gagpinks

I agree completely. Hence why I wrote "partly due to their poor expression". And, don't forget, if antibodies to Lutheran system antigens are in part IgG, they are often they wrong subclass to readily cross the placenta (IgG2 and IgG4).

From the UK BCSH guidelines (these can be found in the reference section of BBT- Library/ UK/ compatibility guidelines):
7.7.2 The specificity of the antibody should only be assigned when it is reactive with at least two examples of reagent red cells carrying the antigen and nonreactive with at least two examples of reagent red cells lacking the antigen. Note that,wherever possible, the presence of anti-Jka, anti-Jkb, anti-S, anti-s, anti-Fya and anti-Fyb should be excluded using red cells having homozygous expressions of the relevant antigen.

Thanks Malcolm !!
I will definitely mention your name.

Just HOW ridiculous is that?
In the UK, even UKAS, which appears to be an accreditation service set up to serve its own ends, rather than that of the laboratory or the patient, allows Biomedical Scientists and Laboratory Aides to "transfer" their competencies from one laboratory to another, if the tests are the same.
This ruling from CLIA seems to me set up to justify THEIR existence, rather than help either the laboratory or the patients, but will end up creating more and more (unjustified) work for all concerned, for no benefit - and they wonder why they get a bad reputation for making such stupid rulings.

I just joined the site, and have some questions about competency assessments.  We have staff that rotate between two different campuses of the same hospital, but the labs have different CLIA numbers.  So we were recently informed that we have to demonstrate competency at each site where our staff works.  (Even though we use the same procedures, follow the same standard work, and have standardized things completely.)  So I am trying to put this into practice without overwhelming our staff, but I still want to make sure we are doing a thorough check.  We have a high percentage of new staff right now, so I don't want to half-a$$ it.
Question 1:  Competency must be assessed for every "test system," but what are the Blood Bank test systems you assess?  Do we need to assess competency for every method of testing we use every year?  Or would I be able to assess IAT as a test system and rotate yearly on what method we use?  I cannot seem to find any Blood Bank-specific listing of test systems that require annual competencies!  It seems pretty clear for other areas, but I am getting a bit stressed out trying to make sure we are fulfilling the requirements for CAP/AABB.  And I also don't want to overwhelm our staff with 17 yearly competencies.  
In my lab, we perform the following tests:
ABO/Rh - automated gel and tube testing Antibody screens - automated gel, manual gel, and tube testing DATs - manual gel and tube testing Antibody titration - manual gel and tube testing Antibody identification Antigen typing Elutions Fetal bleed screens Question 2:  How do you handle items that you want to do a competency assessment on that are not tests?  For example, we do quite a bit of component preparation, so we generally try to do an annual competency assessment and direct observation of our staff splitting a platelet into a pediatric dose.  I am familiar with the 6 elements of competency assessment (show below), but I struggle with how to apply these to processes.
"The following six (6) procedures are the minimal regulatory requirements for assessment of competency for all personnel performing laboratory testing:
Direct observations of routine patient test performance, including patient preparation, if applicable, specimen handling, processing and testing; Monitoring the recording and reporting of test results; Review of intermediate test results or worksheets, quality control records, proficiency testing results, and preventive maintenance records; Direct observations of performance of instrument maintenance and function checks; Assessment of test performance through testing previously analyzed specimens, internal blind testing samples or external proficiency testing samples; and Assessment of problem solving skills."  
Thank you in advance!  
Susan

Well David, I see your problem, but I may be able to suggest an answer.
Firstly, the anti-D seems to be quite weak (which is what made me think of my proposed answer).
Secondly, of the "common" Rh types, the R2R2 type has the highest number of D antigens per red cell (15 800 to 33 300), and so will tend to give stronger agglutination than will an R1R1 (which may explain why you are getting agglutination with all your R2R2 cells).
Thirdly, and turning to the R1R1 red cells, some of these may, of course, be R1r', rather than R1R1, and, therefore, have fewer D antigen sites per red cell (about 9 900 to 14 600, compared with 14 500 to 22 800) and, unless the donor is genotyped, or you can do an informative family study, you may never know (but remember the Cepellini effect).  In addition, the number of D antigen sites expressed on a "normal" R1R1 can vary quite a lot from one individual to another (and, indeed, from one cell to another, in the same individual).  In other words, those R1R1 red cells that react with your patient's anti-D could be near the "22 800" end of the spectrum, whilst those that do not react with this anti-D may be nearer to the "14 500" end of the spectrum.
All figures are taken from Geoff Daniels' book, Human Blood Groups.  3rd edition, 2013, Wiley-Blackwell, page 205.
I am not saying for one moment that this is the only, or the most logical explanation, but it is, at least, one explanation!

Need to rant!
 
I had a tricky one yesterday - massive obstetric haemorrhage on an ANeg patient. No group on the patient so AB plasma issued (both rhesus postive and negative), A positive stock platelets given and ONeg flying squad units.
 
