E Crossmatch and Second ABO

[yiams]

Blood Bankers, We're finally beginning work for a Cerner Millenium Blood Bank module. We wish to perform electronic crossmatching with this module. We've had a question come up regarding AABB Standard: 5.15.2.2: Two determinations of the recipient's ABO group (from Standard 5.13.1) "The ABO group shall be determined by testing the RBCs with anti-A and anti-B reagents and by testing the serum or plasma for expected antibodies with A1 and B reagent RBCs."

For other facilities performing e-crossmatching, do both samples for ABO determination need to have Back Types performed?

The impression we get from others is that the primary sample has Front and Back Type but the second determination is Front Type only. Is that correct? The way this standard reads it sounds like Front AND Back Types need to be performed on BOTH patient specimens.

I should also mention we do NOT have a bar code readers for our blood drawing personnel.

Thanks,

[Auntie-D]

Not sure about how it is in the US but in the UK the second group can be just a forward group.

I did work in one lab that allowed EI on 2 groups done on the same sample - needless to say they lost accreditation at their first inspection

[David Saikin]

A forward type should suffice. If you have a historical type that also suffices as one of the two.

[Steven Jeff]

I did work in one lab that allowed EI on 2 groups done on the same sample - needless to say they lost accreditation at their first inspection

That is an example of inconsistency of the inspection process. At a meeting of the South Thames Technical Advisory Group in Blood Transfusion Science in January this year, electronic issue was a hot topic on the agenda. There were hospitals that require two samples to be tested with a minimum of 30 minutes between collection of the samples and those who test the same sample twice. Both these groups of hospitals were accredited. One of the arguments that developed was that the focus should be on robust phlebotomy procedures that ensure that the correct sample is taken the first time, and personally that is my view, after all it is possible that two samples can be taken at the same time and labelled with different times. Or even worse two samples could be collected from different patients and labelled as the same, which is the correct one?

Robust phlebotomy is the key, not how many samples we test.

Steve

:)

Edited December 2, 2011 by Steven Jeff
spacing

[mhc]

A forward type should suffice. If you have a historical type that also suffices as one of the two.

I think that if a patient has not been previously typed, that 2 forward and reverse groups are required. They can be on the same sample, but FDA recommends against it.

[SMW]

As you referenced, the AABB Standards appear pretty clear on this. For the "Computer Crossmatch" Standard 5.15.2.2 requires two ABO determinations performed according to 5.13.1--which specifies a forward and reverse type be performed. So yes, for a computer crossmatch, a forward and reverse type is required to be performed twice. Many facilities currently requiring two types, but not doing a computer crossmatch, may only do a forward type on the second or "check" sample. The AABB Standards only address the need for a second type in relation to the computer crossmatch.

[tbostock]

We use either a historical blood type or a separately drawn sample (and we do a full blood type, forward and reverse) as the second type before we perform electronic crossmatch.

[Malcolm Needs ☆]

You will have to excuse me if I am a bit cynical about all this.

According to all the rules/Laws/whatever you want to call them, if you perform a serological cross-match, you only need one sample. So, if the sample comes from the wrong patient, and the patient dies from an acute haemolytic transfusion reaction, but a serological cross-match was performed - that's okay.

If you have more than one sample from the wrong patient, you can perform electronic issue - the patient can still die - but that's also okay.

A very good freind of mine told me a story (my friend, for whom I have immense respect, and the hospital involved, will remain nameless). A sample was taken from a patient, and the sample was grouped as A+. For some reason, goodness knows why (fate?) the hospital concerned contacted another hospital where the patient had been previously, and they had grouped the patient as O+. So, my friend's hospital asked for a second sample from the patient. The second sample grouped as A+.

My friend asked for a third sample. This also grouped as A+. He/she was still not happy, and so went up to the whilst a fourth sample was taken. This one grouped as O+.

It turned out that the patient really was O+. The phlebotomist had taken blood from the wrong patient the first time, but on the second and third time (by then having "recognised" the patient) did not do the full checks, and just took the blood.

So, if the Laboratory had not been suspicious in the first place, a group O+ patient would have been given group A+ blood by electronic issue, and would probably have had a fatal acute haemolytic transfusion reaction, however many samples had been tested.

This business of more than one sample for electronic issue is just smoke and mirrors, and does not necessarily give any extra safety (and we all know of stories where the two samples were taken at the same time, but labelled and sent to the Blood Bank at different times).

I'm sorry, but these rules/Laws are complete rubbish. Steve is absolutely right, when he says that the key is a robust phlebotomy system.

Edited December 2, 2011 by Malcolm Needs

[Auntie-D]

There are talks about giving only ONeg until a second sample has been received thus eliminating ABOD problems. In the case above it wouldn't work but I think it could be a good idea - if only we had enough ONeg

[tbostock]

We don't allow the same person to draw the second sample. The second sample is drawn by Lab phlebotomists using MobileLab, a handheld device that is used to scan the patient's wristband and prints the label on a small wireless printer at bedside. If you allow the same people to draw the second specimen, you're asking for trouble, as Malcolm described.

It is also our policy to give type O until two independently drawn types match. We don't have to do it too often because most patients have a historical type on file.

[vam3401]

If we do not have an historical ABO/Rh on file, we collect a second sample and perform both forward and reverse typing. We will also use a sample from elsewhere in the lab to use as our second ABO/Rh sample, if available; example the lavender top CBC tube from Hematology, thus saving the patient the phlebotomy. Our lab also uses a phlebotomy hand held device that reads the patient's barcode on the armband and prints a specimen label at bedside.

