bbkdiane

Currently, we perform the Fetal Screen routinely following the delivery of the newborn(s). All other requests for Fetal Screen are the responsibility of the physician. If we encounter an instance where a physician does not order the test when the situation warrants, we let the medical director handle it. Third and long......punt!

The Lui technique is a total waste of time for routine cord blood testing. If the baby has a positive DAT and the mother has a negative screen, and the ABO of mom and baby is such that ABO Incompatibility is possible, then that's the answer: we report the strength of the DAT and add a coded comment "probable ABO incompatibility". We have done this since 1991.

Our pick up slips have the product, patient demographic label, date, and like a check, the messenger endorses the back with signature and initials. We add the patient blood type and a sticker from the product. These slips are later paired up with the return slip from the transfusion. They are stapled together and kept on site for one year, then off site for a total of 10 years. This system has worked well for 33 years. Also, no tickee no bloodee.

We do the following: 1. Nursing SOP for Transfusion is readily available on a common computer drive available to all personnel. I helped write the SOP for nursing. 2. Each year I make up a short 5 question quiz for my BBK staff based on the latest information on Transfusion Reactions for their continuing ed. 3. We have a Lab Newsletter for physicians called Under the Scope which is a great vehicle to educate physicians to new items and review of problematic issues. Each lab section contributes. We also actively participate in the orientation process for new nurses: we have a Lab Powerpoint Presentation that different techs take turns presenting to the orientees. Transfusion Reaction information is part of this. 4. As BBK supervisor, I offer quick 20 minute reviews annually to the nursing units at their convenience: I e-mail a series of dates and times that I'm available and go to the lounge of the nursing unit...with a basket of chocolate candies and some hand outs of the topic. I make sure to include anything that the unit has had issues with in a friendly non threatening way. The nurses do not receive CEUs because the reviews are short; but the Nursing VP gets a list of who attended and it does count for something for them. They are very receptive...I think the candy is key. 5. Nurses can e-mail me directly with questions regarding BBK policy. The answers are shared with others. The questions can indicate a target need for a particular topic inservice. 6. I am getting ready to redo my transfusion unit tag for our upcoming switch from Misys to Meditech. We already have instructions printed on the back of the tag that instruct the nurse on what action to take if there is a reaction, but I am going to add some symptoms to the instructions. You can make this a win win situation. Reactions are rare. Nurses will tend to forget what to do unless you have some system of reminders in place. I know, you're busy and short staffed; so am I. Like Nike, just do it!!

We are getting ready to go live with Meditech in November. Pray for us. The system has some prompts to selectively pick certain cord bloods for routine testing such as: 1. Is the mother group 'O', and 2. Is the mother Rh Negative? We would like to cut back on the 100% cord blood testing (Blood Type and Direct AHG) that we have done since Athens and Sparta fought. What is your policy for testing cords? The other question: Is it better to centrifuge the post delivery Rhogam Profile sample or work with a well mixed uncentrifuged post delivery Rhogam Profile sample when preparing for the Rosette Test (Fetalscreen)? The package insert for the Immucor/Gamma product does not address the issue and nobody at tech support had a thought. I am not aware of any studies, but if someone knows of any information on this item, please share. A really good project for some poor SBB student would be to Chromium tag some Rho Positive group 'O' cord cells, add a specific amount to tubes of 'O' Rho Negative blood, centrifuge some samples, and just mix others, take samplings from each and see how the two compare to providing a harvest of the cord cells by checking for the amount of Chromium isolated by both techniques. Where do those fetal cells reside? They are supposedly lighter in weight than adult cells so they should hover near the buffy coat layer of a spun sample. Should we be skimming the top layer of the centrifuged maternal sample to catch as many fetal cells as possible? Does this really matter? Would the contamination with white cells from the buffy coat cause more problems? The reason this whole mess came up was because I was looking to streamline our testing workflows for the new system, and I thought we could use the unspun Rhogam Profile sample to perform a quick A/B/O Rho check with no reverse group and also do the Fetalscreen at the same time. This would save 5 to 10 minutes of specimen prep time. All L&D patients receive a full Type and Screen on admission so we have full data that is less than 24 hours old. My older techs went bananas when I suggested the shortcut. To prevent the need to increase their doses of nitroglycerin, I decided to take the question to my peers. Please have at it, and give me your thoughts. Thank you.