It was a total mess!
 
Firstly they came to the lab wanting units without even requesting them, the sample was still in the centrifuge so flying squad units were issued. It was at this point that the lab person asked theaters if they were wanting to initiate the massive haemorhage policy. They did. The theater person was sent away with two units of flying squad blood and told we would phone when we had blood available. The FFP was put into thaw and stock platelets ordered from our sister lab. By the time the sample was on the analyser and had 8 minutes to go. 
 
The theater person turned up and requested 4 blood, 4 FFP and 1 platelets on the baby and had brought down the notes for the baby. We informed them that we hadn't even had a sample from the baby but could take the neonatal flying squad if needed. Rang theaters and they informed us it was the MHP pack for the mother not the baby! The person collecting the products hadnt actually brought the proper noted with the transfusion request, but an addressograph sticker... Theater person was sent away for the correct notes and told the blood would be ready when they returned.
 
They returned and took the blood and FFP - left the FFP paperwork so obviously didn't do the proper checks on it. Called them back to collect the paperwork and gave them the platelets to which was now ready.
 
Next they were on the phone complaining that the platelets were Rh pos. We told that this was fine and we would issue anti-D and just to transfuse. We issued the anti-D and another theater person came down to collect it. When they arrived they didn't have any patient identifiers at all so was sent to collect the notes. Their response was 'why do I need to check again if my colleague as done all the checks already?'. Staff member was reminded it was both national and local policy and the reasons for this. When she returned she was rude and huffy
 
Half an hour after the platelets were collected we received another call claiming they couldn't find the product number on the anti-D to complete the checks (they were looking at the lot number, not the unique identifier). They informed us at that point that they 'couldn't issue the platelets until the anti-D had been given'. They were informed that they had 72 hours to give the anti-D and they shouldn't be withholding platelets in a MHP situation!
 
Grief - imagine if we had run out of rh neg blood and had to issue rh pos?!?! We only had 4 units left at this point
 
Anyway they gave the platelets and anti-D.
 
A few hours later we received another call to say that they had found the baby's cord blood but the person who took it had left and they hadn't filled in a form. My colleague (wrongly) told them to send the sample with a form signed by her and we would accept it.
 
The sample arrived and was labelled as 'baby of YYYYY' when it was baby of XXXXX.
 
Could any more go wrong?? And I was the one who had to fill in the incident form
 
The staff involved are being retrained and competency assessed and the transfusion practitioner is going to do a talk about 'suitable' instead of 'compatible' in an emergency situation and issue firm guidelines.
 
I left with a headaches that day
 
Why can people just not follow policy

This was told to me when I was a med tech student (in ancient times): Better a live patient than a dead "pure" one.
Still holds.

I spoke to the theater sister who was still uncomfortable about giving rh pos platelets - I explained that in a massive haemorrhage situation the aim was to stop the patients exanguinating, not to prevent an antibody developing. That if the patient developed an antibody it would only ever be a problem if she had a rh pos baby in a future pregnancy - it would not pose a transfusion problem as we would transfuse Rh Neg units anyway. That if the patient did have an antibody, and was massively bleeding then we may have to transfuse incompatible blood just to maintain fluid volume - that this would be inconsequential as the reaction would be occuring on theater floor, and we could deal with a delayed transfusion reaction a few days down the line when the patient was recovering.
 
She still claimed it went against everything her gut told her. Both I, and the transfusion practitioner, told her that her gut reaction should be to prevent the patient from bleeding out by ensuring that the suitable blood was transfused in time - that ABO was the only thing to worry about in a MHP situation.
 
I think she was still uncomfortable...

Thanks Malcolm 

I am winding up 43 years of blood banking on Friday. I will still drop in to PathLabTalk from time to time but I'm not sure how frequently that will be. I would like to thank all of our BB Talk family for sharing their knowledge, insights, advice, hints, constructive criticism and everything else that makes this site so wonderful to us BB geeks. I would particularly like to thank Cliff, without whom this site would not exist, and Malcolm, for being himself, a consummate blood banker and consummate gentleman (even when he's dressed in my pajama bottoms - but that's another story!)

Hi Tabbie,
You are correct in saying that the two techniques should be taken separately, but the reason that paragraph 6.2.6 mentions the antigens Jka/Jkb, S/s and Fya/Fyb in particular is that these are the antibody/antigen combinations that show "dosage".  However, I'm afraid that I disagree with the Guideline when it states that a single example of a red cell showing homozygous expression of the antigen can be used to exclude a specificity, unless the donor has been genotyped to ensure homozygous expression of the relevant gene, and I know that NHSBT (at least) does not do this (although it does test expression by flow cytometry (I've never seen this proved as a way of demonstrating a "genotype", I have to say).  Unless a genotype is undertaken, then a donor who has the phenotype, for example, Fy(a-b+) can be either FYB/FYB (a true homozygoyte) or FYB/FY (an "apparent" homozygote), and you would never know, until the patient reacts with a donation that is Fy(a-b+) (true homozygote), which would be too late.  I still think that two examples of red cells is much safer, with very little extra expense.
Yes, we do this all the time in the Reference Laboratory, although, once again, I am a little worried about so doing, but trying to find r'r', Jk(b-) red cells (even for us) is very difficult indeed, and in this case, the expense could not be justified.  In the case you give, why not just give rr, Jk(b-) blood, as if there is a proven anti-C present?

