adiescast

I intend to leave the chart wheel system in place when we go live with our system because that will be the downtime backup and I don't want people to have to search for charts and not remember the process. I am willing to tolerate the duplication of effort for now.

You don't always know if a patient has sickle trait, so I think it would be difficult to apply the policy to them. Our policy is sickle negative for people with SCD.

I hate to be ignorant, but I was always under the impression that cord blood plasma could produce unreliable results in antibody screening. Stickiness from Wharon's Jelly and all that...

We also have a 1-2% rbc wastage rate (this is all forms of wastage, but outdate is probably most of it). We are the end users in our system, however, and usually receive shorter dated blood because the blood center knows we will use most of it. We are a level one trauma center, >800 beds, open heart surgeries, NICU, massive transfusion protocol, etc. We have a blood conservation program started that we hope will reduce our usage.

Trouble?

We had a case like this in which the mother had high titer anti-D and Anti-C. The fetus had multiple IUT infusions before birth and did not require exchange after birth. The funny thing with this child is that he never recovered his D type (or hadn't at 2 years out, which is the last we saw of him). I don't remember his C/E type off hand.

Bill is correct. If an assessor/inspector sees that, they will note that it does not follow your procedure. Is your lab excessively cool or are your samples pulled directly out of the refrigerator before use? That could be part of the problem. It is also possible that you happen to have a patient population that is more prone to rouleaux. As others have mentioned, you could look at electronic crossmatch and get rid of the problem almost entirely.

When we had a Lab Assistant, she did all that Brenda lists, plus order supply inventory and stock it when it came in, perform alarm QC on the freezer and defrost it, call for transfusion confirmations (a whole other story, very time consuming), clean waterbaths, etc. Basically anything non-technical. She did not do retypes, but she did enter units in the computer and do label checks. She was wonderful. The reason I did not replace her when she left was that my staff got reduced (yet again) and I needed more flexibility in scheduling, so the position that went away was hers and not a tech.

I also love my Helmer freezers, but I have to admit that we had power problems with them in the beginning. This was because the information Helmer gave originally about the freezer did not accurately represent the power level the freezer needed. Now that we have the right power going to them, they work beautifully. I can't give you a comparison to Follett because I have not heard of them.

We also have adult volunteers. We have computer based training for all persons who transport blood products.

There was some discussion about this on one of the AABB audioconferences. It seems pretty clear that the person on the CLIA certificate will have to sign off on all new and significantly revised procedures for the entire lab ("more than a full time job, if you ask me, which no one did," says Eeyore). My own CLIA director is very resistant at this point, so I am not sure how we will implement this. The CLIA director does not have to sign the annual review, only new and revised procedures. The blood bank medical director can do the annual review of unchanged procedures.

At least 30 C is less than the 42 allowed for a blood warmer. Unless, of course, it was more than 30 in the sun...

That depends on the situation. If the temperature goes out of range and is detected and quickly remedied, the reagents are retained. If the temperature goes out of range and is not detected (some institutions do not alarm their reagent storage devices), then you have to evaluate the tolerance of those reagents for the temperatures they were exposed to and how long they were exposed. Often in the latter case, you do have to discard the reagents. Remember that your blood typing reagents and screening cells are often exposed to room temperature for hours at a time before they are placed back in refrigeration.

Excuse my ignorance, but I thought that tubes from which you have taken part of the sample are not good sources for hemoglobin measurements because you may not have removed the constituents evenly. I know our Hematology department refuses samples that have been spun regardless of whether or not we have removed anything.

Sorry, I brought up the issue of security. I don't know how it is handled in your country. My intent was not to elicit details, but to suggest that it is good to have a process to ensure that what you want to happen is actually what happens. You say no one enters during use of the device. Is there a process to ensure that no one enters? Does the process work? The organizations you mentioned are not the ones who track security of radiation sources and are unlikely to cite you on that issue. That is not to say that others would not be interested in your security, since cesium stolen from your irradiator could end up elsewhere (just as ours could). Everyone would like the cesium to stay where it belongs.

The main issue here in the US would be one of securing the device, if it is a cesium containing one. How do you ensure that no one walks through while the device is in use?

Cord blood labeling is really a bad problem. The cord blood comes down labeled with Mom's ID information. The only baby information on the sample is the gender (sometimes) and the bracelet number. The order comes down with the baby's ID information. What we did was to have the computer pull mother's ID information and print it on the requisition so that we can correlate the sample. Alas, we had a computer change last weekend that seems to have thrown that off...hopefully we will be able to get that repaired soon!

All tissue is handled by the OR. I consult some to help them be compliant with the regs.

We mostly use the scope for fetal screens. I tell my techs that they aren't seeing anything significant for a crossmatch or antibody screen unless they see boulders in the field. Some people like to call it positive if they see a few cells kissing. I tell them they are being voyeurs and they need to quit peeping! Seriously, I only had problems here with one older tech who was absolutely reliant on the microscope. She looked at everything under the scope. I finally did an exercise with her to improve her confidence in her reading skills and then had her keep a log of when she used the scope and what she saw. We discussed it weekly for a month. We made a pretty significant reduction in her use of the microscope before she retired.

We don't even perform weak D typing on most patients, so we give Rh negative also.

FDA also likes to see annual training that is specifically titled cGMP training. Otherwise you will spend time explaining how the non-titled training was, in fact, applicable to cGMPs. Make sure your staff is aware of the FDA terminology, as it sometimes differs from CAP and AABB.

A sample for anyone who has been transfused or pregnant in the last 90 days has to be drawn within 3 days of the transfusion. If you have a patient with antibodies who has not been transfused or pregnant within the last 90 days, the rules are a little vague. I would recommend drawing a fresh sample for crossmatch so that you don't run into problems with the antibody activity fading from sample age and storage issues.

I believe special requirements in this case means irradiated, leukodepleted, etc, although checking other instructions such as use blood warmer, split and give slowly, premedicate, etc would be advisable also. This standard just codifies what the transfusionist should have been doing from the beginning.

On the killing of sons, remember your childhood and be merciful. It is very difficult to be a highly intelligent (surely your son is!) and quizzical being with few internal controls and no interest in obedience (if he is 12, he isn't even close to the point of making some of these logical connections without object lessons). Let him wear the paint for awhile until it grows to the point you can cut it. Alternately, you can apply some paint thinner judiciously and possibly get most of it out with that and a shampoo and brushing. There is a lesson in everything.

OK...perhaps I have missed something here. Why would pregnant patients be excluded from electonic matching if they have a negative screen and a negative history? Why would multiply transfused patients be excluded? The only patients we exclude from electronic matching are patients with current or historical antibodies (not to argue with Malcolm's point several posts below, which is an interesting way of looking at it), patients for whom we were only able to obtain one type before emergent transfusion this round (automatically excluded by the algorithm), or patients that fall out because the computer has some special dislike for them (our sickle cell patients have information in the computer file about their antigen status so we can match them and the computer excludes them because of that). On Malcolm's point about electronic matching for patients with antibodies, I think one part of the problem is that not everyone will guarantee that the unit is antigen negative (unlike his illustrious institution). I know we have received units that were incorrectly labeled. A second point is that there are antibodies for which we provide crossmatch compatible rather than antigen typed units. A computer algorithm would not be able to account for that situation.