There are many low frequency antibodies for which no commercial typing sera exist. In these cases, we IgG Coombs match the intended unit. Since our Misys system has antigen-antibody logic built into the QA table, the system will alert when no antigen typing has been performed on the donor unit; we enter a reason code such as UNAG (unable to antigen type unit). The question I always hear is: what if the low frequency antibody is so weak that it is not demonstrable? The odds of a low titer, low frequency antibody matching up with the antigen positive unit ...well, the odds are probably in the magnitude of winning the lottery. Should we worry? Probably not. Real worries: patient identification errors by nursing staff/phlebotomy when drawing BBK samples.

I need some input from my peers on two issues: 1. Do you keep a log book to document unacceptable specimens for BBK? It is a requirement for some accreditation groups. My director found an article that stated the quantity of unacceptable specimens (for any reason) should be 0.45% or less. She is applying this "standard" to every lab. It works fine in the Chemistry and Hematology areas because they average 10,000+ samples per month; however, the Blood Bank averages 1500 specimens and we are more picky about hemolysis, clerical omissions, etc. So, if you have such a log book and have criteria to share, please bring it on. I never make the standard set by my boss for this monitor. 2. Our Labor and Delivery nurses draw each patients' admission blood work through the IV cannula before starting the IV. We see more hemolysis with our Blood Bank samples when they are drawn via this method. Since these samples are for academic Type and Screen (we get no pre-natal work on these patients), is there a level of hemolysis that you would routinely work with to save the patient from a second stick? We use Gel. One person told me that their criteria to accept a sample with hemolysis present was to hold printed material behind the sample: if they could read the print through the hemolysis, they could use the sample. Just curious what your policy might be. We were always taught that a sample should be free from hemolysis, but with the Gel system, slight hemolysis to moderate hemolysis does not seem to interfere with the interpretation of the test (according to Ortho). There is also the dilemma with the immediate spin crossmatch with the slight to moderate hemolyzed sample. Should all crossmatches performed on hemolyzed samples be Coombs rather than just immediate spin since the point of immediate spin was to catch ABO errors which cause hemolysis? This hemolysis issue is a major problem with the L&D folks right now. They get upset when we call and ask for a new sample; so I'm looking for some peer help. Thank you.

We require a Type and Screen on any IN house patient for which plasma products are ordered and we have no history or current sample that can be Typed and Screened. Why the Type and Screen?? If the patient is sick enough to be an IN house patient, and sick enough to warrant coagulation therapy, then they are sick enough to bleed or be ripped off to emergency surgery and need RBC therapy. We used to require only an ABO/RH in these cases...but one night, after 4 days of giving FFP to a patient based on ABO/RH, the patient had a major GI bleed which necessitated release by third shift of uncrossmatched type specific RBCs. When the tech performed the followup screen and crossmatch he encountered a positive antibody screen and two subsequent incompatible units. The antibodies were anti-c and anti-E. The patient had a reaction and physician and nursing staff could not understand how we missed them or why we didn't do the antibody screen. Our response was that the screen wasn't needed because only plasma products were being issued; it wasn't policy to perform the screen in this situation. I remember feeling really dumb giving that explanation to the perplexed physician. We decided that we never wanted to be in that situation again so we mandated the Type and Screen for IN house patients for whom we have no current history. Our patient population is 70% Medicare and many have been multi transfused. We also missed a Tja on an O+ patient for Labor and Delivery when only ABO/RH were ordered on incoming OB patients. Lots of fun when the patient bled at delivery. I know these are off the wall cases and there are those who will criticize this missive, but we are influenced by our own experiences and have to do what we are comfortable with. The Type and Screen is the tech's best friend. It is the cheapest insurance policy that you can provide for a patient who may need blood. We do handle OPTs differently: upon first visit, a base line Type and Screen is performed. Chronic plasma product users (platelets usually) have a second sample drawn for ABO/RH. Once we have 2 types on record, the OPT can come in, get their platelets, FFP, or Cryo without further testing. Since these folks are considered stable and are deemed okay to be treated on the OPT basis, they are low risk for emergency transfusion of RBCs. Thank you for listening.

