SMILLER

Sandy Do you have an easy reference from the internet for this sticker thing? We have a two part (front and back copy), full page form attached to each unit. Its large but the form has space for all transfusion info (temps, BP, etc) as well as a documentation area for how the transfusion went. The form also has notes on how to detect a possible (eg febrile) or likely (eg hemolytic) reaction. The top form has a smaller removable sticker that has all of the unit crossmatch documentation on it. When we issue a unit, we peel off this sticker (duplicate info remains on the front and back copies) and stick it on the back of the unit. That way, if the tag is separated form the unit (common during the transfusion), all of the unit and patient ID info is still on the unit. If the stickum is an issue, we have not heard about it. We had the FDA here last year and they said nothing about the stickers (they were very thorough!) Thanks, Scott

Liz We have problems with adequate documentation on the unit tag forms (all transfusion info is recorded here, a copy is charted) when our copy is returned to us, and we have Lab clerks check those for us if there is missing information, and if it appears they missed a febrile reaction or something, we do testing/path review for those patients as appropriate. In the past we have run QA programs to observe and make sure that blood administration is by the book. We have redesigned the blood tags to make them easier to use and have gotten positive feedback about that. We will always be reviewing those tags to make sure nothing is missed re: FDA or JCAHO inspectior review at a later date!

"If we have a historical blood type, we just do the front type as a "blood type verification". We do not require require an antibody screen unless the patient is also receiving RBC's." As a side question, how does a "front type" and a historical record ensure that the correct patient has been drawn ? I would think that you would have better than a 1 in 3 chance that any two people are the same ABO/Rh (in US, majority are A or O pos). I ask because I have seen the use of "history" in cases here as patient ID validation, and I really don't understand how it can be relied upon. Maybe used in conjuction with electronic crossmatch procedures (we don't do that here either)? If there is some question as to a patient's ID (like when they remove thier BB armband), we redraw and repeat both the screen and the ABO/Rh before transfusion.

We are a 270 bed hospital with active intensive care units. Lab collects all BB specimens except for same-day surgery unit patients, where they are collected by RNs. We use BB armbands to connect patients to specimens to units. Patients also have regular hospital armbands, but like many places, thier use is problematic, so we do not soley depend on them for BB patient identification. In general, we do not rely a history to "validate" a specimen that is otherwise questionable as far as being drawn from the correct patient. If there is some question, the patient is redrawn. We occasionally get a Lab-drawn mislabled specimen, or a specimen with two different labels on it, but this type of problem is much more common with "decentralized" specimens. About 12 years ago there was an administrative push to maintain "patient-focused care". Somehow this translated into fewer people doing more things. One result was that we now have many of these decentralized-phlebotomy units (ER and intensive care mostly) that draw their own Lab specimens. But we do not let them draw BB specimens, other the exception for the pre-op unit and OR. Not surprisingly, decentralized specimen problem rates (wrong tubes, clotted, hemolyzed, etc.) are much much higher than Lab phlebot drawn. Here mislabeled specimens rates (wrong patient ID) occur about twenty times more often than with Lab draws. Check the internet for journal articles about misdraws. There have been several that point out the problems with decentralized phlebotomy.

I have never heard anything about a requirement to do a "mixing study" for an automated hematology analyzer. All but the smallest analyzers have a built-in mixer if I am not mistaken. I would think that Coulter could vouch for it's effectiveness. Even when we use the open mode (on our LH780 or LH500) we only spend a few seconds mixing by inversion and rolling. Specimens waiting to be put on the analyzer we keep on a rocker.

I suppose that nurses would only be present if they were out there having a smoke along with the patient.

Mari I would say that exposing a patient to D is more likely to cause an immune response than other antigens, but I appreciate your point. It is just not practical to screen for all antigens a apteitn might respond to. But all blood units are already screened for D when we get them. However, if you have a short supply of O negs, that is another factor you must take into account. In your situation, we would probably have the same policy as you are considering. ('course, I would make sure that your pathologist has signed off on everything, and it goes throught he usual committees before you make any policy changes.) It seems like you should be able to keep more O negs on hand, however, than just 6 or so. We keep 20 on hand, and if the outdates get short, we give them to other A or O patients and restock.

I agree that if you have a successful and thorough training session and review, and file the competencies (just like you would for anything else in the Lab), there is no good reason not to let non-tech associates issue blood.

Our policy has us switching if it looks like our inventory of O Neg units is going to be exhausted (generally, if it looks like 10 units or more will be needed). We usually have plenty of O negs on hand so we do not have to do this very often. When we do switch we are to inform the physician and BB manager. We also have a protocol for giving rhogam to appropriate cases. We just dont like the idea of immediately switching Rh on those males and older females just because pregnancy is not an issue. Patients who end up being Rh neg and having anti-D as a complication for Blood Banks for the rest of their lives doesnt sit well with us. We are fortunate to have a nearby Blood Supply Center that usually can respond within 45 minutes with more O negs if we need them.

We only draw a second specimen in cases where the Blood Bank armband has been removed or when the specimen outdates. Once upon a time, when pre-admit testing was not done almost always the morning of the procedure, we used to armband patients and have them wear it for a few days until they came in for the surgery. If they lost the armband, we would redraw them. Scott St.Marys-Saginaw, MI

We do it every day. But this is done electronically by using the "HI" and "LO" alarm buttons on the refrigerator and freezer panels, not by physically raising or lowering the sensor probe temps.

Not sure about AABB or whatever but CLIA surrogates like CAP and JCAHO are going to want to know what you used for ANY test in the Lab. I believe this means that, should an inspector trace a BB test, they are going to want to see documentation about which reagents are used in addition to abunch of other stuff. Having saud that, look at your software and see if you can set up alternate fields on the same entry window for entering screening results. One set for gel, one set for tube. You'll need to do the same thing for crossmatch entry. I would contact other users of your system (if you haven't already). These types of problems have probably been figured out by some other lab using ther same software.

