SMILLER

Right. As long as the patient is positively identified (still has blood bank armband on), and we still have the original ABO/Rh specimen, if they need platelets or plasma, we go by what is already on record.

We have used HCLL for years. We have gone through a number of dot-matrix printers for our two-layered forms and finally have a newer EPSON FX-2190. I would think that it is much cheaper to use than any laser printer. We use full-page forms with a label at the top. The label goes on the back of the unit when issued like vam3401's above. We have had trouble with nursing using proper documentation so the form includes pre-printed condensed guidelines on what to do in the event of a transfusion reaction as well as an area to document hang times, BP, etc. The top copy gets charted, the backcopy comes back to BB for review.

Here we simply use panel cells (or screening cells) that are positive and negative for the particular antigen you are testing with the matching anti-sera. Try to use heterozygous cells when available for positives.

I would agree that your outdate rate is the best way to monitor whether your inventory is appropriate. I am not sure any formula is going to be as useful as what you yourself see happening in your blood bank. We only have about 100-130 units of pRBC at a time here, but we are a smaller Trauma II hospital. If we have outdated units, they are ususally short-dated units on consignment so that when they expire, we return them to our supplier for credit. We are fortunate to have a blood supplier within about 15 minutes from our hospital so that we do not have to keep more than one 5-pack of platelets on hand.

We looked at that a year or so ago. We had alot of trouble getting reproducable results. The test was hard to read. Its possible that the test has improved by now. We decided to go with a reference lab for our HITs. We were lucky to find one that picks up daily as needed. We get results back the next day. Our docs don't complain too much about this. One of these days there will be an automated assay available.

If the lab uses a "converted" value (such as taking the analyzer's ng/ml result and multiplying by 2 to report it in FEUs), and this calculation is done manually, I am not sure that checking the analyzer results for QC would satisfy any documentation requirements that patient results are also calculated properly. If both are automatically converted by the LIS, or by the analyzer (like INRs), then I suppose you would be covered by just documenting that the analyzer's calculation setup is correct once a year. The answer would be to drop reporting in FEUs altogether, if this is the case here, and just report as ng/ml like most labs do. On the other hand, if you are getting FEUs from the analyzer, I guess you are stuck with all of this calculation validation stuff.

Like many others here, we have a Massive Transfusion Protocol that includes sending FFP automatically at a certian point based on the INR. 2 u if >1.5, 4 u if > 3.0, etc. For regular traumas, we send 4 O negs when requested to ER. We would rely on the ER doc or OR to keep track of the Lab values. It does seem alarming that a bleeding patient would be shipped out without attention paid to the coag results, if that was the case.

We have always kept validation records, with each cooler labeled with a simple code (A, B ,C, for OR and trauma 1, trauma 2, etc.) that is repeated on the log sheets. We had a recent FDA inspector that recommended we do this with all coolers, even the ones used to send between labs at off-sites. I beleive we check them once a year.

Thanks Deny. I forgot about the Immature Retic Fraction. That would be a whole other thing we would have to educate our people on if we started reporting it. However, we do not have peds or a dialysis unit here so I am thinking our pathologist would pass on the ide aof reporting the IRF out.

Does anyone report out an absolute retic count from thier analyzer as opposed to the old corrected % retic? It seems like the use of a corrected % count is archaic, since it seems like all the analyzers that do auto retics report out a absolute in addition to the %. We still take the % from the analyzer and calculate a corrected retic %. I guess if we switched we would have to come up with a validated reference range and possibly do some education.

The "Plavix" and "Aspirin" effects can be measured to some degree with analyzers such as the Dade PFA (aspirin and general functional screen) or the Accumetrics Verify Now (Plavix and aspirin). These are easy to use analyzers and I beleive the reimbursement is adequate. We use them routinely here for surgeons who want to make sure their pre-op patients have no residual plavix or aspirin effect on their platelets before surgery. The Accumetrics people also are pushing the idea that many patients on Plavix needs to be monitored empirically beyond a standard dosing regimen.

What are the ways in which urine culture orders are screened? For some time, we have been going by the concept that we can cancel C&S orders with a "screen negative" comment if the UA shows no evidence of a UTI. In practice, our protocol is way too complicated. We have so many exceptions that it generates far more work than we save by cancelling the few C&Ss based on the protocol. If a UA is not ordered at the same time, and recent UA results are not available, we order one ourselves. If the nitrite and esterase are negative, we have to look at the microscopic for WBCs or bacteria/yeast. We do not screen outpatient UAs, just those collected in our hospital. We do not screen prenatals or pediatrics either. I would be interested in any other facilities experience with screening urine C&Ss by using a UA. Thanks.

