BldBnker

I would just like to add one 'grain of salt' to this debate.  You cannot detect all D variants - whether D weaks or partial Ds by serological methods alone. Neither D weaks or Partial Ds behave in a way that allow one to say that all D weaks  or partial Ds react with such and such a strength.  You will always miss some.  You will miss some D+ donors because their D antigen is so weak that it is not detected by even the most sensitive of routine serological tests - or because despite using at least two different monoclonals the donor has an extremely unusual variant that is detected by neither.  You will miss some 'D-neg' patients  because they have sufficiently large numbers of D-antigen sites that they give a normal reaction with the anti-D reagents used.  Follow the manufacturer's instructions for the reagent and method used and you will detect as many as you can hope to detect.  And before you shoot the manufacturers because their reagent/instrument gave a 4+ reaction with a partial D known to have 10'000 D-antigen sites per red cell, and discovered because the lady made an anti-D and she is pregnant - please take a minute to think about the theory behind the serology.  Maybe in years to come there will be a foolproof routine method for catching every single one……...

I would have got her RHD gene sequenced earlier in her pregnancy, so that I would have a better idea as to whether she required anti-D immunoglobulin.
If she turned out to be (potentially) a Partial D, or a Weak D other than Types 1, 2 or 3, I would give a double dose of the normal dose of anti-D.  Anti-D immunoglobulin is still derived from humans, which means it is a "soup" of different anti-D specificities against the 36 odd epitopes, some of which would be expressed on the lady's red cells, and some of which would not.  Therefore, some of the anti-D specificities would be adsorbed onto the lady's own red cells, but others would remain in her plasma, and would be "available" to react with the red cells of her foetus's red cells, and so would give her some protection against producing her own immune anti-D.

So, a pregnant woman tests 1+ pos with anti-D.  Do you give her RhIg?  She has many (MANY) Rh pos cells of her own, will the RhIg simply attach to those cells.  What if she tests 2+?  What if she previously tested 0 (prior method for us was solid phase (or tube)) and now tests 3+, do you change her type?  Do you give her RhIg now because you used to call her Rh neg even though now you call her Rh Pos?  What if you didn't have a prior type on her, you'd only know her as Rh pos.  What do you tell the docs when you gave her RhIg at 28 weeks when she tested 1+, but now tests 3+ and you call her Rh pos and don't recomend RhIg?
We are having more and more trouble, no idea why this seems "new" to us.  We currently have a pregnant woman who tested 4+ with anti-D in gel and has a history (at another facility) and anti-D and anti-E.
The more we talk about this the more confused we (I) get.

It was a bit of a troll question. It seemed to me that if we can't trust the reactions we get in gel then what's the point of using it. As far as I can tell regarding the IFU's Dansket is right.
I realize the importance of precision and care being taken in the blood bank, but I think a lot of times we fall victim to an overabundance of undue caution.

NO!
I am a professional blood group sereologist!

Does your Pathologist not understand that Lewis antigens are not intrinsic to the red cell membrane (in fact, in all probability, if they were discovered now, they would almost certainly NOT be recognised as red cell antigens by the ISBT).  As such, even the small amount of plasma contained in packed red cell units is sufficient to adsorb out most of the patient's Lewis antibodies in vivo, during the actual transfusion.  Those transfused red cells that survive in the circulation (i.e. about 100%) will very quickly assume the Lewis type of the recipient.  He or she might like to read Sneath JS, Sneath PHA.  Transformation of the Lewis groups of human red cells.  Nature 1955; 176: 172, as this may serve to stop the worrying.

I would do a bit more work on it.
There are two things I would do.  Firstly, I would incubate a 4oC (but would include a group O cell in the reverse in case there is a "cold" auto- or allo-antibody there).  Secondly, I would papain or ficin treat the reverse red cells (including a group O cell again as a negative control).
As long as the group A and group O red cells remain negative, and the B cells react more strongly, but not as strongly as normal, I would be happy to call it a group A.

When we had our shooting here two years ago, we just handed out emergency release OP and ON PRBCs to the ER.  There was no documentation regarding these units, and we still don't know which patients received which units.  They did not ask for blood for a certain patient, just that they needed units.  One doctor charted that he gave a unit of platelets to a patient-we didn't issue any platelets.... To comment on Carolyn's post, if we have another mass casualty, we will send a med tech down to the ER with the products in boxes with ice, and the tech will coordinate with the nursing supervisor to make sure when we hand out a unit that a sticker gets put on that patient's chart.

It must be a very interesting policy/procedure that allows falsification of information.

Agreed. It is very easy to fall down the "What if?" rabbit hole and get lost in the details. Complicated systems lend themselves to failures and unofficial shortcuts.
The various regulatory agencies were supposed to be incorporating a risk-based approach to their inspections. One could argue that it worked for a while, but now in the absence of big issues, the inspectors are back to the minutiae.

About 10 years ago I was having a deep philosophical discussion with the best blood bank medical director I ever worked with.  During that discussion I told her that I thought the decline of the American Healthcare started when physicians stopped being hospital administrators and they started hiring MBAs to run the "business".  She completely agreed with me. 