I was not thrilled with the Ortho letter. We all knew about the issue with weak E's and other antibodies from a few years ago. Since we stepped up to Gel from tube testing, I felt that even though Gel had its warts, it was a safer system than tube testing for multiple reasons which we all know. Now, Ortho's latest letter appears to be suggesting that we 'change' our procedures to one of 2 options. I didn't care for either option. We use a PEG screen to follow up weak Gel reactions before we waste time on a panel. When we do perform a Gel panel following weak Gel screen reactions we automatically increase the incubation time. We've been on Gel for 4 years. It has enabled me to crosstrain some folks who were too scared to come into BBK for the lack of confidence in their tube shaking. Gel has standardized our tech to tech readings, and I can review the work of the helper techs on second and third shifts. Gel is great. We look at our 4 year history and have not had any clinically recognized delayed reactions due to a Gel miss. I'm sure they are out there, but we have decided not to change anything. The only difference in the Ortho letter is that now they know why the problem exists and they will address the glycol issue. Before, they just stated that not one system detects everything and we were okay with that. Now that the reason is known, there is the need for the company to 'do the right thing' and give us interim options. I do not agree with the wording of the letter, however, I do understand where they are coming from legally. Now, it is our turn to make the decisions: go through your medical director and risk management department and let them assist you with your decision. We are legally comfortable with ours to continue with our current policies. I also think we are a little irritated at this type of grey area issue because we have been the brunt of other legal grey areas such as random platelet bacterial testing (don't get me started!) and the old solvent detergent FFP routine (buried for good, I hope) I want concrete guidelines that make sense, but lately, we seem to be recipient to wishy washy edicts from sanctioning organizations and vendors all due to the legal climate. Thank you for listening.

