. She was not a great autologous donor, running a 9 and change hemoglobin and having bad veins. The above posts mention looking at these patients' siblings; if one looks at our patient's pedigree (in a lot of BB texts) you'll see she had twin sisters who were also Oh. They never seemed to be available to donate, though. Whenever she needed surgery, no one seemed to inform her surgeons about the potential transfusion difficulties. So it always fell on us. One time a surgeon told me, "OK, no problem, we'll be extra special careful" which I found very disturbing. Shouldn't that be the standard of care for everyone? Would you do a crappy, careless job on me because I'm a run of the mill O Pos? Good luck with you all with these patients!

Terri no doubt has an elegant solution involving packing foam, but have you called Helmer? Their tech support is very good. I'm not aware that the scribes can be adjusted but you never know...Short of that, you could replace the scribe, readjust it every morning (you're probably looking at it daily anyway), or learn to live with it. An hour is not much of a space on that little disc; I'm happy if my techs just get the right day of the week and AM or PM. The purpose, beyond satisfying AABB and CAP, is redundancy to your alarm system to see if your blood got cooked while no one was looking, and to see if an unfamiliar tracing might indicate a potential problem down the road. The batteries, by the way, are only for backup with a power loss and shouldn't have anything to do with normal operation.

You win. Great idea.

We've had the same tray for decades! You seem to have lost the frame that holds the tray. But I bet if you propped up the front of your tray somehow (stick-on rubber pads maybe - your clinical engineering dept would probably have something) so that the vials were leaning back slightly on their friends behind them, they wouldn't tip over so easily. Or leave them in the 10 pack sleeves that they get shipped in. I liked the idea, though, of a couple of pounds of mercury holding them in place!

I'm not aware of any regulation, but I suspect this idea might come from trying to satisfy the old 3 positive/3 negative statistical application of Fisher's method to get your magic p value of a 1/20 chance that your conclusion is incorrect. I read (or heard) long ago that since our reagent A1 cells and A2 cells are pools from at least three donors, they (in a Mickey Mouse sort of way) meet this.

I was never a fan of "Nonspecific". Antibodies have specificities; sometimes we're just not clever enough to figure out what they are. We use unidentified.

And sometimes it's great fun to "poke the bear!" I think two points are worth repeating: we happily use antibody screening cells positive for both the K and k antigens all the time and don't worry about missing the rare, weak anti-K that might only react with a hom....ahem, an antigen whose controlling gene is in a homozygous dose. Second, I don't know about your luck, but I buy a 16 and an 11-cell panel and it's quite rare to get a K+k- cell. I wouldn't worry about it.

Since you wash the cells several times anyway before use, it seems logical that any anticoagulant is washed away (or at least mammothly diluted). We have this issue more frequently finding enough cells for an eluate, or an eluate and autoadsorption. For both procedures I have successfully used citrated cells and cells from lithium heparin chem tubes if you can fight your way through the gel. (Speaking of lithium heparin, if a patient has a juicy antibody, I collect all the lithium heparin chem tubes and EDTA heme tubes I can to pool and freeze to torment future generations of students. If validated, does anyone know a reason why lithium heparin plasma cannot be used for, say, a panel if your serum or EDTA plasma is in short supply? Seems to work fine for the students.)

Your are correct that for a variety of reasons it's advantageous and sound practice to know what the timeline is surrounding the transfusion: time specimen drawn, time received in lab, time pretransfusion testing was completed, time issued, time transfusion started, time completed. Issue time is captured in our LIS like Tricore. We also record it on the crossmatch form that accompanies the unit, a carryover from the old days when that time started the countdown for the now discredited 30 minute rule. Again echoing Tricor - if you don't issue in the computer, don't you have some sort of paper log on which to record the time/date/inspection results/tech/who or where the unit is going? If you are issuing in the computer, isn't that captured there? Precomputer we had 4-copy crossmatch forms on which we recorded patient and unit info and, when issued, issue data. First copy was the permanent record of the transfusion for the chart - it was full size and had room for the nurses to record pretransfusion check and transfusion data. The other copies were 1/3 size. Second copy was the bag tag. Third copy we saved and transferred the issue data to our permanent crossmatch log. Fourth copy went to billing with the appropriate charges checked off. I did not see a specific CAP requirement to record the time issued. Phil

Welcome to this wonderful site Urvershi. Phil

Malcolm, that is indeed remarkable, if not more than a little masochistic. A few years ago I read about a case where a woman went in for a routine C section and to their great surprise, the baby was not in the uterus. It apparently had been an ectopic pregnancy and the placenta attached to the small intestine. The baby spent nine happy months in the peritoneum with no complications. It was observed that, since a womb was apparently not a necessity, with the proper hormones a man could indeed carry a baby himself (although a natural delivery might prove difficult). That being said, I'm still with Anna on this one.

I can, Anna, that would be me having one at my age. I think I would get negative feedback from my wife......

Wholeheartedly agreed! Here's what I posted on a similar thread earlier this year: "For decades we hired only MTs, but have had to hire a few MLTs over the last couple of years due to MT shortages. I find the quality of work varies not from the number of college courses they took but the innate ability, initiative and interest of the worker. We train equally and job responsibilities are equal (although the MTLs cannot do some things, like review results etc). I had a MLT generalist on last weekend. He had a patient who got 4 units of blood the week before who now presented with anti-c and a positive DAT, weak mixed field. Pretty classic delayed reaction, except that the eluate reacted with all the panel cells. DAT was negative the week before. He dug into it and tested some more c-negative cells and found that there was also anti-Fya and -Jkb in the eluate (but not in the plasma yet). En route he tested the eluate with ficin-treated cells and PeG and ficin-treated some additional ones himself to help untangle the specificities. I did give him some phone coaching along the way, but it was an excellent job of blood banking. "Just" a MLT, but he really digs BB."

There's the key right there. The easy things to do are the ones you have total control over. The difficult ones are when they involve other areas.....

They drew the line at me making nametags for their foreheads.

Yes Amy. If they receive any amount of a unit the charge goes through. Keep in mind that hardly anyone pays out of their pocket for anything anyway. Phil

Our old Jewett refrig came with these mounting strips on the shelves in which you could insert a paper label "Unprocessed" etc. The strips were held on by an adhesive which gave up the ghost after a decade or so. Now I have labels from a Dymo label printer (they have very cool ones which work from your PC - my favorite lab toy) that I stick directly on the ends of the shelves. If you remove the shelf and let it warm up and/or wipe any moisture off and quickly apply your label they stick pretty well. Mine have been on for a couple of years and still are in good shape. The labels peel off pretty easily too.