SMILLER

On one hand, this seems to be a valid point. On the other hand, no QC material, serum or cells, can be said to be "geniune". If I am not mistaken, they all have been manipulated and contain adulterants to extend shelf life. On the third hand, we also use a 10ul QC serum to 8 drops 22% albumin to get a 2+ to 3+ reaction with our 0.8% screening cells in gel. The screening cells insert only says to test each day of use with "weak antibodies"--it doesn't specify how to get them. I am thinking the main point is to prove that you can pick up a weaker reaction with the gel/QC cells--not too knock oneself out trying to replicate what happens with a live patient. We have had several inspections since switching to gel--no-one has questioned this technique for QC. On the fourth hand... oh, forget it, I'm already out of hands! Scott

When we use diluent for a neg control, we are using the gel screening cells with them, just like we use the screening cells with our corQC plasma for a positive control. Unless you check the screening cells with something that is going to give a negative reaction, it does not seem like you are QCing the screening cells properly. Scott

I think I also read somewhere that people with red-green deficiency can see through camoflage better. So there may be some evolutionary advantage I suppose. Scott

We are using Ortho gel cards with the same QC material that we had used before switching from tube (which is Immucor corQC). As suggested by Ortho during our gel training, we use the MTS diluent as a negative control, and dilute the QC serum 1:8 with albumin to give us 2+ to 3+ positive results with gel. Scott

Interesting question! To exclude you would have to document incompetency, and to do that, you have to show how you document competency in the first place! True color blindness is really rare if I am not mistaken. A few years ago, one of our managers was instructed to document color competency based on a reading of some regulation--maybe the same one you cited. There are a few color-blindness tests on the internet you can google for. She had all of us take the test and document our scores. The results were that several of us (including me - I already knew) were found to have red-green "color blindness", which is relatively common, especially in males. We see red and green, but the tone is different from what others see. But anyway, she ended up documenting the results, but never really did anything with them (no one was found to be totally color blind--if someone was, that would be a problem in many areas besides BB!) Scott

Stephanie, Thanks. What happens to the tag after they are done with it and everythiing is in the EMR? Does it go back to the BB? Discarded? And do you review each transfusion record on the EMR? Currently we use the back copy of the tag to do this. Scott

I would also be interested in how you deal with "paperless" transfusion tags in the world of EMRs. Like most hospitals at this point, we are still currently sending out units with a tag/logsheet that includes a carbon. A sticker from the tag has unit and demographic info. This sticker is stuck to the back of the unit when released from BB. At the bedside, after the read back and armband check, the tag is removed when the unit is hung. Vitals, etc are recorded on the tag. The carbon is sent back to the BB for later review. The top tag copy goes in the chart. With the MR, the tag can't be put into anything. Not sure if it going to be practical to enter vitals, etc into the EMR at the bedside when the time comes for conversion. Perhaps the tag can be used as a worksheet to enter into the EMR and then returned to BB for review? As far as that goes, I guess BB should be able to review on the EMR. Maybe the tag will be totally superfluous? Just the sticker with patient name, ID, etc. and unit info going on the bag when it leaves the BB? If anyone has fully converted, I would be interested in how this is going for you. Thanks, Scott

Someone correct me if I am wrong, but the point in re-typing a unit recieved from a donor center is to validate the donor's center ABO/Rh. It doesn't matter where the unit goes after that. As long as it is still tracked within your system (documented where and when it went from place to place) and the label does not fall off or whatever, I would think that re-re-typing is not necessary. Scott

Thanks, Malcolm. Can you tell me the special significance of the IgM part of the comment? If I am not mistaken, detecting IgM can help in predicting when an otherwise IgG titer starts to rise, but I am not sure why they mention it in regards to a transfusion when reporting out pre-natal screening results. I wonder if they have their disclaimers mixed up a bit. Thanks, Scott

We came across a report from a reference lab (not a BB specialty lab, and not one we routinely use ourselves), that had this comment after the results for a negative prenatal type and screen: "This test is intended as a screen to detect those IgG antibodies implicated in hemolytic diseases of the newborn. It does not routinely detect IgM antibodies and thus is not suitable for screening for irregular antibodies prior to transfusion." We are debating why this lab thinks that this disclaimer is necessary. I have an idea, but I wonder if anyone else has any thoughts. Thanks, Scott

Ours also simular: EPI 77-170, ADP 57-109

Anyone know the serological reason for this "suppression" when giving large amounts of Rh pos units to a Rh neg patient -- as opposed to only a few? Thnaks, Scott

Thanks Lah66 I am indeed surprised that JCAHO is more strict on this than CAP! They both kowtow to CLIA, and I always think of JCAHO as regulating to the minimum. Its possible they are over interpreting the requirements. With a recent inspection we now have a 6-point competency check-off that is way out there. Hours and hours of work for managers and supervisors that we did not do before. There is always something new, but I wonder if someone at JCAHO has been drinking too much coffee...

I would say that it was a problem with the draw--the syringe-left-standing-for-two-minutes thing is an ongoing problem with decentralized phlebotomy. As for running the specimen after plasma was removed for some other chemistry test--I don't see how that would cause the WBC to go down AND the Hgb to go up--if anything, all counts would go up. Often its not the current specimen that's bad but the last one. In this case, apparently all were the same blood type--but that does n ot prove that the odd draw was the right patient--you just cannot say for sure that it is not. I think an important note, though, is about delta checks. When the Hgb jumped up 4 grams in one day, the tech should have confirmed with the RN before releasing results. Here, we would check with our own BB first to see if the patient has been transfused. If not, the redraw would have avoided releasing the crappy results.

