jeanne.wall

ElinF You have asked a question that is steeped in mystery and assumptions! AABB Standards do not prescribe a time transfusion to be initiated or for that matter when it must be completed. Folks have given you lots of good information, but I thought I’d just share a little history that might help you sort through all the information. The four hour time frame comes from concerns about bacterial growth in a unit held at room temperature. Since I was around “way back when” folks started to limit the time units of blood could be infused over (obviously I’ve been in blood banking a long time), I can tell you that folks “adopted” the four hour rule based on the outdate of room temperature products manufactured in an open system, which had (and has) a four hour outdate. I’ll add that back in the day, it was a HOT topic for sure. So this assumption about safety has become a fact of life that is now the current standard. There are some variations – folks that measure from removal from the refrigerator or cooler/ or from when the unit is spiked but four hours, however it is measured, has become the standard of care. I think it would be difficult to defend a decision to use a longer time frame, without a tremendous amount of documentation and proof. As for the “30 minute” rule, it is again an assumption that has become a gold standard – but this standard has been challenged to a certain degree. The 30 minute rule has been used for years (maybe even longer than the 4 hour rule, I think) for the length of time that a unit could be out of blood bank refrigerator and still returned for reissue. That rule has then been used to communicate to nursing that they must either start the transfusion or return the unit to the blood bank within 30 minutes. It has no real science, just a guess about how long it would take a unit of blood to reach 10oC. The magic 30 minutes to 10 degrees has been challenged and certainly AABB has been asking for some documented proof to demonstrate that the number is accurate for use to determine if a unit may be reissued. Most folks I’ve found have given up on the time a unit is out of the refrigerator and are using temperature to determine if a unit can be reissued (either measuring the temperature or using the temperature dots). I find it interesting that so many of our “golden rules” are based on best guesses or assumptions that have not been proven. I don’t by the way think that it bad, just interesting. Hope the background helps you find your way through all the information. Jeanne

Good idea Mabel but I have to admit I was a little taken aback by the apparent advertising in a couple of recent posts! I might have to comment on that too! But first and foremost, their support is important and I do appreciate that. Hope to see everyone Sunday noon. Jeanne

I'll be there Mabel - would really enjoy a chance to meet up with you and other folks. Should we pick a location and time, maybe lunch Sunday or Monday? We could find a spot in the exhibit hall after we pick up our lunchs and share a few minutes. Jeanne

I think this is a place to use some of the knowledge we’ve gained over the years. Definitely when you consider reagent red cells reactions, you need to understand the limitations – no one can assure the antigen status for every antigen that there could be on a red cell! We also know that antigens have different characteristics and behaviors – some stay on red cells better than others; some have a wide range of the number of antigen sites on the cell surface – really many, many different things can be going on. So, why do we do QC and what are we trying to demonstrate. On screening cells we do QC because these are the cells that in most laboratories get “abused”, often sitting unrefrigerated, on a counter for hours on end. QC serves the roll of showing that the cells are intact and behaving in an expected way. We want a positive reaction. It doesn’t tell us much, we are only testing with one or two antibodies, but it does show that the cells are able to behave in an expected way. Panel cells generally don’t face the same “abuse” as screening cells, only coming out of the refrigerator when they are needed. It is actually easier to know that the cells are working, you expect a positive reaction for some of the cells and you usually get the positive reactions that you then use to identify the specificity of the patient’s antibody. I think we understand the there are limitations with reagents and with our efforts to “QC” these particular reagents. So when you see something that doesn’t make sense, an unexpected positive reaction or a negative reaction where we thought it should be positive, we think about it, we investigate it, and we understand it. This thought process always includes “is there something going on with a cell – is it contaminated, has it lost an antigen, what is going on in this particular test tube. We can’t just think about the patient’s sample when we use red cell products, even though we spent money to buy them and have some expectations about them, every red cell used in a panel or as a screening cell came from an individual donor. Add to this mix, how they are manufactured and handled - just too many variables – that is why they have us around to have the knowledge to understand all of the potential things that can be happening. I think rather than worrying about how to QC these products, we need to worry more about how do we help the technologist with limited experience understand all the dimensions that we need to consider when we use these products.

