Tube Groups- decline of ?

[RR1]

Just had a meeting today where it was mentioned that there are some labs in the UK where staff don't know how to perform tube groups, and are totally dependent on gel groups. This is beginning to worry me...should I be worried?

[Eagle Eye]

That is why when I train my MT student they get trained by traditional tube technique. Even when I hire new employee first few week I make sure that staff is completly trained in tube technique then I switch over to gel. We have ProVuu and manual gel as our primary technique.

But everyone need to know traditional tube technique. We still use tube for our trauma. I tell my student that if you know traditional tube technique, you will be fine. semiautomation or automation is easy to learn.

[Eagle Eye]

That is why when I train my MT student they get trained by traditional tube technique. Even when I hire new employee first few week I make sure that staff is compltley trained in tube technique then I switch over to gel. We have ProVue and manual gel as our primary technique.

But everyone need to know traditional tube technique. We still use tube for our trauma. I tell my student that if you know traditional tube technique, you will be fine. semi-automation or automation is easy to learn.

[Fluffy agglutinates]

Tubes are getting very old school nowadays! It really makes me feel my age & I thought I was quite young

We run a 5 day practical intro to transfusion science here at the National Blood Service. On the first prac we make them do 5 tube ABO's (forward & reverse) & they absolutely hate it! They come away thankful for the column technique but appreciating what used to be done. Most of the attendees we get are hospital based & have never used tubes for anything. I think we are in a 'de-skilling' time.

What really strikes me is the amount of labs that no longer have access to cellwashers - in my opinion that is definitely a skill that should not be lost. There's a beauty to serology that is taken away by columns (but I appreciate their own 'brilliantness'!).

Just wait unitl we're all doing microarrays - no serology at all!

Hopefully it's still a way off though...

[Malcolm Needs ☆]

YES, YOU SHOULD MOST DEFINITELY BE WORRIED.

There is an old saying that "you should learn to walk before you learn to run" and another that goes along the lines of (and I paraphrase, because I cannot remember the exact phrase) "Those who don't learn from history are destined to re-live it".

There are very many occasions when tube techniques are still superior to column agglutination technology, liquid phase microtitre plate technology and solid phase microtitre plate technology, not least in cases of a "cold" auto-antibody of wide thermal range.

One of the main reasons that I insist that all of my staff are adept at and all of my students are aware of tube grouping and tube antiglobulin techniques is so that they have a basic (and I use the term in the meaning of fundamental) knowledge of how human (patient) IgM molecules and IgG molecules react and, most important of all, what are the fundamentals of the direct and indirect antiglobulin techniques. Without such knowledge, they are learning by rote, and will perform as a person who has learnt by rote.

I REPEAT, YES, YOU SHOULD MOST DEFINITELY BE WORRIED.

[RR1]

Hi Fluffy aggs, i'm surprised folk hate doing tube groups....when I have visiting students I get them to test by tube and they absolutely love it...becomes the highlight of their time in Pathology.

You are right Malcolm...how do they get a group result on a cold- aggs sample?

I was also informed that in an urgent situation they reduced the centrifugation time of their gel cards...I hope they validated their technique!

[John C. Staley]

When was the last time any of you saw a hemocytometer in Hematology?

Think about it!!

[RR1]

I think John has a very valid point !.....so, if we did away with tubes (for grouping only), and we had a faster gel grouping technique (to deal with the trauma cases),would there be a situation where a group discrepancy could not be determined by gel? I must admit - have not tried to group patient with cold aggs using gel yet.

If we take this even further.......why are we even bothering to perform reverse groups?

JUST BRAINSTORMING !- PLEASE be nice Malcolm!

[Fluffy agglutinates]

Hi Rashmi, it's the labelling that gets them! They do love actually being able to do manual work though. Most of the attendees no longer do much beyond machine monitoring & the occasional panel (& even they are starting to be done on the analysers).

I'm definitely with Malcolm & yourself - it does worry me a lot.

[rescyth]

do you still wana do mouth pippetting??? but seriously, it doesn't hurt to know tube methods.

[Fluffy agglutinates]

Please don't go down the 'H&S gone mad' road

I've never seen anyone hurt themselves with a tube!

[Malcolm Needs ☆]

Please don't go down the 'H&S gone mad' road

I've never seen anyone hurt themselves with a tube!

Sorry Fluffy, but I have.......but it was on a plastic tube! These were brought in because they were thought to be safer than the glass tubes (by someone in H&S who didn't actually work on the bench - heard that one before?) and the cut was far more jagged and deep than I've ever seen with glass in a Laboratory.

Well now Rashmi, where shall I start!

"cold" auto-antibodies can be a pain when you are grouping in gel, as they usually group as AB forward and O reverse. However, if you wash the patient's red cells in warm PBS a few times, before suspending for the actual test, 99 times out of 100 you will get a sensible forward group. As long as the negative control works (and this is a MUST) then you can ignore the reverse group, on the grounds that you are using incredible strong and specific monoclonal antibodies in the forward group.

As far as I know, we haven't killed any patents yet (but give us time)!

[RR1]

Thanks Malcolm, but it's so much easier centrifuging your group tubes,sticking them in the incubator for 10-15mins then reading...... hasn't failed yet.

But I suppose when we do go totally tube-less for groups- will have to do it your way.

[Malcolm Needs ☆]

I know you're not going to believe this Rashmi, but I actually agree with you (now there's a first!).