That's odd-- much less strict than what I thought they were. Do you have a reference? Two inspections ago we were surprised to be cited by JCAHO for not having QC on both modes. Likewise, they wanted to be sure we ran at least one level of QC per "shift". Rather than using up twice as much QC material, we have been using a patient control to correlate the two modes once/shift. We are running two levels of QC for coag tests/shift as well. Maybe we are overdoing it. I imagine that, if anything, CAP regs would be even more strict. There is a more practical issue as well. If you only run QC once every twenty four hours, what happens when you find you are out of control? If it can't be resolved, you have 24 hours worth of results that you will need to somehow validate. For the same reason, I believe you are required to run QC after a reagent change.

I don't think a 'return" has never happened here. I would wonder if the surgeon would even consider using the flap again after the problem with the re-implantion. (Regardless of culture results or whatever.) I would gather what research you can regarding regs (FDA?) and go to your pathologist with it. If you do not currently have a policy for re-issue, it would seem like you would have to get your pathologist to sign off on a re-release. I would be interested in how you end up with this, as we may want to alter our own policy. Recently we threw away a flap at six months per our policy, and when a surgeon found out about it, he was pretty upset. (Throwing away the flap caused a flap.) Apparently he was still planning on using it. Now we have a notification system in place that allows the surgeon to designate whether or not to toss a flap when it expires. Thanks, Scott

We are fortunate here to have a blood center only 15 minutes away. We use O negs for almost all traumas. If the area supply is low for some reason, we will switch to Rh pos RBCs for males and over 50 females. But this rarely is necessary. If we know that a patient is going to bleed massively, we will switch them early. My main problem with transfusing Rh pos units to a patient (known or unknown depending on how quickly the ABO/Rh is done) is that they will seroconvert to produce anti-D. As has been pointed out, the next BB that sees this patient is going to have a delay in providing blood. Our biggest nightmare is a trauma that turns out to have allo-antibodies. And if we routinely use Rh pos for all traumas, there are going to be alot more of those. Now for someone with only anti-D, I get it that all one has to do is select Rh neg units, but in the meantime, a bleeding arrival may have already recieved several Rh pos units (if that is the policy.) I say if that is not necessary don't do it. Likewise, if we have a patient with only anti-E and is c antigen negative, we will screen units for both. But I do appreciate the issue with some big medical centers that do not want to risk exhausting O negs.

Years ago, we sweated in the summer and froze in the winter. Since then, they have added more big cooling units outside for the lab and improved the heating. But when we relocated our BB a few years ago, we found that the decent airflow was again a problem, both for summer and winter. We bought a few of those ductless dual wall units and they work pretty well. If you Google them I think that you will find they run about $500 and up. If your situation is bad enough, you should be able to get the hospital to budget them for the Lab ("Can't be sure patient work is OK with all this sweat in my eyes..") Pretty sure the main regulatory agency for fans would be your local Fire Marshall. Beyond that, maybe OSHA, and like has been pointed out, JCAHO will expect you to follow your Infection Control policies, so i would start with them first if you haven't already.

I get all that, but I really do not think that requiring an observer once a year to document that an associate: does QC related to releasing a FFP, does maintenance related to releasing a FFP, does a "blind" related to releasing FFP, performs a "test" related to releasing FFP, releases results related to releasing a FFP, and a written test related to releasing FFP: will not guarentee that an associate who does not work in Blood Bank often will be competent when they try to actually release a unit of FFP months down the line. If someone is not proficient in an area, I agree that observation and/or testing is needed to ensure they are competent when they need to be. This is something that management needs to be aware of, but no amount of documentation, by itself, is going to guarentee anything. I think this may be another case where a massive amount of documantation may give a false sense of security. We shouldn't be so superficial with competencies. These blanket requirements for comeptencies are draconian. Managers will be spending a hige amount of time documenting that the regs are followed, when they should be more concerned with how associates are doing in each area on a regular basis. At least, that's what I think. We will, of course, comply with the regs as written.

I think you will find that in the US Hematology QC requires at least two levels run every day with at least one level run every "shift" (8 hours). Scott

Great, now they will start censoring "poof". Next thing, we will be noting on unit crossmatch tags: "Compatible-As far As We Can Tell"

Nova As a matter of fact, we just had a Lab JCAHO inspection and found that regulations for competency documentation is way beyond what we would consider adequate. See this link for some details: http://www.jointcommission.org/standards_information/jcfaqdetails.aspx?StandardsFAQId=331&StandardsFAQChapterId=99 We are wondering if the JCAHO committee that came up with this stuff ever actually worked in a Lab! Scott

Acetest tablets are no longer available from Bayer. After some research, I find that a beta-hydroxybutyrate acid test is a better test anyway for screening for ketoacidosis in diabetics. What methods are out there to be used for a BHBA? Thanks, Scott

Liz I think like I said in that other thread we are both looking at right now, the tag IS the form. A sticker on the tag with all of the crossmatch ID stuff goes from the tag to the back of the unit so when the form/tag is removed, the unit is still kosher. Scott

Ya. 9 by 11 1/2 or whatever.