Do you think we excel because root cause analysis isn't that different from scientific method?? :D

I actually have seen this (D negative at IAT, D control negative at IAT, in a patient with a weak positive DAT) happen once in my almost 40 years' experience. My theory was that the antibody coating the red cells actually eluted off during the incubation phase and in fact I could actually demonstrate the antibody in the supernatant of the tests collected prior to washing. I think it is a fluke, all stars aligned, the moon in the right phase, and I must have twitched my noise correctly as well, but it was reproducible. I will also accept Malcolm and the rest of you telling me I’m crazy – I couldn’t have seen it. If I were you, Labgirl, I wouldn’t include it in a chart like the one you are creating. Understanding when something really odd happens is part of the fun of Blood Banking and that is the fun of Blood Banking that those odd things do happen once in a lifetime. Our responsibility is to understand they do happen, but may not happen again and shouldn’t become part of every decision we make. Jeanne Wall, M.Ed., MT (ASCP) SBB

I think the value in event reporting comes when they are none punitive. According to statistics, if your root cause to an event comes back to staff more than 4-5% of the time you aren’t doing a good root cause. My favorite line is that people don’t get out of bed in the morning to come to work and do a bad job, events occur because we (management) have created a system that caused or allowed the event to occur. If you have someone that comes to work to do a bad job you have a performance issue and it should be dealt with there, not with the events that occurred to clue you into to the performance issue. Even when a bad employ has an event occur, it often highlights a system failure – the good employee has added their own “safety measures” to prevent the event while a poor employee follows your failed system and the event occurs. Use the information from events to improve your systems, use your performance review process to improve staff’s performance. Jeanne

It has been some years since I was in a transfusion service but a positive antibody screen, or even a history of an antibody in a patient with a negative antibody screen was a “call value”. We’d call the physician and have a discussion about blood need and availability. It really helped getting everyone on the same page. Sometime was did the compatibility test, other times we just found antigen negative units, and, on rare occasions, we did nothing because the physician had determined that the patient wouldn’t be requiring transfusion. Jeanne

Oh Donna - It has more to do with time out of class and doing what everyone else is doing, but if you aren’t seventeen you don’t get to donate, so access to the right ID gets you in the door and “old enough” to give! The interesting side line is that these kids often become regular donors down the road - donor centers love and hate those high school drives all at the same time. Jeanne

I agree Brenda - I remember once having three Moms to be all using the same insurance card at the same time! Have no idea what they thought they would do at delivery, since they were all due about the same time. But my stint in a donor center makes me think high school girls sharing IDs to donate blood is a close second. And as bad as those Moms were to figure out, putting an entire blood drive on hold to figure out the ABO discrepancy was so painful!

I think the biggest key is the documentation of the what you do and the why you are doing it. Capturing the assessment and your rational for why you did or didn't do centrifuge calibration, or temperature mapping or whatever is the key. I can disagree with your rational but I am unable to say you ignored something important and didn't bother to do the testing. I'd much rather have a discussion about why I believed my decision to be correct, than say oh I didn't think I needed to do this or that. When I moved a transfusion service, I did repeat everything on the centrifuges and cell washers except the centrifuge calibration - my rational was that the ability to form cell buttons was a function of rpms, timer, and the centrifuge head and since my other checks confirmed that the rpms stayed the same, there was no change to the timer function, and the centrifuge head was the appropriate (matched) one and it wasn't damaged, I felt I was "good to go."

Many of us are in the same boat but remember the FDA requirements are "minimum" requirements and it is perfectly acceptable to exceed them. As well because these are laws, they do not change often and reflect the knowledge and beliefs at the time they were created. They are not frequently updated because of the difficults in making those changes.

