Lcsmrz

I work in a small rural facility running the Meditech system. The only BB thing still on paper is reagent QC and equipment PM, since the effort to put these online wouldn't be worth the small payback -- but I'm thinking about it! Each workstation has a PC, and reactions are entered as we read them. We've almost eliminated the transfusion form, too. Modern enterprise systems are very good: mirrored, automatic backups, redundant. You still need a good backup system, just in case the network goes down, but it's pretty rare. Our operation is mostly plagerized from larger sites I've inspected over the years. We consider ourselves "paper lite", not paperless. But being a green-thinking, tree-hugging Libertarian, any paper I can eliminate is fine with me. You just have to give up the ways things have been done for 30 years and be able to sleep well at night.

We transitioned away from our manual backup patient cards a few years ago, after two years online. First, we entered any "positive" cards not in the system. Then, we had a second person verify the presence of the "positive" records in the online backup system. Finally, we filed the small number of "positive" cards in our store room for 10 years, even though I doubt it we'll ever look at them again. The remainder of the cards were discarded.

The purpose of the cell washer is to automatically remove protein from the cells, not to produce a dry button. The automated decant cycle of all cell washers I've used will inevitably leave a small amount of saline, as will a manual decant unless you're really, really good at blotting it. I guess the question is how much is too much, and we defined it as one drop (25uL?) A small amount of residual saline will not affect the test results. DAT testing can be performed with a 3% cell suspension, which is almost all saline in the drop you add to the tube. Since moving to gel, we hardly ever use our cell washer anymore ...

I follow the recommendations in the product insert: saline cell control for Anti-IgG and 6% Alb cell control for Anti-C3

We do testing on cord bloods only on request. For admitting panels for NICU, we require a heel stick sample and repeat the testing on that sample. In most cases, the NICU sample arrives before the cord blood, so we just cancel the latter.

The security code is an option on our TransLogic system and on most pneumatic delivery systems. Used mainly by Pharmacy, Blood Banks can use it also.

When I worked with a consignment system, I would do that annually on Jan 1st. Now, I do a monthly reconciliation to account for every unit. Our bean counters never ask me to do anything special.

Someone in the great wisdom years ago (not me) purchased a two-slot plasma thawer, so that's the maximum we can thaw at one time. We do not relabel for 5-day plasma, and we discard 1-2 plasma a year.

If a duplicate account is inadvertently created, it can be merged with the original. The computer tracks the merge for us. Otherwise, I've seen a variety of processes for correcting patient reports, but all are messy. Our current process is to "correct" the bad results with the alpha "See comment", which places a huge footnote on the result (previoiusly reported ... as xxxxx) and reorder on the correct patient using our downtime restore procedure. We try to be careful with explanatory comments -- I particularly like the "nurse mislabeled specimen" comments that techs like to use. All changes to verified records are considered incidents that are documented, investigated, etc. They are also treated as critical results, with call comments appended. We have an audit to make sure are documenting everything correctly and consistently.

How true, John! Until a few months ago when I redid the dictionary, our computer would allow incompatible platelets, but not incompatible FFP. I don't recall a published study concluding that the isoagglutinin titers in apheresis donors are less than the titers in whole blood donors

There are alot of Blood Bankers -- esp old Blood Bankers -- who don't like the temp guns. They measure surface temp (which changes very quickly) and are subject to the emissivity (how efficiently heat is given off by the material). They are thought of as less accurate than a NIST-traceable Liquid-In-Glass thermometer, so many sites use them as a screen (if out-of-range, retest with LIG thermometer). I felt the same way, until I had lunch with a Metrologist many moons ago, who changed my views on temperature measurements forever ...

I've heard that the TAR will be fully functional in the next version, scheduled for late 2008/early 2009. We're on C/S v5.6, and we're validating a partially-functional "intervention" system that allows the nurses to document online.

I believe there is a chart in the Tech Manaul for giving non-group specific plasma, based on isoagglutinin titration studies in donors. It's listed in my SOP for those situations you describe. I vaguely remember -- and I "vaguely remember" just about everything nowadays -- that the Anti-B in group A donors is usually less than the Anti-A in group B donors, with group O plasma as your last resort. We set a maximum "incompatible" plasma that can be transfused without getting the Medical Director involved.

I believe the AABB has a publication for validating tube systems ...

