kirkaw

We had a dialysis patient this morning with a positive antibody screen and a negative panel except that auto control was positive. The DAT was positive with the polyspecifc reagent and anti-IgG but negative with complement. My co-worker mentioned that 'back when we did auto-controls on everybody' that we frequently saw positive autos with dialysis patients. I've never heard of this. Has anyone else? If so, what is the cause? Thanks!

To play the devil's advocate here: The infraction itself doesn't violate the CFR, it is not in compliance with your policy and procedure, which to me, would be of more interest to CAP/AABB or Joint Commission. The question is, does the omission of the immediate spin crossmatch adversely affect the safety, purity, or potency of the transfused products. What method of Coombs crossmatching is being performed? We have both a computer truth table that prevents the selection of ABO incompatible units and we did a validation study to show that gel technology does detect ABO incompatibility; therefore, we have deleted the immediate spin crossmatch when a Coombs/gel crossmatch is performed. BUT, this is NOT in violation of our policy and procedure.

I'm thinking 5 years, based on AABB standard 5.14.3, but I am not completely sure.

Thanks Everyone! We do not require a copy of the transfusion order when blood products are picked up. I suspect that we have a fair number of 'crossmatch for 2' orders with orders to transfuse only 1. This creates a lot of 'held' inventory. We transfuse over 500 red cells/month in our hospital and our average daily inventory of uncrossmatched red cells is 130 units. I feel that this is a bit much. With the Red Cross medical director's suggestion of not holding crossmatches >24 hours, I was thinking about A) requiring nursing to bring a transfusion order when they pick up blood products and asking that the physician's ordering screen NOT have an option for 'type and cross'. I hate that terminology anyway, but that is an aside. I feel that they need to assess the need for transfusion carefully before ordering the crossmatch. As stated above, we can generally get red cells ready pretty fast in the absence of alloimmunization. Any thoughts on these proposed changes from a 'best practice' point of view?

Back on topic, people! One of the Red Cross medical directors spoke to our transfusion committee and suggested that it is not efficient use of inventory to keep units crossmatched for the entire (72 hour) life of the sample. The idea is that if blood is not going to be transfused, why crossmatch it all? The proper order in this situation would be a type and screen. Agree or disagree? Please tell me why.

We dilute our Ortho Confidence antibody to QC manual gel as well. I believe this was a manufacturer's suggestion when we purchased the gel workstation.

Greetings, How long do you hold red cell units in a crossmatched status? For the life of the specimen? For 24 hours? Also, do you crossmatch the same unit on multiple patients? Thanks!

You can't really give enough Rhogam to counteract the effects of a whole unit of packed red blood cells. I believe one vial covers a 30 ml whole blood bleed. When our O neg inventory is critical, we give O pos to males and to females >50 years. In the past 3 years, we have not had to give Rh pos red cells to an Rh negative women <50 years.

Can someone (Malcolm?) explain the differences, both clinically and serologically, between CAS and a cold autoantibody?

Pool the bags right before issue. Then the product expires in 24 hours.

JC did not tell us that we qualified as a donor center because we draw therapeutic phlebotomies, but we were told that lab staff should not do the vital signs because it is outside of our scope of practice. As a result, we now have a lab person do the actual procedure but a nurse assess the patient before and after the procedure (during too, if it lasts >30 min.) This has become quite cumbersome, but we are trying to make it work. Is anyone else doing a hybrid process like this? If so, does your organization have 2 procedures - 1 for nursing and 1 for lab?

cswickard,can I ask the size of your hospital? We are considering going from Joint Commission TO CAP and the issue that you describe is exactly our concern. Thanks!

I agree with David. It has been YEARS since we had a refrigerator outside the blood bank for blood storage...for this very reason. However, if you have constant temp monitoring on the refrigerator in your OR, I would probably not discard the units.

I believe Goodchild is correct based on our JC inspection last year. As an MT with many years of experience, I only qualify as the general supervisor and I think I qualify as a technical consultant based on CFR 493.1411, but for high complexity labs, which immunohematology (BB/TS) is always considered, you must have a technical specialist who is an MD. We have crafted our job descriptions, including those for medical directors very carefully. What was confusing to us, was transitioning to the terminology that CLIA uses. The person we call our Lab Director is not really the lab director because of CLIA requirements. The person they call lab director is actually the lab medical director. As for my question about MLT versus MT, I agree that there are many MLT's that are at least as competent as MT's. BUT I have found that some recent graduates from MLT programs are lacking so much theory that their critical thinking skills are poor. It's like I have to re-do their clinical rotation education and that is very time consuming. I think that resources are shrinking and programs are having a hard time finding hospitals that have the time and personnel needed to teach students. Therefore, the quality of the clinical rotation is decreasing, making the initial training/competency needs for these new graduates tremendous. I am worried about the destiny of our profession from that stand-point. I was just wondering if other folks had had that experience.