TheFDA has very few requirements for screening cells. The FDA requires that screening cells musthave a positive cell for D, C, c, E, e, K, k, Lea, Leb,Fya, Fyb, Jka, Jkb, P1, M, N, S, s and has no requirmentsaround homozygosity. Either 2 cell or 3 cell screening cells are licensedfor use in antibody detection, so that takes you back to defining thefacilities’ requirements – do you believe you need homozygous cells, likelydemonstration of a negative cell with screening results, do you want to do moretests per centrifuge head, or a thousand other reasons you might have to selectone over the other. I’dsay I’ve come across an equal number of passionate folks about the selection ofone over the other, and I’m not sure that either group is particularly right orwrong (although many in either group would disagree), then there is a smallergroup of folks who don’t think it matters that much and have determined thatthey would use a 2 cell or 3 cell screen based on some random factor – price,what was in place, what fits in their bench rack, ... I think the real decisionpoint is that you understand what the pros and cons are for your particularneeds and you understand the limitations of your choice – all the things thatmake you a good blood bank. Don't know if my ramblings helped but hope it at least gave you an opportunity to consider. Jeanne

Interesting - I had just been communicating with the FDA about RhIG and requirements of CLIA testing. It appears that they consider RhIG the same as a blood product based on the CLIA testing requirements. If the testing must meet CLIA requirements and is not considered waived, I'm not sure how RhIG can be treated solely as a drug. Of course, dealing with JCAHO is a horese of a different color but I think it at least needs to be considered. Jeanne

JohnJ. Moulds, MT(ASCP)SBB, diedof cancer on Monday, June 13. He was 67. Mr. Moulds was known for his work inimmunology, including during his tenure at LifeShare Blood Centers, inShreveport, La., where he had been director of Scientific Support Servicessince 2004. He recently received two major honors: in February, LifeSharededicated its new John J. Moulds Reference and Scientific Support Laboratoriesto recognize his lifetime achievements, and in March, the Institute forTransfusion Medicine gave him its 2011 Award for Excellence in TechnicalOperations (see ABC Newsletter, 3/18/11, 4/1/11). Mr. Moulds, who wasoriginally from South Dakota, earned his bachelor’s degree in biology andchemistry at Chadron State College, Neb., in 1965, the same year he completedthe Medical Technology program at St. John’s McNamara Hospital (now Rapid CityRegional Hospital) in Rapid City, S.D. He earned his SBB certification at theMinneapolis War Memorial Blood Bank in 1968. His first positions in serologyand immunohematology were at St. John’s; Chadron Community Hospital, in Chadron,Neb.; and the blood bank. He then worked for almost 20 years as a researcher atGamma Biologicals. By his retirement in 1997, he had become the company’s chiefscience officer and a senior vice president, and he was a member of its Boardof Directors. Mr. Moulds then spent two years on the research faculty of theDepartment of Medical Hematology at Baylor College of Medicine, in Dallas, andthen he moved to the East Coast to join the Immunohematology Assay Developmentand Research division of Ortho Clinical Diagnostics. In 2004, he and his wife,Joann, moved back to Texas, and Mr. Moulds joined LifeShare, just across thestate line in Louisiana. He expanded the blood center’s ImmunohematologyReference Laboratory by adding the Scientific Support Services and ClinicalImmunogenetics divisions, and by donating his personal collection of referencecells to LifeShare. His gift made the laboratory’s reference cell collectionone of the largest in the world. In an announcement, LifeShare President and CEOMargaret Wallace said, “We mourn the loss of our friend and colleague JohnMoulds. At the same time, we celebrate his life and the influence he had onthousands of lives – patients and medical professionals alike – all over theworld.” She added, “To say we will miss John is truly an understatement.However, every time we help another patient, or collaborate with another bloodbanker to help them resolve a complex issue, John will be with us, for we havethe honor and responsibility of carrying on his great legacy.” Memorialcontributions may be made to the John J. Moulds Reference and ScientificSupport Laboratories, Attn. Libby Murphy, LifeShare Blood Centers, 8910Lin-wood Ave., Shreveport, LA 71106. There was also a notice in the AABB newsletter on Friday.