This may sound twisted, but we do the following: Phlebotomists are Lab Trained AND must take a short special "Meet the Old Smiling Blonde in BBK" who will give you a friendly inservice and quiz (inter-active so it's not too threatening). She will be attentive to your questions, will show you exactly what is expected and will be your mentor as you encounter situations that are gray area. Hint: You do not want to screw up..you do not want to go there...it's not pretty.Phlebs can use the Misys pre-printed labels for BBK samples as long as they copy the special account number from the patient's armband onto the label. This must be done at bedside. There is no other easy access to this number. Phlebs carry Typenex bands on their carts for instances where there is no ID band on a patient and no time to get one made.Nursing is also inserviced by yours truly. The inservice includes some legal facts and scenarios whereby they come to understand that a untoward patient event due to mislabeling will result in a non-defenseable legal issue that will most likely result in the loss of their license and possible personal lawsuit for gross negligence. I created a special bright yellow label for nursing to use just for BBK samples: all information prompts are on the label along with the statement that only information from the armband is used. Nurses sign an affadavit that they understand the policy.Samples must be 100% El-Perfecto or they are trashed.Patient armbands are barcoded and have a small color picture of the patient. Nursing can download a new band on their unit computer; no more dependency on the Admitting Dept. for a new armband. We don't have the barcode readers yet; we will switch to Meditech next year and will wait to spend the money when the new system is up. Once the barcode system is in place, labels for samples will only print at the bedside when positive contact is made with the band to the scanner. The patient ID band will have a special check digit so nursing can only get labels at the bedside.Nursing is under the same disciplinary guidelines as the Phlebs. This was a special moment in time when nursing administration agreed to this one! Mislabeled samples (usually core lab samples where nursing can use pre-printed Standard Register patient labels) result in a written disciplinary action as a first line penalty. Since nursing has to hand label all BBK samples, it slows them down a little and they 'think' about it more.We have administrative support for this patient safety issue. This is very important to the success of any program. We sponsor a committee called the "ILS" for "Inappropriately Labeled Samples". Mislabeled samples of any type are documented by a Risk Management Variance and a root cause analysis follows. The person or persons involved must attend this monthly meeting with their nurse manager to explain just how the accident happened. These meetings have resulted in process changes throughout the organization to further the cause of patient safety. Mislabelings happen two or three times per month in the core lab where nursing samples can have pre-printed stickers on them. (This is a 600 bed hospital)I know nurses still cut off ID bands routinely in surgery and during the start of IVs if necessary. The phlebs document any patient without a band and this is also followed up. Phlebs are not allowed to stick anyone without a band. Either the nurse takes a minute to get one and place it on the patient, or the phleb writes up a chit that says "We couldn't obtain a sample because.......".If the situation is super stat, the phleb puts a Typenex on the patient.I would really like to have the rule that if there is no blood type history and the patient is non-O, a second sample would have to be procured by a different person and rechecked before the release of blood. Right now, enacting this policy would cause such hassles that I fear other more serious mistakes would be made by my already stressed staff. If we were in the core lab close to Hematology, I would consider using a properly labeled, phlebotomy drawn sample as a recheck to our BBK sample on patients for whom no history exists. Unfortunately, we are a long way down the hall, and when you work alone, running up and down the hall while phones are ringing is just not doable.I've been in the field over 35 years..have done plenty of inspections and have not seen one armband system that is any better than good inservice and use of the patient armband that exists. Specialized armbands for routine use are very expensive and the effect of one pair of scissors = double work and double time. We Type and Screen most of our surgical patients and all of our Labor Room patients: Most of our patients that are Typed and Screened do not receive blood. I know that when we used the emergency armbands for all patients during a hospital admitting computer change (for two weeks) it cost us close to $1000. I am comfortable with the phlebotomist rule of adding the account number from the existing regular patient ID band. The nurses still make me a little nervous, but our approach of inservice, inservice, and more inservice followed by root cause analysis and finally disciplinary action with termination hanging at the end seem to be working. Again, I have had only 3 mislabeled BBK samples in 6 years; all by new phlebs; all caught at specimen log in because the account number did not match. I have had one mislabeled sample by nursing in the same time frame; the nurse looked at the armband and wrote the physician's name instead of the patient name. Sorry to be long winded, but this is my first day off for a long time and I couldn't help myself.

I think one has to look at the services offered in their institution to decide what patient population and procedure risks are present. If you have an Emergency Dept. or Obstetrics, you need to have enough Rh negative blood to service child bearing age females and newborns. Our blood center monitors the amount of O Neg donor blood that we use. They use 6% as the community number of O Negs. We have a 580 bed hospital with a large cardiovascular program, large orthopaedic center, a cancer center and moderately large OB service and finally a 40 bed Emergency Dept. We keep a minimum of 6 O Negs and try for a dozen as routine stock. We keep 12 to 15 units of A Neg RBCs in stock at all times. Our total daily inventory is approx. 150 units of RBCs. There is abuse of O Neg RBCs in our area because some of the smaller hospital blood banks use O Neg on everyone after hours so there are no "accidents". This is the reason our blood center monitors usage of O Negs. We've had occasional shortages of O Neg and we have converted elderly patients to Rh Pos blood in emergent situations such as prolonged usage for GI bleed or a difficult surgical case. Some hospitals routinely give O Rh Pos units to O Neg patients if the patient is over a certain age. I've seen too many of these cases live long enough to come back and haunt us multiple times with Anti-D. All the experts say it is a rare phenomena, but we have at least 4 cases a year that fit this category. We encourage patients to know their blood type so they can get directed units from friends or relatives for elective surgery if they are Rh Negative. We have local health fairs for the public a few times each year; the blood type booth is a favorite. We give out wallet cards with the type and tell them what their % is. An educated Rh Neg patient can do alot to make sure they get the proper donors lined up for surgery.

