Confirmation of ABO/Rh Type

[jhaig]

How does everyone handle retyping of patients with no previous blood type history? I've heard of doing two separate blood draws, two techs doing typing from the same tube, two aliqouts from the same draw, and others, but I'm just trying to get a overall idea of what is the easiest way to do this.

[rcurrie]

It depends. What is your intent, to ensure that the blood type is interpreted correctly, or to ensure that you have the right patient? If you want to ensure that the interpretation is correct, then a retype by another tech is the way to go. That is what we do. If you want to ensure that you have the right patient, then two separate draws is preferred. I don't believe in doing this because I know what nurses (and some phlebotomists) do when they know that they will be asked for a second draw: they draw two tubes at the same time, send you one, then when you ask for another draw they send you the other.

BC

[Mabel Adams]

I am trying to figure out a way that a small place can do anything meaningful with the new retyping rules.

We seldom have more than one tech working BB and on nights have at least some time when there might be only one tech in the whole lab. Weekends occasionally have only one tech trained to do BB on duty for at least a few hours.

Do I try to have the second type done by another tech maybe hours later--maybe flag the units that they can't be issued till the repeat is done??? Or do I just meet the letter of the law and have my same tech toss the cell suspension and repeat the type himself? I don't really want to have separate rules for different shifts, but I also want extra work to provide some meaningful benefit.

[jhaig]

We're in the same situation. We usually have only one tech in blood bank and the off shifts cover the rest of the lab as well as the blood bank. If a patient has a type already on file in the computer, we accept that history check as the first 'type'. The second type is performed on the current draw. At the present time, if the patient has no history, the blood bank tech performs a repeat ABO off of the same draw. This is done out of necessity since on the off shifts not all techs are trained in blood bank. On night shift, where there is only one tech, they have to have the ability to release units and can't wait for another tech to check their work.

My main concern is that the right patient gets drawn. Our phlebotomy team performs all of the draws at our hospital (nursing has all the power and doesn't have to do anything they don't want to do). In my experience, if a phlebotomist can cut a corner, they will. So asking them to do two separate draws for a repeat blood type is asking for trouble and would not serve any purpose for us. They could very well draw two tubes on the first draw and then send you the second one later, saying that it was a redraw. So we really rely on phlebotomy to draw the right patient the first time. They cannot draw a patient without a hospital wristband and they will then place a blood bank wristband on the patient as well.

I'm just not sure how CAP/AABB will interpret our policy as it relates to the new standards. Because of our staffing situation, I feel like I'm stuck between the proverbial rock and a hard place.

[rcurrie]

Mabel, why don't you just have everyone in the lab, regardless of any section they routinely work in, trained and competent to perform the ABO/Rh? That is such a simple test that I would hesitate to hire anyone not willing to remain competent to perform it or retain anyone not willing to perform it. They are techs, are they not? Some things are so fundamental that it is shameful to not be able to maintain competency to perform.

Alternatively, you can have a policy to issue only O cells until another tech performs the retype.

Just to be clear about what is up for discussion, you are only talking about the requirement for retyping when a computer crossmatch is used and there is no patient history, aren't you? There is no retyping requirement unless you are performing computer crossmatches.

BC

[BSIPHERD]

Mabel, When we don't have a historical type, we require a repeat front type if units are allocated. It can be done by the tech who did the first type. But our requirements are that it be done on a new cell suspension prepared after the units are allocated.

The reason for after the units are allocated is to separate the repeat in time from the original type, to make a repeat of the same mistake less likely.

[rcurrie]

"We're in the same situation. We usually have only one tech in blood bank and the off shifts cover the rest of the lab as well as the blood bank. If a patient has a type already on file in the computer, we accept that history check as the first 'type'. The second type is performed on the current draw. At the present time, if the patient has no history, the blood bank tech performs a repeat ABO off of the same draw. This is done out of necessity since on the off shifts not all techs are trained in blood bank. On night shift, where there is only one tech, they have to have the ability to release units and can't wait for another tech to check their work."

I think your repeat policy is just fine. As far as I can tell without reading the exact wording of the SOP, it meets AABB and CAP requirements for computer crossmatches. When we only have one tech and we get a patient who has no history, we revert back to performing the ISS crossmatch until a second tech can repeat the ABO. That is overkill, but it works for us.

