amym1586

We do not charge for wastage . . .  some is acceptable, but if it is not we refer the incident to quality

Liz & David~
Will the fetal screen kit you use detect the cells of a weak D+ fetus?  Ours (Immucor FMH RapidScreen) doesn't, so we can't do it until after delivery & Rh is known (or we would risk a potential sensitization on the off chance the fetus was weak D+ and a large bleed was missed).  If your kits do detect them, I'd love to hear about it so we could reduce the K-B we perform.  Thanks!

I'm wondering if you use a different kit than us (Immucor FMH RapidScreen)?  Our package insert states that it can only be performed after delivery of all products of conception (so not after an obstetrical event mid pregnancy) and only on a known D negative mother and recently delivered known D positive child (but not a weak D infant).  In the event of an event <20 weeks, we give one vial.  If >20 weeks w/ unknown infant type (so most amnios), we have to do Kliehauer to quantitate a potential bleed.  We routinely have student interns and our mantra w/ them is "if you don't have a baby, you can't do the rosette test".  If there is another kit option that permits it, I'd love to hear about it!

Oh I understand completely!   I have not been the blood bank supervisor here for very long. They do a few things I do not agree with.  I'm working on so many things but  I hope to get this process fixed.

Currently we are doing     Autocontrol in Gel.  If positive--> Poly DAT in tubes.  If positive--> IgG DAT in tubes.  Then mass confusion.   

First and foremost...if you are going to go back and do a DAT because the AC came up positive, make sure you do it with a freshly made cell suspension.  Also, if taking that step and you have the reagents, test with polyspecific (PS) and IgG at the same time  since you suspect it will be positive.  If you only test with PS and it comes up positive, you'd have to make ANOTHER fresh suspension to test with IgG if you were going to do that.  The 10-12 minutes it takes to do the PS test is too long for cells to sit in suspension for an accurate IgG DAT.

The following are our criteria for performing a KBT:
Order a KBT on an Rh-negative obstetrical patient for any of the following:
post-delivery Fetal Screen test is positive,
trauma during pregnancy (ordered by the physician),
mother had a vaginal bleed, fetal death, terminated pregnancy, amniocentesis or CVS at > 20 weeks gestation,
mother had a version procedure, and/or
neonate is Rh-negative with a positive or invalid Weak D test, or Rh cannot be determined.
At less than 20 weeks we issue one dose of RhIg without further testing, other than the type and screen.
 
CarrieM has nicely summarized the use of the Immucor FMH RapidScreen if that is the kit you are using.
 
Additionally at delivery, we use an on-line calculator recommended by the AABB to determine the amount of RhIg to be given based on the mothers height/weight:
W:\AB\Bloodbank2\CAP AABB RhIG calculation\RHIGCALe.zip\

For what it's worth...we really don't do that many.  We are a large hospital (450+beds) w/ trauma center, and we average maybe 1 per week.  We don't even have our 3rd shifters maintain competency. Most of the miscarriages are early enough that they don't need quantitated so we just give one vial.  We just get the occasional amniocentesis or late loss on an Rh negative mom & trauma/fell down and bumped belly to perform the K-B's.  It is on our fetal demise & pregnant trauma order set, but it's just not that common.  Take care

We will perform a rosette test if the pregnancy has reached 12 weeks but not routinely.  If we have request from the E.D. for RhIg due to a threatened abortion or trauma we would perform the test.  We do not use it for routine antenatal RhIg requests.  Usually we have an antibody screen early in the pregnancy and another performed with the antenatal RhIg request.

I'm not sure I understand the question...
In order to perform a fetal screen (rosette test), you must know the infant's Rh type as it is not valid on a weak D infant.  This is rarely known in an early loss.  For a loss/bleeding up to 20 weeks gestation, we do an antibody screen to make certain that the mother is not previously sensitized to D, and give one full dose.  After 20 weeks, we would perform a Kleihauer-Betke for a loss/bleed if the infant's type is unknown to determine if > one vial is needed.
 

For every test 'system', you must evaluate competency with all of the following elements:
Direct observation - test performance, including patient preparation, specimen handling, processing, testing, performance of instrument maintenance, function checks Review recording and reporting test results, review worksheets, QC records, PT results and preventative maintenance worksheets Written exercise to assess knowledge of policies and procedures, problem solving skills Verbal questions which are related to the task or job performance to assess knowledge of lab and Blood Bank policies, procedures and problem solving skills Survey participation - must analyze samples according to policies and procedures used for patient testing and must get the 'correct' results Practical w/ wet samples to assess test performance - can use previously analyzed samples or blind samples So, if I'm evaluating competency for the test system 'antibody detection', I would observe the tech performing an antibody screen. I can ask them to use the Echo and repeat the test manually. They would be expected to perform any necessary QC. The sample they are using could be a patient sample from normal work flow OR I could use a wet sample (blind sample)/survey sample. Using the second option covers 2 elements in one observation. In addition, while the tech is working I would ask questions about how the testing was performed, what he/she would do if a particular problem arose, instrument trouble shooting questions, what if blood is needed before the screen is finished, etc. That's 3 elements covered. Once they've finished with the sample, I can review their documentation and that would cover all or part of the 4th element, depending on what they did.
The more elements I can pack into the direct observation time, the quicker the tech is checked off. In this example, if I included questions about antibody detection - problem solving, method, etc in the written exercise, fifth element checked off. Once that person has done a survey sample, element #6 is covered.

 

I have used both types of specimens - real and fake.   I prefer the fake (expired unit of red cells and plasma).   I can make up a lot of fake specimen and can use one for each associate.  By using a fake specimen, the answers are known and will be the same for each tech (I don't have to remember what the results should be if using a different patient sample for each tech).   All DOs are done with the fake specimen.   Results are recorded in LIS and on any worksheets.    Any instrument maintenance is included in the testing DO.   A test is included for each test system.       I am sure there are so many other ways to accomplish competency.  I have attached a CMS document that I have found very helpful. 
how-lab-personnel-competency-assessments-041316.pdf

Someone please tell our administration this!

