Dr. Pepper

I join the others in applauding what had to have been a very tough decision.

We have a separate refusal form. And thanks Terri for the clarification.

I thought the stranger in the background was just trying to remember where he left his glass! He did look a little perplexed.

We have a statement in our transfusion policies, OKed by the medical staff, stating that irradiated RBC can be used to fill an order for regular RBC for inventory control purposes. If you are concerned about billing, you can do as Mollyredone and get around the billing issue one way or another with your LIS, although with DRG patients it might be a moot point.

Terri, do you have the joint commission reference? Thanks! Phil

There is activity afoot in my hospital asking if nurses can obtain consent for transfusion. Does anyone know of any agency or regs that say it has to be a physician? Thanks - Phil

Mari, I'm guessing that the child is just coincidently a little late in developing the antibodies. They seem to be there, just not in a very high titer yet. The tech manual says "as early as age 3-6 months, with nearly all....at 1 year." She's within this range.

We use Meditech too, but the "significant or not" designation is internal and drives some QA aspects(warnings for allocating unscreened units, EXM eligibility etc) and does not get reported. I would bet that there's only a small fraction of physicians who actually understand what we do and are talking about; the rest trust us in varying degrees to take care of "that antibody business". Our pathologists trust us and don't review or comment.

"Wow, do you have your work cut out for you." And how. DKarrie's and Tricore's advice is spot-on. If I may add: 1. Keep caught up on your paperwork. Get on a daily, weekly, monthly schedule of review as applicable. I'm assuming the last 8 months worth of QC, proficiencies etc. have not been reviewed. Catch up on this as you can. Hopefully evrything that should have been done has been done, just not reviewed. If things have been missed, set up a schedule so that doesn't happen again. 2. Keep all your records organized in readily available files, notebooks etc. Nothing sets a bad tone with an inspector like unorganized or misplaced records. 3. I keep an inspection notebook with things like blood supplier agreement, nursing cont ed documentation, checklist crosswalks ("for standard ... see policy BB-...") and other miscellaneous items you will need at inspection time (and probably not much else!). Inspections are unannounced, so be prepared to be able to pass it even if you're not there. 4. For CAP, don't forget that BB also has to comply with the All Common Checklist as well as the Transfusion Medicine. If you do RPRs or rapid tests in your area you will have to comply with the pertinent areas of the Immunology checklist as well.Your lab might already have adequate lab general policies concerning continuing ed, proficiency testing, quality management etc that you can refer to or keep copies of so you don't have to reinvent the wheel. You will no doubt get more advice. This site is an invaluable resource, chock-full of smart, experienced, knowledgeable and helpful BBers. Welcome, and good luck.

Jesus did work for our lab for a while but then he got accepted into medical school.

We do as well.

Twenty-eight dittos to all of the above (if dittos are in policy and I have been trained in the use thereof and found to be competent). Needs to go through the exact same training/competency/signoff. The only possible variable in our training is time: obviously, a seasoned vet will need less training time than a new graduate.

After I posted the above, I was half tempted to go back and edit it to say what you just said, because I agree completely, I don't think it's really any different. I'm just passing on what the guy said (maybe because that's what they did in HIS lab), and that's why I asked if anyone had a black and white standard for this.

Are ditto marks then the "little marks of death"? (I like the line by the way, Terri). And, individual inspectorial preferences aside, it's a good question if there is a hard standard on the use of arrows/dittos or not. We did had this same issue on a pre-computerized form (crossmatch logbook - think writing the same guy's name etc 50 times during his ruptured AAA) and an inspector suggested using a sharpie to block off a box of entries on the form, and have procedure state that the one date, name, MR# or whatever was for all the data in the box. No one ever took issue with that afterwards.

Long, long ago, in an exam room far, far away, I took the exam on my own and managed to pass. I don't know what your particular circumstances are, but what was invaluable to me was a Red Cross center an hour away that had a SBB program. They let me attend all the weekly review sessions prior to the exam (I seem to remember a dozen or so) and it was a huge help. I sent the head of the program a pile of roses after I passed! Good luck Jane12 and Terri.

Despite both cells being R2R2, perhaps the screening cell donor still had a little more antigen on his/her cells than the panel cell donor. You wouldn't see the reverse situation because the screen would be negative and you wouldn't do a panel. Still, 2+ vs. nothing (the original post) is pretty impressive.

David, do you have a thought as to why a R2R2 cell would react with a screen but not a panel under what I would think would be identical circumstances? Phil

The answer to the question is "way too often"! I agree with Brenda that, all things being equal, the panel should show parallel reactivity with the screening cells unless the antibody was teetering on the edge of detectability. Also, you mention that the E-positive ficin cells reacted. What I didn't see was the rest of them did not react. Please forgive me if a full ficin panel was performed - but be careful about just taking selected cells and testing them with a different methodology. The reactivity you see may not necessarily be due to the antibody you're suspecting - something else could be popping up that was not observable with the first method. Phil

Beth, it's funny you say that. Of the 6 students in this year's class, he was the only one who gave me (and I assume the rest of his instructors) a nice thank you card at graduation. So I guess you're right.