BC

[jhaig]

So the same tech can perform another ABO on the same specimen if the patient has no prior history present in our computer (Meditech) system? I guess I'm a little confused on the 'computer crossmatch'. Is this the same as an electronic crossmatch? We perform all of our compatibility testing in gel unless an emergency presents itself. In reviewing the AABB standards for electronic crossmatch (5.14.2.1 - 5.14.2.5) our system meets all of these requirements. Maybe I'm just confusing myself with terminology or it's just too close to the weekend...:cool:

[rcurrie]

Computer crossmatch = electronic crossmatch

There is absolutely no requirement for a second type except for institutions using computer crossmatches. "Computer crossmatch" is the term used by both CAP and AABB.

This is from CAP:

"A computer crossmatch is an electronic method that is used to confirm that the unit is appropriate fortransfusion to the intended recipient through the use of validated software logic to determine compatibility, rather than serologic techniques.

This section does not apply if the laboratory does not perform computer crossmatches."

The Computer Crossmatch section of the checklist begins with checklist item TRM.40660. The "repeat ABO type" requirement under this section is TRM.40670:

"Has the recipient's ABO blood group been verified by repeat testing of the same sample, a different sample, or by performing a historical search of laboratory records?

NOTE: Verification of the patient's ABO blood group must be performed by repeat testing of the same sample, a different sample, or a historical search of laboratory records for that patient. Repeat testing of the same sample may be inadequate unless the sample has been drawn using a mechanical barrier system or digital bedside patient identification system."

The AABB Standard is 5.15.2 Computer Crossmatch. The retype requirement is 5.15.2.2:

"Two determinations of the recipient's ABO group as specified in Standard 5.13.1 are made, one on a current sample and the second by one of the following methods: by retesting the same sample, by testing a second current sample, or by comparison with previous records. Standard 5.11 applies."

My guess is that some of the people who are confused by all this do not understand that these two requirements pertain ONLY to computer crossmatches. There is absolutely no such requirement if you perform ISS crossmatches or AHG crossmatches.

BC

[Mabel Adams]

Except for the new CAP item (50575 or something) that seems to strongly suggest reyping patients.

On the AABB site I asked if anyone was planning to meet this requirement by doing anything other than retype the patient and no one answered. This CAP requirement is the one I have to meet. I may choose a method that also meets the electronic xm requirements because we may want to go to it anyway if we have to do all the work.

As for other techs doing the blood type--they already have full-time jobs and we are understaffed as it is. It isn't whether they are capable opf learning, but whether we can further disrupt the workflow of the whole lab to pull them into BB. Not that this is impossible, but we will be begging if management and the other depts don't buy into the necessity.

[rcurrie]

Mabel, which checklist are you looking at? There is no TRM.50575 (Transfusion Medicine checklist). The 50000 series of checklist questions are all Personnel questions, regardless of what checklist you are looking at. If you find it, let me know, as I would hate to have overlooked one that I am not meeting the requirement.

We retyped patients even before we did computer crossmatching, but it has never been a requirement. Only with the advent of computer crossmatching has the retype been required.

As far as "strong suggestions" goes, it has always been up to the institution to heed or not. No one can penalize you for failing to heed a "strong" suggestion or any suggestion. As the judge always says, "I will take your suggestion under advisement," meaning, "No way, Jose'."

BC

[jhaig]

So the bottom line is... CAP and AABB have requirements for retyping only if the blood bank performs electronic crossmatches, and if the blood bank performs a serologic crossmatch, there is no specific requirement for a retype.

[rcurrie]

"So the bottom line is... CAP and AABB have requirements for retyping only if the blood bank performs electronic crossmatches, and if the blood bank performs a serologic crossmatch, there is no specific requirement for a retype."

Yep. That's the way I see it. That said, it is still good practice to do a retype, and if it were up to me in my lab, we would issue only type O blood until we got a second specimen. And that said, if you do an ISS, it will detect an ABO mismatch, which is all the retype is designed to do. I always look at the ISS as a type of ABO retype.

BC

[Mary]

It is CAP TRM.30575. What a controversy this has created!