There is a reference here: http://jco.ascopubs.org/content/27/11/1844.short, to an article about the number of smudge cells and a CLL cases's prognosis. We had a pathologist a few years ago who would do this little "spot continuing ed" bits with whoever was in Hema when he wlked through. I believe this is when I first heard of this particular theory. Since then I have seen a few articles on it. If you google "smudge cells CLL" I am sure you will be able to find a couple. The idea is that CLL is chronic because the tumor cells are fragile. Fragile enough to rupture on a push smear but not so fragile that most automated analyzers can count them accurately. Not sure why young children often have smudge cells. But for CLL patients this is good, because it means that their NK cells or spleen or whatever is able to get rid of the tumor cells before the load gets too heavy. When the lymphs become more robust, the leukemia becomes more acute, and the prognosis worsens. Something like that, anyway.

I would agree that while smudge cells are almost always the result of fragile lymphs, you cannot count them as such since you really do not know. Sometimes PMNs smudge also, they do look different from smudged lymphs. Smudged lymphs are not unusual in CLL patients and sometimes young children. Some think that once smudge cells dissapear in a CLL smear, it means a worsening prognosis for the patient, as the tumor cells have become more robust.

An older middle-aged woman came into our clinic to pick up her husband's Lab results for a routine physical. The clinic doc looked over his batch of Lab reports and then told her that there was a problem. "We lost the identification information for two patients. We know that one of the reports is for your husband but we do not know which one, and I am afraid that there are bad results on each". "What results are those" the wife asked nervously. "One report shows early Alzheimer's Disease, the other is HIV positive. I'm sorry." said the doctor. "But, can we repeat the tests to see which one is my husband?' "I checked with Medicare already", replied the doc, "they will not allow us to repeat the same tests." The woman, now even more upset, asked "But what should I do?" The doc replied "I asked Medicare that, and they suggested that you drive your husband into the middle of town and leave him there to see what happens." "Then what?" "Well, if he finds his way home, don't go to bed with him!"

We have been using FS 5,1s and ECis for several years, and are considering the 5600s. Does nayone have experience with these? We are especially concerned about maintenance and downtime. For example, if the immuno side of a 5600 needs service does that mean the whole analyzer is unusable for the duration? Is the 5600 more reliable and less prone to problems than the ECi and FS? Any other information that you think may be useful in making a purchase decision would be greatly appreciated. Thanks!

It seems to me like there is much more of a tendency for distortion of the cells when a cytospin is used. I try to avoid it here, other techs use the cytospin almost exclusively, even to the extent that they will dilute a very thick specimen with saline before spinning so they can use the cytospin. If a specimen is cloudy enough, after aliquoting to an EDTA, I will spin it and make a push-smear from the button. These slides stain with cells that look like a peripheral smear and I think that the differential distribution is maybe more accurate than what you would get from a cytospin. If the button is very small, you can always resuspend it and then go to the cytospin. I agree that for very thin specimens like CSF that have to be cytospun, adding a drop of albumin to slow the cells down during spinning is important--otherwise some cells just get sucked into the filter paper. Beware of messed up diff %s if this occurs, some types cells will do this more than others.

Where is the appropriate place to post about these and other topics that do not fit easily into the current four forums? I am new to Pathlabtalk and so far it seems to be a great resource. Good job to whoever maintains this site and thanks! Scott

One **** and two hetero, if available. On non-dosage antigens, we would allow just 3 heteros. Obviously an AG can be typed positive on the patient we would rule those out as well.

About twice a year. I started donating about 20 years ago. I work 40 hours a week.

Lab phlebots would never draw below an IV. We encourage them not to draw anywhere near an IV if at all possible (especially ones in the hand!). The problem is with decentralized phlebotomy performed by RNs. Education is not as effective with them and is a constant struggle for us. A more serious issue is when an APTT is drawn through a heparinized line, or when a central line is not cleared properly before a Lab specimen is drawn. We have had a special problem with TPN contaminated specimens over the last year.

Here, we would rarely repeat a slide review on the same day or even during the same inpatient stay unless we saw some sort of change in the CBC where morphology comments added to the report would help in treatment or diagnosis (eg increase in neutrophil count on a post-op we may want to report toxic change if present). The only other reason would be if flagging on the analyzer makes it necessary (NRBC, platelet clumping, etc.)

Years ago we dropped reporting % differentials on our CBCs. The idea being that absolute counts are more significant if elevated or lowered. There is still some contention here among the techs as to whether %s should be still be used to screen for slide review (eg, high lymphs to be screened for reactive or atypical morphology). Do any other labs still report or otherwise make decisions based on % counts for automated diffs?

I had to check our procedure-we have it written like yours too! However, since counts below 5 per ul are considered normal, it perhaps is not important. In you example, whether you report a 1 or 2 makes little difference. We do have a thing in our procedure for counting bone marrow diffs where we allow for more variance on very low counts instead of just a straight percentage for all amounts.