I wholeheartedly agree with what you say here Marianne, and that is how I have found most inspectors in the UK.  Sadly, though, much as I would like to say that is how I have found ALL inspectors in the UK, I have come across a minority (not just one, but certainly a minority) who have gone "well over the top", and the work involved in successfully defending the "non-conformances" "found" by such inspectors is dis to the proportionate to the seriousness of the "offence".
As all inspectors are supposed to be "singing from the same hymn sheet" (i.e. looking at the same standards), I fail to see how the inspectors can vary so wildly in their findings, or how the same inspectors can call the same non-conformances either elsewhere, or at the same establishment at the next inspection; surely, they should be re-trained?
Sorry for the rant, because the vast majority of inspectors are, as you say, well trained, educated in the subject and have, also as you say, the patients' care in their mind.

Hi Malcolm- no apologies needed (and that was far from a rant, haha).  I know there are the few out there that are perhaps a bit overzealous or misfocused, been on the receiving end of that myself!  I once did call the AABB office prior to summation to contest what was going to be cited and the process worked.  The AABB lead in the office listened to the inspector we had and then to me and told the inspector she was incorrect.  So the process worked.  I probably would not have done that in my younger days of managing, but with age comes wisdom.

I've been through many inspections / surveys / assessments over the years.  I have found all of them to be biased, it's just a degree of how much they are biased.  Also, pretending that "tracers" are being done well is frustrating.  For us, it turns into "go gather lots and lots of records on patients we are tracing and let's go sit in that room and plow through those records".  So often the inspectors do not talk to staff.  That is a shame.  We are a large, complex organization, I would imagine it would take 5 people a week to review all of the Standards for us, but we got 3 people for 1.5 days the last time.
I think the one that comes the closest to getting it right is FACT.  You must submit a pre-assessment checklist that covers every Standard (and their Standards are free for download and very concisely written).  Then when they come, they review every single Standard - they can do this because you've already submitted your checklist and you're prepared.  There is no bias on picking and choosing what Standards they like or have time to assess.  The one thing I will ding them on is again, not spending time with staff.
Phew, I feel better.  I am not knocking anyone in this thread, I think the system is very flawed and offers no real value to patients or donors.

Now let's not be harsh here.  Some of us have been AABB inspectors for many years and have only one head and no fangs :).  It requires a lot of CE,training, time and dedication to being a volunteer inspector.  The majority of people  that perform these assessments try very hard to do a good job for the site they are inspecting against the Standards.  Quality and patient safety are why labs choose to be accredited by AABB and the assement is part of what they pay for-it helps to ensure they are meeting the standards to deliver best care to their patients.
That said I will jump off my soapbox. The form and instructions to submit and the 30 day due date for sending in your corrective action plan is part of what is left at the end of the assessment with your non-conformances.  Records and document control are important and a constant challenge for any of us to stay on top of.  Not having a good plan in place for managing change control can lead to serious holes (like missing new standards) so you will definitely want to make sure you have a good policy/procedure in place to guide you moving forward.  So amym1586 has some work ahead of her (and her team should be part of that work).  This thread has provided some great advise and direction (as always) and it will take some time to get through it all.  Don't get overwhelmed, make a plan, do your research, ask here and on the AABB HUB for copies from others willing to share (never recreate the wheel-who has time for that!) or check out the recommended practices on the AABB website and take it one piece/procedure at a time. 

I think a few months is acceptable.  They will be more interested in evaluating your root cause and proposed corrective action than the timeline (I suspect).

Yes, we charge the floor/unit responsible for the waste.

No,  I wish we did.  

From experience let me tell you that staffing is much more of a justification for automation than numbers of tests.  A small rural hospital that is staffed with only one or two techs at a given time would find automation invaluable regardless of the number of type and screens they perform.  Automation can literally be life saving under short staffing situations and I'm referring to patient lives not staff!   

That's certainly terrifying. Thank you for sharing.

Our basic post-transfusion work up includes clerical check, hemolysis check (pre & post), icterus check (pre & post), post ABO/Rh, post DAT, pre DAT if post was +, elution if the post DAT is stronger than pre. Additional testing is ordered if any of these results dictate.  A blood culture of the bag is requested if there is unexplained hemolysis in the recipient, or when a fever greater than or equal to 39 degrees C. or an increase in temperature of at least 2 degrees C over pre-transfusion temperature is reported.
We encourage and constantly educate nurses to identify and call transfusion reactions.  We have found that physicians tend to be dismissive, and want the unit continued.  An area hospital actually transfused the entirety of a contaminated platelet because the physician paused, gave Tylenol, and continued the unit.  The patient died.
Hives/urticarial only requires clerical check.  We require pathologist OK prior to issuing another unit. The only time we will allow a transfusion to continue is if hive/urticaria are the only symptoms. 
We continue using the original specimen for crossmatch.

Yeah, I've done plenty of KB stains at my old hospital ( I don't miss them )
I've been here for a year and so far have not had one patient need one.
I just wonder if that will suffice to give one dose of RhIg to an Rh Neg Weak D pos mother of an Rh Pos baby.  Or if more testing is required.
I guess we are getting by with our procedure of them not being a candidate but I don't like that.
 
I still don't understand why there is so much gray area in blood banking. I feel like there should be way to do it and that is the way to do it. 

What size tubes do you use?
Is the red cell suspension made from whole blood or packed cells?
Do you leave the plasma on the red cells in one tube during and storage?
 
Thanks!