[jhaig]

This is one of those checklist questions that CAP seems to specialize in, a question that is vague at best and leaves the standard open to multiple interpretations. We'll continue to do retypes as we have but it seems like they want more. They give suggestions like an electronic ID verification system. I don't know if anyone has noticed, but a barcode system is extremely expensive to adopt, especially in a medium to smaller sized hospital like mine. As long as each institution can figure out how to monitor their own transfusion system, then CAP should be happy. And how does having a separate blood bank wristband (Hollister, Typenex, etc.) with another independent blood bank identifying number on it not satisfy this requirement to reduce risk in transfusions?

[rcurrie]

In my opinion, the best risk-reduction system is to verify the patient's blood type with an historical check or a second draw, provided you can guarantee that you truly are getting a second draw. However, that second draw guarantee is hard to come by. I have done many misidentification investigations, and have uncovered standard practices where the collector, knowing that a second specimen request was most likely to appear, would draw two specimens, hold one back, then send the second specimen when it was requested. I only feel comfortable when I have an historical match with the current specimen. I have seen the same phenomenon with blood cultures when ordered "x 2, 15 minutes apart" or "x 2, different sites." Therefore, at this point in time I have no intention of implementing a second draw policy, regardless of the TRM checklist recommendation. I made this decision knowing my institutional staff and their tendencies. Everyone else should go through the same decision-making process rather than blindly instituting a policy with no real basis for doing so.

BC

[Eagle Eye]

Ok. CAP revised the checklist on 10/31/2006. They revised TRM 30550 and added new phase -I question TRM.30575, this is where using seperate BB band is not sufficient. Retyping from 1st specimen is not sufficient either.

I called CAP and there suggestion is to draw second specimen but we can also have two person checks at the time of phlebotomy.

Or we can have a system inplace capable of reducing the risk of mistransfusion.

Remember this is for non-emergent red cell transfusion.

**NEW** 10/31/2006

TRM.30575 Phase I N/A YES NO

Does the laboratory have a plan to implement a system to reduce the risk of mistransfusion for non-emergent red cell transfusions?

NOTE: Mistransfusion occurs from misidentification of the intended recipient at the time of collection of the pretransfusion testing sample, during laboratory testing and preparation of units to be issued, and at the time of transfusion. Misidentification at sample collection occurs approximately once in every 1,000 samples, and in one in every 12,000 transfusions the recipient receives a unit not intended for or not properly selected for him/her. The laboratory is expected to develop a plan to reduce these risks through implementation of a risk-reduction system. Among options that might be considered are: (1) Documenting the ABO group of the intended recipient on a second sample collected at a separate phlebotomy (including documentation in the institution’s historical record); (2) Utilizing a mechanical barrier system or an electronic identification verification system that ensures that the patient from whom the pretransfusion specimen was collected is the same patient who is about to be transfused. The laboratory may utilize any one or more of the above systems, or another approach capable of reducing the risk of mistransfusion. The laboratory should monitor the effectiveness of the system that it implements.

Simply using an additional banding identification system does not satisfy the intent of this checklist question.

**REVISED** 10/31/2006

TRM.30550 Phase II N/A YES NO

Does the facility have a documented program to ensure that the risk of pretransfusion sample misidentification and other causes of mistransfusion are monitored and subjected to continual process improvement?

NOTE: The laboratory must actively monitor the key elements of the transfusion process, including, as applicable, donor management, unit production and handling, sample identification and testing, and the transfusion itself including recipient identification.

[rcurrie]

The laboratory may utilize any one or more of the above systems, or another approach capable of reducing the risk of mistransfusion.

Here is what we do to meet this checklist question. We have a multidisciplinary team (doctors, nurses, lab, unit clerks) to address specimen labeling. Does it meet the test (capable of reducing the risk)? You bet- not only is our system capable of reducing the risk, it has actually reduced the risk. We have reduced specimen labeling errors by 50%, and continue to gnaw at the numbers. We consider it a specimen labeling error when the requisition and specimen labels do not match, and that type of error is the one we see the most. Education, reporting, and corrective action are the key components of our system. We had a meeting today, and we had 20 team members present. We have created a computer module that anyone who collects blood must complete annually.

We would love to have a system that uses barcode technology at the bedside. But, such a system would cost millions of dollars for our institution, which has close to 30 clinics, many of which are the size of a small hospital and some of which are the size of a large hospital. We will not get such a system unless it is mandated by law, and that isn't about to happen any time soon.