Quiz question: For a prenatal administration of Rhogam, if the IgG anti-D "takes out" the fetal cells in the maternal circulation, why isn't there a problem with the IgG crossing the placenta and attacking the fetus' cells inside the fetus?

T&S 45 mins T&S and XM 1 hour Uncrossed-not type specific 15 mins Uncrossed-type specific 25 mins

We have been using Ortho gel cells for a few years now and occasionally have problems with them. What does Ortho say? If they sent out a bad lot they will have had other complaints.

QJULI I want you to know how appreciative we are for your dedication to the profession in pursuing this. You have already gone above and beyond what most people would have done in this situation. Your concern over patient safety -- regardless of your own problems in trying to rectify the situation -- shows a high standard of ethical conduct that we can all be inspired by. Once again, I urge you to try to find out what passes for a compliance officer in your facility. You may want to call your Risk Management dept for this information, sometimes an employee there will be designated as the CO. There has to be someone you can approach, not in the usual chain of command, that can help you at this point. You need to find protection for yourself as a whistleblower in addition to making sure the problem is being corrected, and this is exactly what a CO is supposed to do. In my facility I would not mess around too much with our pathologist--this is an administrative issue and with all you've already gone through you need to try to get physicians tied up in this if you can avoid it. Good luck, and thanks again. Scott

And this seems to be what you were looking for as a reference: http://www.mlo-online.com/features/201105/tips-from-the-clinical-experts/review-of-platelet-estimates.aspx

We have found with our scopes (at 10 x 100, High power field) that a count of 14-40 corrisponds to a normal count. We know this is roughly adequate from comparison with accurate counts from our analyzer, which is something you should do regardless of the magnification used. What's important is how your manual estimate compares with actual counts. If we cannot report out the analyzer count for some reason, we blank that result and report out an estimate as Low, Normal or High. You really cannot get a more precise estimate beyond that without using a hemacytometer. When you look at a field of plts and RBCs on a scope, you are arbitrarily comparing the number of platelets in the field to the number of RBCs. So the ratio of RBCs to platelets will also depend on the RBC count, NOT just the platelet count. The key thing to do when scanning a slide, I think, is to check for for things like platelet clumps in addition to a rough estimate (lo-norm-high) for platelets and WBCs. That's all you need to decide if a follow-up is needed before releasing results. Don't worry so much about an "exact" estimate.

OK. Well if that's the case, then maybe we just don't even do a screen at all on known alloantibody patients? There will then be no evidence of a new antibody, so I guess we can all be good with that?

We are a 260 bed level 2 trauma center. We get 3-5 MTPs a month. In order to get certified as a T2, we had to have everything worked out at all levels--Lab, OR, ER, Trauma-- and all of the P&Ps for all of the associates and docs involved. This took several months. We have a protocol to follow in BB when a MTP is started and follow it until it is called off. An MTP is usually started by ER or OR. Once begun, we look at lab values and usage to decide what needs to be set up next. Having said that, you may need to see if you can get a trauma surgeon or ER doc to take the lead in deciding what is needed for your facility. It needs to be a multi-diciplinary process so that everybody is on the same page when the time comes. But I think, even in a smaller facility, someone has to take the lead in coordinating the process to establish P&Ps for all concerned.

Yeah, that seems confusing to me. It seems like it is saying to check for a change in AB strength or reactivity pattern (which you would have to do a panel to determine) and at the same time that you do not have to do an AB ID. Again, once a certain amount of time has passed, there is no way to determine if another AB has developed without doing another screen, and if the screen is positive (which it will be in the case of a patient with a previously ID'd AB), you would have to do a panel to determine whether or not anything new is present. (you can't just say that there is nothing new developing because the AB screen is simular to a previous one). Is it possible that the procedure is wrong? Or am I totally missing something here?

Not sure if I get what you mean by Antibody ID. If you mean to completely ID a known antibody, the more important thing is to rule out any new antibodies that have developed since the last screen/ID. If that is what you are asking, we repeat all "IDs" after the last screen/ID for a particular specimen expires -- every 4 days. Even if the patient has not been recently transfused (or pregnant in the last 3 mos). Your: ". All other patients : every 30 days if there is no increase in strength of antibody reactivity or appearance that there is a different antibody present than what was previously identified." confuses me, how can you tell if there has not been another antibody developed unless you do a panel to ID what is there?

We have a Coulter LH780 and a LH500 for backup. We do not run Retics on the 500, so we keep a few manual tests around and do them with a Miller ocular if necessary when the 780 is down (which is not often). If we had two analyzers that we could run retics on I doubt if we would keep the manual method around.

Q Juli You may want to stop posting things like this on a public forum, as it sounds like you have several violations here of federal regulations, involving not only a testing associate but also possibly supervisory as well. Having shocked you (hopefully) with that, I would say that you need to go up the management chain with any complaint that invovles a corporate compliance issue like this. This does not sound like something minor like a dress code violation: If you feel the immediate supervisor is not acting appropriately then you are obligated to take it further. Next to your administrative director and then his or her VP if necessary. As a last resort, at our hospital, we have a corporate compliance system that includes a system for reporting stuff like this (anonomously if you want to) that is outside the usual chain. You should have something like this. Good luck.

In reference to Mabel's last couple of sentences: The article added that they found that non-specific "nusance" reactions seem to be reduced when a bubble is left during incubation. As some others pointed out here. So the bubble does indeed seem to increase both sensitivity and specificity.