I agree with R1R2 and Bill. Why use them on every unit you send up to be transfused? With what you'd save in a month or two you could buy a thermometer to take the temp of any unit that does happen to get returned. We only use them on units that go into coolers to the OR or off-site. And they are very touchy.

Same as Terri.

Thank you Pony, very good points. And it was basically a "how come" question anyway. I really don't have a problem interpreting mixed field typing results when there's a smattering of donor cells in there that you may only be able to see microscopically. I had a delayed rxn due to anti-Jka + E the beginning of the week that presented just like that. It can become a grey area, though, when you have no choice but to take that risk: the more blood they've received, if the antiserum you're using gives you a weak 2+ under the best of circumstances instead of a whopping 4+ , if you have no pretransfusion sample to test, if you really need immediate accurate typing results to try to unravel your ID puzzle, and/or genotyping may not be readily available.

amym1586, on 22 Jul 2014 - 5:19 PM, said: Is there a way to make a fake Lui Freeze ? I start off my students doing a mess of typings on random "just in case" tubes from the main lab about to be discarded - CBC and coag tubes. You don't need to do 40 typings to learn how but this also gives them good practice making suspensions, reading reactions, figuring out which end of the pipet to hold etc. Save the specimens. Next day, I tell them they will do one typing that will take all day. I show them on paper what they would have done to get to that point: O on front type, A or B on back type, couldn't get that "missing" back type cell to react with a cold back type. You should have plenty of O and A specimens, maybe a few B/AB. Make pools of each type and wash. To make your weak "patient sample", spike 2-3 ml of washed packed O cells with 10 drops of A or B cells. They also do the procedure on straight O and A (or cells. It works with either human source anti-A or -B (saved from the previous day's specs) as well as reagent monoclonals. I probably should spike the mock patient sample with fewer cells as you will probably adsorb out all the antibody, but they get the point and I want it to work. Other student stuff: A2 or A2B with anti-A1: spike a real A or AB serum with reagent anti-A1. O with weak anti-A+B: make a 12-tube serial dilution of O serum. Test each dil against A and B cells in the cold. Find the dil that gives you a w+ or 1+ in the cold. Make sure that dilution is not reacting at IS. Make up more of that dilution and give them O cells and that for their typing - the goal will be to get them to do a cold back type. Typing with unexpected abs in serum: Spike your serum with reagent anti-c etc or a patient ab that will react at IS. Review your panels often. If someone has an antibody, scrounge up the stored tubes, even coags, from other depts if they save them, then pool and freeze to torment future students down the line. Freeze some specs with nice rouleaux. Make DAT positive cells for eluates by adding reagent anti-D to Rh+ cells as others have suggested. Our QC reagent ab has anti-A, -B, -D, -c. After the kit ODs I use it to get a "panagglutinin" by sensitizing D+c+ cell, or auto-anti-c by sensitizing D- cells. Transfusion reactions: Add 1 drop check cells to 12 or more drops non-coated cells to give mixed-field agglutination. I teach PeG autoadsorption by starting them with a pseudo-patient with the above "panagglutinin" on cells and in serum. They then use some frozen samples with anti-K and a couple of old CBC tubes that I've typed and are K- for their patient serum/plasma and cells (there's no "autoantibody" in the sample now but they'll never know that). Take advantage of fresh real specs when you have them (known weak Ds or weak subgroups), and in particular freeze specs with cool stuff like and-Sda or RG/Ch that you can do urine or plasma neutralization with. I also take them to watch a unit being hung, show them our QA process, involve them in audits and whatever periodic QC comes due while they're in the dept.

Two things I'd like to be able to explain to my students: 1. Retic separation: I understand that patient retics have a lower specific gravity and will thus end up at the top of the column of cells. But there must be retics in the transfused donor cells as well. How come they don't end up mixed in there with the patient’s retics? Is it that they are several days older, and, if so, what does that do to them that makes them denser? 2. Lui freeze-thaw elution: I get how low pH and organic solvents will drive antibody off of cells. What is the mechanism, though, whereby freezing and thawing will do the same? I would think you'd end up with antibody still stuck on bits of red cell stroma. Inquiring minds want to know. Thanks - Phil

We did this because Peter Issitt (and others) told us to. He regretted it in the next Applied Blood Group Serology. In hindsight, it was undoubtedly a conspiracy masterminded by the manufacturers of anti-Lea, anti-P1, anti-M etc.