I know it is difficult to find a successful wayto accomplish that when you have staff limitations but AABB BBTS standard5.1.3.1 (6) does apply, not to mention the FDA requirements on labeling as well. If you can find a way to use your computer system to confirm the labels,that is the easiest that the most straightforward to demonstrate as well. I've seen facilities that have used checklist to aid tech's or even nursing staff indoing a better second check of the labeling. Maybe some other folks have ideas that will help not only you but allthe other facilities that face this problem.

The retype practice is in place to confirmlabeling, so once the mother bag is retyped you know it was labeled appropriatelyand would not need to type aliquots. Ofcourse, you do need to include the second check by a second person in the labelingprocess for the aliquots – a commonly overlooked AABB requirement in my experience.

Another out of print book that offers some good basic informaiton is "Immunohematology for Nontechnologists" which was published by the AABB as a workshop book in 1983. I've gone back to it a number of times, when working with beginners. AABB is considering offering some books (such as the one I've listed) electronically. Probably not quick enough to help you but it may down the road. Jeanne

It is (9235-TC) Research and Progress (RAP) Session: Family Feud: Differences in Opinions on Tube, Gel, Glass Beads and Solid Phase Application on Sunday, October 10th, 6:00 PM - 7:30 PM

Here are a couple of references - conflicting of course Immunohematology Journal of Blood Group Serology and Education Volume 14, Number 4, 1998 Immunoprophylaxis using intravenous Rh immune globulin should be standard practice when selected D-negative patients are transfused with D-positive random donor platelets C.A. EWING,D.H. RUMSEY,A.F. LANGBERG,AND S.G. SANDLER Immunohematology Journal of Blood Group Serology and Education Volume 25, Number 1, 2009 D+ platelet transfusions in D– patients: cause for concern? A.N. Bartley, J.B. Carpenter, and M.P. Berg

I remember Clinical Microscopy class during my internship. The Pathologist was an older gentleman. He went through a careful explanation on how to instruct a patient on the collection of a semen analysis, in spite of the fact that it was the early 70s and everyone in the class was up to the task. He then went on to say that if we found a patient that did not understand our explanation, not to worry – he either truly didn’t understand or was trying to embarrass us. We could resolve either issue in the same way without being embarrassed. Simply explain how to collect the sample in the “language of the streets.†He then went on to demonstrate the needed street language for use because he was sure that at least the women in the class would not be familiar with such language. He was right – for the men that didn’t understand, they weren’t embarrassed by my explanation, understood exactly what I needed from them, and brought the specimen back, as instructed. For the men who were trying to embarrass me, they usually ended up being embarrassed themselves, but they brought me back the specimen I needed and I bet thought better of trying to embarrass someone else another time.

Sorry to add to the pressures of your day, but I couldn't help but state the obvious! Just remember, everyone has a book in them - some are just shorter than others.

Welcome - congratulations on your new opportunity! Glad to have you join our fun.

Malcom - Please consider writing a text book - you could impact so many new blood bankers and help those of us that have been around for a while as well. Thanks so much for the excellent description! Jeanne

Liz The technique has been around forever and I'd say a fair number of folks still have the procedure in their procedure manual. I think it has more to do with providing comfort to the pathologists and physicians. Those folks want to make sure you can say "compatible" to something. My approach would be to not bother with the "in vivo" crossmatch if I can say compatible to something. I use to just note compatible with absorbed plasma, or whatever. As you have seen from the comments most folks don't think the technique is going to offer much benefit, but if it is needed to assist in comfort levels because you can't use the word "compatible" with something, I'd use it and be done with it. Jeanne