This is our policy also.  Almost all c negative units will be E negative so we trust to statistical luck for patients with anti-c.  We started this policy long ago when one edition of the Technical Manual recommended it.  When the wording was changed to say some recommend it, I considered our situation and continued the policy.  We are several hours away from our blood supplier so if we have caused an anti-c to develop we can't get c negative blood imported quickly like we could if we were just across the city from the supplier.  We could screen for it but would have similar results as described above after the supplier saves out the R1R1 units.  Also, our region has a lot of small hospitals that don't do Ab IDs.  I feel that this policy preserves the chance of finding crossmatch compatible blood or even to expect that O negative will be compatible with a patient with anti-E in an emergency (Rh negative is about 99% E negative).  I have never had a hemorrhaging patient with anti-E saved by this policy so maybe it is overkill, but that is our logic.  We have the added benefit now that our supplier sends us a batch of 10 historically negative units (for various random antigens) every Friday that usually includes some c negative units.  That has been a big help.

there was an article on this in the last issue of the biomedical Scientist.  When I read it, I have to confess,
a - I didn't really understand the point and
b - moved one step nearer to total despair about the useless requirements that might have sense in chemistry but in IH just get in the way of doing useful work
I'm ranting again

Hi Malcolm 
Sorry about using wrong terminology , and yes I would love to learn from you. We arre monitoring this lady as per guidelines. It was just thought came in mind because she developed anti-c during pregnancy.  We have performed antibody identification at room temperature and it was reacting strongly 4+( anti-c).

If baby'sDAT is negative and mother antibody screen is negative at the time of birth or  within 72 hours. There is no need to perform antibody screen on baby sample and that result is valid for up to 4 months. 
 

Could it be the modified KB that is being developed? If you do a KB then dip in Geimsa for 5 seconds it stains the nuclei making it easier to differentiate between lymphocytes and foetal cells.

Yes first time heard.  We have 2 remote fridge one in maternity and one in theatre for emergency o neg and recently  we had UKAS inspection but they didn't raise any NC. In fact they actually went to examine both remote fridge. 
 

In the UK we are forbidden from having remote sites now. We have O-Neg, CMV neg, K-neg, HEV neg, units. We do not have irradiated units, or less than a certain date as we do not have babies who have undergone IUT, and if we do we are notified in advance and we get irradiated units in for them.

If baby'sDAT is negative and mother antibody screen is negative at the time of birth or  within 72 hours. There is no need to perform antibody screen on baby sample and that result is valid for up to 4 months. 
 

Holy Cow!  Something is wrong here!  The proposed rule by CMS as sent to CLiA inspectors states:
"In proposed § 17.415(d)(1)(i), a CNP would have full practice authority to provide the following services: Comprehensive histories, physical examinations and other health assessment and screening activities; diagnose, treat, and manage patients with acute and chronic illnesses and diseases; order, perform, supervise, and interpret laboratory and imaging studies; prescribe medication and durable medical equipment and; make appropriate referrals for patients and families; and aid in health promotion, disease prevention, health education, and counseling as well as the diagnosis and management of acute and chronic diseases."
 
So not only are these "super" RNs allowed to do lab tests, but also apparently radiology and other imaging, as well as diagnose disease? This can't be correct.  Something is being mixed up here in the reporting.
 
Scott
 
 

I sincerely hope you are correct Scott.
I have the utmost respect for nurses and transfusion practitioners (many of whom started out as nurses, but neither they, nor many haematology doctors (let alone general doctors) should be allowed anywhere near a blood transfusion laboratory, without extensive training and education - something that we have been exposed to for many years.

Most of the common Rh antibodies have been reported as IgM. A "saline-reactive" anti-E is probably the most often seen. I've personally seen an anti-e that appeared to be IgM.
Way back when, in the dawn of time........there was serious concern over examples of IgM anti-D potentially causing ABO reverse typing discrepancies - hence why the commercial reverse calls are all Rh-.

Hi , we have in the last couple of weeks had two cases of patients with anti-c , reacting with the A cells of the blood group, i have never saw this before ( only the usual cold reacting antibodies such as Anti-M etc)  and was just wondering if this is something that others experience and why this is happening? The supplier has confirmed that the A cells are A neg (rr) cells. 
 
 
Thanks
Tricia 

Hi Tricia,
It isn't actually that uncommon a phenomenon, and is due to the anti-c being, at least partially, IgM in nature.