We actually have a choice of entry methods. All patients have a patient card made up with demographics and work history. The cards function as a work summary or can be used as a downtime worksheet. I have one rule: the test reactions must be recorded dynamically as they are read. The tech can either record them in the computer grid (Misys) or onto the patient card grid then enter them later into the computer. This option works well with new hires or generalists who are a little slower at computer entry. Cards with negative screens and normal blood typing results are purged every 12 months from the file to keep it manageable. Cards with problems are red dotted with an Avery paper dot and kept indefinitely (or until we read the obit). Techs can get themselves into trouble if they attempt to rely on memory. We are burdened with so many interruptions; phones, signouts, surgical needs, AM admit nightmares such as missing Autologous units,unexpected antibodies and my favorite, the last minute request for 4 or 5 doses of platelets STAT for Open Heart Surgery. The techs all know that dynamic entry of reactions is one of my non-negotiable rules. Failure to comply results in a Performance Improvement documentation (reminder) which in itself it non punitive as long as the problem does not occur again. Second occurrence of the same issue within a 3 month period could initiate formal written warning. The interpretation and entry of the patient ABO and Rh result is single most important task that a tech performs. This is a high volume high risk task that must be 100% correct 100% of the time.

I spoke with my blood center yesterday. It is my understanding that the FDA requires that a variance be applied for in this case. One of the apheresis equipment vendors is creating a downloadable form to assist the process. As soon as all the paperwork is taken care of, we will see the seven day platelet apheresis products. I am disappointed that the Tampa project to pre-pool and culture randoms is "dead in the water" with the FDA. We need some help with the bacterial detection issue on the randoms. There is an editorial in this month's Transfusion discussing a platelet apheresis product that was pH'd as normal but caused a septic reaction in a patient. The article called for apheresis manufacturers to use culture methods available and stop using insensitive tests such as pH and glucose. Meanwhile, there are a handful of very large hospitals in my area that are still non-compliant with AABB and CAP over the random platelet testing issue. We all know that 'swirling' is not the best, but is it really so bad compared to pH and glucose insensitivity? If you have any hard numbers on the differences, please share.

Life used to be so easy. We had default volume set in Misys (Sunquest) to reflect the majority of differences: CPDA was 250, Adsol was 300, and CPD was usually low volume with an actual weight printed on the label. Neonates get their pedi bags weighed. Now, we have these wonderful "Twin Apheresis RBCs" where the donor gives 2 RBCs at one time and each unit has its own special volume which must be hand typed. Just another nightmare for training the generalists. I'd vote for a disclaimer that says, "hey, it's a Red Cell, be happy you got one...Volume between 250 to 400 mls. " Kidding of course. We also type in specific volumes of platelets and FFP, however Cryo defaults to 20 mls. each per the blood center (lately, that is very optomistic..10 is more like it!)

We also purchased a Helmer thawer a few months ago. Great machine. Easy to use and easy to maintain. Our blood center packages Cryos like mens' hankerchefs...folded in quarters. We place 3 in one overwrap, thaw for 10 minutes, unfold the softened bags and set the timer for another 10 minutes. No problemo. We recommend using the nifty plastic inserts to compress the tops of the overwrap bags so the Cryos don't creep up above the water line (because they are so light weight). Another great feature of this machine is that the rack actually rises up above the water level when the product is finished...no more forgotten products (like with Thermogenesis). Now, if they would just reconfigure the plastic lid with some baffles to allow condensation to drain easier that would be icing on the cake. (I want free overwraps for life if they use my idea).