Acceptable range for a timer is dictated by the event you are timing. If it's an manual enzyme reaction, it could be very compact, whereas if you're timing BB tube incubations at 37C, you have a little leeway. We use ~2% as an acceptable deviation from out NIST device (2 sec every min) for BB events, and we've switched to all digital devices to achieve that. My procedure manual specifies acceptable ranges (37 +1 C, 10-15 min, etc). Freezer range is determined again by the application. If you're storing frozen plasma, -18C or less is what you're shooting for. However, if in the same freezer you're also storing some reagent that needs -20C or less, then that becomes your standard. And if you're trying to store frozen plasma and a reagent needing -10C to -20C, you only have a 2C range to operate within -- difficult to maintain! Same with using a a BB Storage Refrigerator to store blood products (1-6C) and RhIg (2-8C). Your operating range is really 2-6C, and with alarm activation temps a half degree from the the edges, your cabinet must consistently hold 2.5-5.5C. And it gets even trickier when using a backup refrig or freezer. It has to meet the same operating criteria as the original.

Gel is just another way of looking at good ol' agglutination. You get the cards into 37 C fast, so cold auto's are less likely. Reactions are stable for days, so I review them the next day (small facility). Small volumes are helpful, but the system is almost too sensitive. There is a learning curve when switching from tubes to gel, but I wouldn't give them up!

I think there should be a difference between a Reference Lab and the rural 100-bed hospital: one stocks multiple panels, while the latter is lucky to stock one. One panel will have modified rules to decide when to call an ID and when send it out. Our little hospital with one panel uses one homozygous or two heterozygous cells (apologies to Dr Judd) to rule-out antibodies, with the exceptions of Anti-C and -E in the presence of Anti-D.

Transfusion Reactions are currently part of our annual Skills Fair for nurses, although we're considering going to on-line modules in the future.

Check out Labsco, too, in Indianapolis.

I don't think there is a regulation that says you have to use Anti-C3, but it's a good idea! When a physician orders a DAT, the usual expectation is that both IgG and complement will be included. It's also very useful in post-reaction workups. I know the thinking: C3-coated check cells are expensive. But it's worth having them for the above reasons.

Eoin: I would like a copy of your audits also. We are in the process of revising ours ... Thanks! Larry

Our policy is that the unit be completely infused by the exp time (usually 23:59) on the exp date. Any remaining product should be discarded. If issuing an extremely short-dated product (such as plts or cryo), we let the transfusionist know the policy at the time of issue. Theoretically, if a unit was issued at 23:58 and infused within 60 seconds, we would be in compliance ...

With the Tech Manual recommending "within one hour" and the product insert saying "wait 1 hr, then ASAP thereafter". the only time to be in compliance with both is EXACTLY at 60 mins post-delivery -- just what the PA wanted! The next question is at what point of the delivery process does the timer start ... I'm hunting down the original reference to this recommendation. We've been drawing with the AM CBC for ages, as is everyone else I contacted in Indianapolis. While nucleated cells and ABO-incompatible cells are probabably cleared within a few hours, compatible fetal RBC's have a relatively normal lifespan in the maternal circulation. Waiting 71.9 hrs is probably not good, but a 8-12 hrs delay to save an extra venipuncture seems like compassionate care to me. If the worry is about accurately quantifying incompatible fetal RBCs before the maternal antibodies destroy them, isn't that what the RhIg is designed to do anyway?

That's exactly what I was trying to avoid in the future ... There's a discrepancy between the Tech Manual and the product insert. Can you tell me here it's located in the Tech Manual? Doesn't seem to be in the FMS section ...

Am I thinking correctly -- or just tired from working extra covering for vacations? An associate -- gotta love students and new employees! -- remembers being cited at a past facility for not collecting a Fetal Screen shortly after delivery, immediately after Stat cord blood testing confirms baby is Rh positive. Those of us reading product inserts know the wording is close to "at least 1 hr after delivery, but as soon as possible thereafter". I've always defined that as "with the next AM CBC." Injections are always given within 24 hrs. A quick google search for something later than 1990 and rereading Bowman's more recent talks yielded nothing. So, other than a fading memory of something I read in the past, I have no quick evidence that the citation was in error. (Personally, I think it sounds more like a CYA statement, prevalent in many product inserts.) While I'm not disputing that an expeditious RhIg injection is probably advantageous, the logistics of testing Stat cord blood, a Stat phelbotomy and a Stat Fetal Screen 24/7/365 seems a bit exagerated for the low clinical benefit. And I'd rather give the new mom a few hours rest before disturbing her with an unneeded blood draw. BTW, this person is definitely a Democrat: "If we can prevent just one mother from forming Anti-D ..."