The other piece that is usually considered in those efforts to cut FTE's is that much of the time in the Transfusion Service isn't measured by "billables" as it is in the other sections of the laboratory.  The time needed to work out a complex antibody cannot be equated to running an automated line in Core lab.  Things like thawing plasma and so forth, take time, but aren't really represented by billable time.

The corporatisation of Healthcare in the US has naturally led to administrators who are more and more likely to trust other corporation's advice on how to justify business changes.  This is bad business and bad for the patients.  It seems like health care administrators who seek out advice on direction from those who are actually taking care of the patients are few and far between.
Scott

I found it amazing that one of the corporations I worked for loved hiring consultants and on any given subject they would hire one after another until they found one that would tell them what they wanted to hear.  It just never made sense to me to spend that kind of money only to search until they found someone who would confirm their chosen course of action was a good idea no matter how many others told them it was a bad idea.  One place actually fired me because I told them the CEO's idea was a bad one when a consultant was blowing the expectations all out of proportion.  Five years later they are still trying how to figure out how to make it work and it never will.  

Oh, you mean that they have suddenly woken up to the realisation that their figures don't add up, but are too embarrassed to admit it.  

Dear God, you have my deepest sympathy. 
1.  Push the company to give details on their benchmark standards and where they come from.  Chances are, you are not in the same boat.  We had a similar problem here because our Micro and BB staffing for the weekends did not meet corporate standards (desires), but we were unable to cut staff because of the physical layout of our facility and the distance between the departments. 
2.  Your situation matches one hospital I know of, if you could contact them - University Medical Center, El Paso, TX.  The Blood Bank is in the Main hospital and the main lab is way across the parking lot.  They are a level 1 trauma center and a big surgical hospital, but the NICU is in a separate hospital next to them and did have it's own Blood Bank staff.
3.  Do you have current FTE numbers that justify your current staffing?  What is the difference in the "factors" in the staffing equations that are being used that lead to this new company coming up with their figures vs. your current FTE figures?
Good luck.  Patient safety arguments sometimes sway Administrations when nothing else will.  If you can make a case for how dangerous it is for the staff of a Trauma center to be too little, too late - maybe it could help.
 

I am at a large level 1 trauma center.  In addition, we have an active liver transplant program among other specialties such as a 40+ bed NICU.  Our organization is now using benchmarking to force a reduction in FTEs.  They are using a vendor called Truven who is claiming we need to cut out staff by one third.  Our biggest problem is that we not physically located anywhere close to our general lab.  Our Transfusion Service is located in the main patient building while our general lab sits in its own separate building about 1 block away on the same campus.  It is one thing to cut FTEs when you have generalists who can cross train and be quickly pulled from general lab.  What do you do when you have no other lab staff to pull from?   I am hoping to identify if there are any other facilities who are in a similar boat, i.e. they operate a Transfusion Service that is isolated from the rest of the lab.  Also, do other folks have experience with benchmarking?  When you have no idea who they are benchmarking you to, how do you know if the "big wigs" are comparing you to the right per group?      

According to AABB Standard 5.30.2 part 2; "the woman is not known to be actively immunized to the D antigen."  We perform an antibody screen, along with an  ABO/Rh on a current sample before issuing a Rhogam. This is for ED patients and LD patients.

The patient's DAT is positive, right?  Has the patient received ABO incompatible platelets lately?  Or received Immunoglobulin therapy (gamma globulins)?  I have seen both of those scenarios cause incompatibilities with the patient's own type.  Could be either Anti-A or Anti-A,B from O platelets or the gamma globulin therapy.  

I do not open the lid intermittently, not a bad idea though

Hi - We use coolers for blood storage (1-6C) in the O.R. and some select locations in the hospital.  Validation is performed when new, once/year, and as needed, using LogTag temp recorders with probes inserted in expired RBCs.  Two trials per cooler, min (1 RBC) and max (6 RBCs) are performed.  When 6 RBCs are validated, one LogTag on either end unit and one in the middle.  I was wondering, for those sites using similar type validations, when you test your max capacity, do you open the lid intermittently during the trial or do anything else to try to mimic actual use?  Thank you.
 
 

I brought this up many years ago to one of the Reagent Manufacturing Companies (cannot recall now which one it was....Immucor, Gamma or Ortho....or maybe one of the ones that is no longer around).  When changes are made to Manufacturer's Inserts (and they can be as minor as a change in 1 word, which we can spend a long time searching for), it would be really nice if the Manufacturer would indicate the changes on the inserts (i.e. maybe italicize what is changed; or underline it; or highlight it......just give us a clue)!  We want to catch the significant changes, but not spend an hour reading and re-reading the insert to find the    ever-so-subtle and non-significant changes.
Thanks for listening,
Brenda Hutson, MT(ASCP)SBB

I don't know where you are reading this Tabbie, but I can assure you with absolute certainty that this is NOT accepted by either the Royal College of Obstetrics and Gynaecologists (see their Green Top Paper) or the British Society of Haematology's Guidelines, and the reason for this is that IT DOESN'T WORK.  I should warn you that, if you do decide to go down this road, and there is a single case of HDFN as a result, you will end up in court.

Please supply the reference for this absolute nonsense. It sounds like I would enjoy reading such fiction.

When in doubt, you can ask them at BP_Deviations@fda.hhs.gov. They're very helpful and usually respond the same day.