[Avid123]

For all patients, we require a full ABORh on 2 different specimens-can be a specimen in the lab or a specifically drawn one.

For Electronic XM (EC)-2 types and screens on different specimens performed by different techs-our Tango counts as a secondtech.

[EDibble]

I agree with Steve and Malcolm on this. We routinely perform electronic crossmatch on patients with either a historical and current full ABO Rh, and negative screen, or two current full ABO Rh and negative screen. We often use only one sample for this. We have rigid checks and balances in place for patient identification, including a barcoded system for wristbands. Our automated instrument reads the specimen barcode, and we techs have a step by step system to check specimen identification integrity.

Of course, there are situations where the patient is unidentified (as in a John or Jane Doe in the ER), and the patient may not yet have a patient band, but we have rules in place for that too.

There simply do not have to be two specimens from the current admission.

[Tiggie2]

I am at a small hospital (25 beds) we do not perform electronic crossmatch, but we've recently made it policy to have a previous type or perform a second type to avoid ABO incompatibility issues. The only exception I would accept as the supervisor is if the person performing the crossmatch draws and bands the patient him/herself.

[Kashmira patel]

A second determination of ABO on both front and back type is required. FDA has a new guidance on Electronic (computer) Crossmatches.

[Malcolm Needs ☆]

A second determination of ABO on both front and back type is required. FDA has a new guidance on Electronic (computer) Crossmatches.

I have absolutely no doubt that what you say is true Kashmira patel, and the same applies to the UK Guidelines - doesn't make them correct though!

[Annadele]

Hi again All!

I have a couple of polls for the group related to electronic crossmatching and to the ABORh recheck.

1. According to the AABB Technical Manual, the electronic crossmatch is permissible if, among other things, "A method exists to verify correct entry of data before the release of blood or components." How does everyone interpret this in their laboratory? In ours, if the LIS is down, manual entry of ABORh type and/or recheck performed on an automated instrument is permissible and electronic crossmatch can still be used. This seems reasonable because presumably even if there were an error during result entry, requiring an ABORh recheck prevents an error from resulting in the issue of ABO incompatible products. I read however a SHOT report in which a patient was issued an ABO incompatible unit of RBCs because of incorrect manual result entry. (It's attached and the incident is described on page 56.) I'm not sure if the laboratory involved in that incident required rechecks or not. Are there labs out there that require a completely automated T&S process including crossover of result entry in order to use an electronic rather than IS crossmatch?

2. Do some labs require a current ABORh type (in nonemergent situations) on a sample drawn on a current encounter in order to issue components? I'm thinking here of a situation in which a patient is impersonating someone else for insurance purposes or in a case of misidentification at intake. My guess is that this isn't required because a transfusion reaction associated with the issue of ABO incompatible components is less severe than with red cells but I'm curious if other hospitals take a more conservative approach here.

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[tbostock]

Hi again All!

I have a couple of polls for the group related to electronic crossmatching and to the ABORh recheck.

1. According to the AABB Technical Manual, the electronic crossmatch is permissible if, among other things, "A method exists to verify correct entry of data before the release of blood or components." How does everyone interpret this in their laboratory? In ours, if the LIS is down, manual entry of ABORh type and/or recheck performed on an automated instrument is permissible and electronic crossmatch can still be used. This seems reasonable because presumably even if there were an error during result entry, requiring an ABORh recheck prevents an error from resulting in the issue of ABO incompatible products. I read however a SHOT report in which a patient was issued an ABO incompatible unit of RBCs because of incorrect manual result entry. (It's attached and the incident is described on page 56.) I'm not sure if the laboratory involved in that incident required rechecks or not. Are there labs out there that require a completely automated T&S process including crossover of result entry in order to use an electronic rather than IS crossmatch?

2. Do some labs require a current ABORh type (in nonemergent situations) on a sample drawn on a current encounter in order to issue components? I'm thinking here of a situation in which a patient is impersonating someone else for insurance purposes or in a case of misidentification at intake. My guess is that this isn't required because a transfusion reaction associated with the issue of ABO incompatible components is less severe than with red cells but I'm curious if other hospitals take a more conservative approach here.

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1. We do not allow electronic crossmatch when our LIS is down.

2. We require two separately drawn blood types to issue red cells. For components, we have to have a current (within 3 days) type and screen; we do not ever use a historical type only.

[Auntie-D]

EI is only permissable for a completely closed computer system with no manual entry. As soon as anything need to be entered manually EI is no longer appropriate.

[Annadele]

Both of our groups are done on the same sample but by different techs and/or automated instrument and include forward and reverse (though no reverse is necessary if it's an infant). I work in the US.

I'm really curious about all of these discrepancies in policy for Transfusion between developed countries. As a newbie, it's hard to tell how many of these policies are based on preventative theories and how many are based on practice (like changes in policy in response to SHOT findings, etc.) or research findings. It's interesting that it seems like the tendancy to be more conservative is on the side of the countries that have a centralized health system - you'd think that if anything, there would be motivation to be more conservative in the US where in theory a hospital could charge a patient more for extra testing, etc. and therefore would want to adopt more conservative policies. The hole in this of course is that medicare reimbursements haven't increased much for laboratory work in the past decade so there's pressure to keep costs low.

If anyone comes across a source about this, I'd really love to see it.

Not sure about how it is in the US but in the UK the second group can be just a forward group.

I did work in one lab that allowed EI on 2 groups done on the same sample - needless to say they lost accreditation at their first inspection