[OPUS104]

We get regular calls about smaller hospitals not getting valid Gel ABO's. They want to send them in for workup because they dont have the reagents or experience to deal with basic ABO problems. I have never used Gel for ABO and dont plan on it here. (Blood center, not hospital) I can do an ABO in about 2 minutes so I'm not sure what the trauma references are about. (I'm sure theres a situation in the hospitals I'm not aware of there) How are anti-Ms handled? A or AB subroups with anti-A1? I personally dont like the lack of basic blood banking knowledge needed to push a button and put on a sample. NO I dont want to mouth pippette, but it would be nice if I roll into the ER to think the tech in charge of my life can solve a simple ABO dicrepancy.

[Malcolm Needs ☆]

Could not agree more with you OPUS 104.

[transfusionpgi]

YES, YOU SHOULD MOST DEFINITELY BE WORRIED.

There is an old saying that "you should learn to walk before you learn to run" and another that goes along the lines of (and I paraphrase, because I cannot remember the exact phrase) "Those who don't learn from history are destined to re-live it".

There are very many occasions when tube techniques are still superior to column agglutination technology, liquid phase microtitre plate technology and solid phase microtitre plate technology, not least in cases of a "cold" auto-antibody of wide thermal range.

One of the main reasons that I insist that all of my staff are adept at and all of my students are aware of tube grouping and tube antiglobulin techniques is so that they have a basic (and I use the term in the meaning of fundamental) knowledge of how human (patient) IgM molecules and IgG molecules react and, most important of all, what are the fundamentals of the direct and indirect antiglobulin techniques. Without such knowledge, they are learning by rote, and will perform as a person who has learnt by rote.

I REPEAT, YES, YOU SHOULD MOST DEFINITELY BE WORRIED.

Dear Malcom,

I fully agree with you and just to complete your quote - "Those who don't learn from history are destined to re-live it"

was originally written as ""Those who don't learn from history are liable/ prone to repeat its mistakes".

[Malcolm Needs ☆]

Thanks transfusionpgi, I knew it was something like that!

[TimOz]

I have to agree that unfamiliarity with so called "old fashioned" methods can bite you.

I was recently teaching for the WHO in Cambodia. I had done a preliminary survey to find the lay of the land (and the mines) to decide the most locally appropriate curriculum and to arrange translation.This may sound strange to many in the developed world but I started the wet workshop component off with grouping in tubes followed by tiles - and I mean real bathroom tiles. The posted WHO consultant (who was a Singaporean) went nuts. "Tiles are old fashioned" and so on. Half way through the practical the power went off the the whole hospital and stayed off for 40 minutes. It did that 4 times during the day and does this almost every day. I also showed her how we set up a full patient group in tube and the ABD check group on tile. I asked a local staff member to do a group and check group both in tube and they did it from the same cell suspension - not actually understanding why this was a bad idea. We went out that night and bought some more tiles for the equivalent of 20c. She soon got my point. All this apart from the high rates of cold aggs and autos they get that are hard to handle in gel. And they simply do not have the money.

This in a setting where I saw staff wander into the lab with unlabelled blood samples. The staff would Immediate Spin crossmatch a unit of blood and send it out unlabelled back to the ward. Frightening.

Anyway. I firmly beleive that all real IH staff need to have the old fashioned skills. They may not use them often and this makes it harder to keep them current but they will need them.

[Malcolm Needs ☆]

Once again Tim, I couldn't agree more with you.

When I first started in this delightful field in which we work, I was taught to perform the antiglobulin technique on tiles (by Carolyn Giles and Joyce Poole no less). Admittedly, the reactions were not as "crisp" as we see today (not least because the AHG was awful in those days), but one thing you could quite often see was reactions due to different antibodies in a mixture coming up at different rates. This was extremely useful in sorting complex mixtures, as it gave you a clue as to where to go next.

Ah, happy days!

[RR1]

Dear Tim,

I think you need to write a book. We are all waiting with baited breath for your next post on this forum- it's great having you share your knowledge with us.

many thanks

[Tonyd]

I'd just like to echo points made on here regarding deskilling and loss of serology knowledge in hospital laboratories especially.

CAT systems are an integral part of the high volume, fast throughput pathology world we live in at the moment, but it breaks my heart when I teach graduate students who have no concept of what is actually going on in those columns and have no idea of how to apply 'old-fashioned' serology to resolve discrepancies that will inevitably appear on a daily basis.

You only have to look at the SHOT report to see how inadequately performed manual techniques can lead to major morbidity in patients, and we now have a generation of healthcare professionals whose expectations of automation, IT and electronic systems in general lead them to ignore basic science and common sense.

[eric1980]

TimOz: By any chance, is the WHO consultant you mentioned by the name of Tan Meng Kee?

To topic: IMHO, BBers should expect to be proficient in tube method, until the time comes when the challenger method performs better than the tube method is every aspect. I am expecting tube method to be phased out in the next decade or two.

[marilynm]

If tube technique is so "outdated' or archaic, or whatever, why do almost all the 58 IRL (Immunohematology Reference Laboratories), which is all but 9, in the US, use TUBE technique for all their testing!!

Sorry, but I think tube testing is here to stay, even if it is not the main technique used in a lab.

Marilyn Moulds

[RR1]

I agree, in which case we need to make sure all our lab staff know how to perform this correctly. This basic test cannot be forgotton or ignored by labs using full automation and deskilling their workforce.