BC

[msmc]

Mabel, you are right. CAP item #30575 strongly suggests a second type. What I plan on doing is if we have a CBC or H/H sample in the lab then that sample will be used as the 2nd ABO provided that it is properly labeled. Other than that a second phlebotomist would have to be sent to the patient for a second sample.

[jhaig]

Mabel, you are right. CAP item #30575 strongly suggests a second type. What I plan on doing is if we have a CBC or H/H sample in the lab then that sample will be used as the 2nd ABO provided that it is properly labeled. Other than that a second phlebotomist would have to be sent to the patient for a second sample.

Sounds like this would work. I'm wondering, however, when this second type would be performed. Would a previous draw done before the blood bank order was placed be used? Or would you wait until another specimen is drawn later, after the crossmatch has been completed? And if so, would you hold the units until the blood type is confirmed?

Or does it even matter as long as you have a properly labeled specimen when you actually do the second type?

It sounds like CAP is leaving it up to each institution to figure out a system which can reduce the possibility of misidentification. It would be nice if the patient wouldn't have to be drawn twice just for a blood type. Until CAP says we need two separate draws to confirm ABO, I'd prefer a method similar to this one being suggested, as long as the specimens are properly labeled.

[rcurrie]

Mabel, you are right. CAP item #30575 strongly suggests a second type. What I plan on doing is if we have a CBC or H/H sample in the lab then that sample will be used as the 2nd ABO provided that it is properly labeled. Other than that a second phlebotomist would have to be sent to the patient for a second sample.

What is important if you decide to use a second specimen is to insure that it is truly from a separate draw. If you use a purple top tube submitted for hematology testing as your second specimen, there is a pretty good chance that it was drawn at the same time as the blood bank specimen. The issue is not testing a separate specimen, it is testing a separately drawn specimen.

BC

[msmc]

The plan is to use samples that were drawn before the BB sample. If those are unavailable then a 2nd phlebotomist must go a restick the patient for the 2nd type. We have not yet implemented this. I was hoping to gather suggestions from the postings so that maybe we wouldn't have to have multiple sticks.

[msmc]

The laboratory may utilize any one or more of the above systems, or another approach capable of reducing the risk of mistransfusion.

Here is what we do to meet this checklist question. We have a multidisciplinary team (doctors, nurses, lab, unit clerks) to address specimen labeling. Does it meet the test (capable of reducing the risk)? You bet- not only is our system capable of reducing the risk, it has actually reduced the risk. We have reduced specimen labeling errors by 50%, and continue to gnaw at the numbers. We consider it a specimen labeling error when the requisition and specimen labels do not match, and that type of error is the one we see the most. Education, reporting, and corrective action are the key components of our system. We had a meeting today, and we had 20 team members present. We have created a computer module that anyone who collects blood must complete annually.

We would love to have a system that uses barcode technology at the bedside. But, such a system would cost millions of dollars for our institution, which has close to 30 clinics, many of which are the size of a small hospital and some of which are the size of a large hospital. We will not get such a system unless it is mandated by law, and that isn't about to happen any time soon.

BC

So basically the team keeps track of any mislabeled samples and implements training and competency for those employees who draw samples? Sounds like a great plan especially since you have the data showing your success in reducing risks and patients are no restuck. Our lab has a similar approach to tracking mislabeled samples but I never thought that it was enough the meet CAP requirements. Thanks for the idea!

[jhaig]

What is important if you decide to use a second specimen is to insure that it is truly from a separate draw. If you use a purple top tube submitted for hematology testing as your second specimen, there is a pretty good chance that it was drawn at the same time as the blood bank specimen. The issue is not testing a separate specimen, it is testing a separately drawn specimen.

BC

If we were to institute a second re-draw, how should I go about investigating whether or not it is being followed? I would anticipate having similar problems with my some of my phlebotomy staff drawing two purples at the same time then changing the time on one of them and submitting that specimen as the "second draw". If this happens, then I've got a policy which does accomplishes nothing.

I could also see a potential problem on our night shift where there's only one tech and one phlebotomist available. If the phleb draws a patient with no history in the computer, the tech cannot go draw the patient for the retype since they are not allowed to leave the lab unattended. There must be a happy medium somewhere.

[Mary]

What guarantee do you have the the other sample (i.e.CBC) was not mislabelled?