I have to be honest, based on the original scenario, I probably wouldn't have reported this as a BPD. BUT, after reviewing the CFR, I can see how this is a reportable event. Sec. 606.171( says, You must report any event, and information relevant to the the event, associated with the manufacturing, to include testing, processing, packing, labeling, or storage, or with the holding or distribution, of both licensed and unlicensed blood or blood components. (1) (i) Represents a deviation from current good manufacturing practice, applicable regulations, applicable standards, or established specifications that may affect the safety, purity or potency of that product. In my opinion, the instance described was a labeling issue that could have affected the safety of the product.

I agree with RaeRae. That is exactly the reason that we do no do exchange transfusions.

We take the temperature of everything when it is returned, unless it is returned in one of our coolers..that has been validated.

Greetings, I am curious to know who out there, is employing MLT's (medical lab technicians) versus MT's (medical technologists. For those places that use both, do you find any difference in the quality of work of the techs? Any difference in the time it takes for orientation and training? If you use MLT's do you serve as a site for their clinical rotations? If so, how much time do they spend in your BB/TS and how much do they do (antibody panels? eluates? adsorptions?). Thanks!

In my opinion,knowledge is power. If you have access to a Technical Manual or some other Immunohematology-type text book, just start reading. Sometimes, lack of knowledge in theory and hamper your critical decision making skills, as maybe happened with your anti-M. Also, if you get a chance, spend some time on day shift and see how those folks handle antibodies and emergencies. Granted, it will be different on evening shift, but at least you can observe their thought processes and process flow. I am a supervisor at a non-trauma center community hospital and my techs call me at night, on weekends and when I'm on vacation. I'm more knowledgeable on day to day stuff than our pathologist. But I also TALK to people and see if there's any learning opportunity that they need to make them more confident, whether that's doing an in-service with me, having me work with them for part of a shift or having them join us on day shift. It's a coordinating effort but well worth it. I want my techs to be confident and one of the better ways to do that is teach them where to find the information they need and how to make good decisions.

I feel the same way about going from gel method to tube method (no enhancement), which happens where I work. That being said, if you have a patient that has a previously identified cold, but the current antibody screen is negative in gel, what crossmatch method would you use?

I have been reading about this too...and very little seems to apply to strictly BB/TS testing. We do not use any 'kits' that we do NOT do QC on day of use. Nor do have any instruments with internal QC. Is anyone doing anything differently as a result of this initiative? Thanks.

I am considering scheduling myself on a 2nd shift and a partial 3rd shift once/quarter to get direct observation done for folks on those shift. It is difficult to get all 6 elements done for each test that produces a result. Plus, I feel obligated to assess competency on things not strictly required by CLIA like product dispense and component preparation.

We have been charging both patients in the situation initially described and never had Medicare or any other insurance kick it back. There are lots of things we cannot charge for, so I don't see what is wrong with charging for something the patient NEEDS, even if it wasn't ordered for them originally. If anything in this scenario seems unethical, it's charging the 1st patient for the antigen typings on blood he/she did not receive. But I agree with the person that stated that this can be a nightmare, because that account might already be weeks old and closed out.

We had a rigorous JC inspection this past summer and the timing of QC was not questioned. They did however, state that every bottle of reagent, used for tube, gel or automated testing needs QC run at least once daily. We have 2 sets of reagents for our Provue that are changed at approximately 7 AM and 7 PM. they are always the same lot #. Prior to our inspection, we were only running QC on the AM set. The inspector told us we needed to run QC on the PM set daily also, But she did not remark on a timeframe. I have studied the JC standards, CLIA and AABB standards quite thoroughly, and I do not recall any standard that states that QC needs to run +/- 30 min. of the same time each day.

Our Joint commission inspector in 2012 said that staff transporting blood should wear gloves. Our 2014 inspector disagreed, saying there was no biohazard sticker on a unit of blood. The issue of an outer covering/bag never came up.