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Second specimen when there is no historical Group & Type


kbailey

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Just trying to get an idea of how many Transfusion Services are having a second specimen collected when the patient has no historical group & type. We are trying to implement this in our facility as a safety feature, not as part of an e crossmatch implementation. Thank you.

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Without knowing what testing you’re talking about exactly (ABO/RH, Type & Screen, type & crossmatch), I will answer this the best I can.

You might want to look at AABB (5.13.5) Comparison with previous record. Computer Crossmatch (5.15.2.2) require two separate ABO/RH. From you question I see that you are trying to implement this as a safety standard and it not in accordance with Crossmatch.

Medicare and Medicaid have rules against unnecessary testing, and may not pay for another ABO/RH just for verification unless it’s part of the required testing (Type and Screen, Type and Cross,). I don’t know the rules and you might need to check with you business office.

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We do not charge for a 2nd type - it's part of the cost of doing business.

CAP TRM.40300 Historical Record Check says "If no record of the patient's blood type is available from previous determination(s), the transfusion service should be aware that there is an increased probability of an incorrect blood type assignment and, consequently, of a hemolytic transfusion reaction. If a laboratory collects an additional sample for the purpose of verification of patient identity, a repeat antibody screen need not be performed on this specimen."

CAP TRM.40670 ABO Verification (Computer Crossmatches) "The recipient's ABO blood group has been verified by repeat testing of the same sample, a different sample, or by performing a historical search of laboratory records..............Note:................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."

So, since you are not doing a computer crossmatch, CAP does not 'require' a second sample. If you are doing a computer crossmatch, you have options other than a second sample, but those options are going to be pricey.

Since your concern seems to be safety, look at how your facility IDs patients, how many admitting errors or fraud cases (patient admitted under someone else's name), who draws samples, do you have control over the collection process, how well can you enforce the rules of patient ID at the time of collection, how many 'wrong blood in tube' incidents do you see, etc, then decide what gives you the most secure, safe process. Lots of variables. The answer may or may not be a second specimen.

I think the day will probably come when the 2nd specimen will be required if you don't use a digital bedside ID system. I don't think that's an absolute solution to the problem, because that requires that there is never an admitting error/fraud that puts the wrong ID band on a patient's arm. And it also requires that people faithfully and carefully ID their patient the old fashioned way every time a sample is drawn and blood is given, not blindly zipping that barcoded armband and calling it good. But what do I know.......I'm just a blood banker. Actually I do have the answer. We all should all get a computer chip inserted in the scruff of our necks, like we do for our pets!

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we retype the same sample using a different method (tube) and also get a second sample if there is no historical type (different draw and perferably a different phlebotomist). We do not charge for the second typings and the order is generated by the bb for the second sample. We retype all patients (not just type O) without history to be consistant, we have many generalists. We had a transfusion reaction years ago and for patient safety we started to do the second sample. We had full support by our administration to do the second typing for patient safety....support is very important for success.

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We have had the "2nd typing rule" (from a different draw time) for several years. If the patient needs blood before the second typing can be done, we give group O RBC or AB FFP or platelets. Usually this is not necessary. Inpatients are usually frequent flier repeat customers or there are other lab samples from different draw times to use for the retype. OR cases that we crossmatch we redraw on the morning of surgery. OR cases that just have a type and screen ordered we don't redraw, we would give these patients group O RBC but the occassion never rises. ED patients are the typical ones who get the O RBC because we can't wait for the 2nd spec.

We haven't had any reimbursement issues for the 2nd typing, mainly I think because if you need blood you'll end up an inpatient and your stay will be paid at the same DRG rate, one typing or a million. If you do it for free, a typing doesn't cost that much to do anyway.

Support is indeed important; get this into your lab and, better, hospital transfusion policies, OKed by administration and medical staff.

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We do a second type on everyone who has no historical type at any of our 4 facilities, unless they type as goup O.

Usually we can find a hematology or chem specimen that was drawn at a different time, so we use that. Pre-ops have to be done the morning of surgery. The cardiac ORs have gotten pretty good about calling and checking before they send someone to pick up blood. For pediatric OR they usually draw the 2nd sample after the child is under anesthesia (if it is a young child) and bring the sample when they come to pick up blood. The runner just waits while we do it. Its really quick because all we do is a forward type and Rh.

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We type a second specimen from a different venipuncture or else give type 0 red cells if there is no historical blood type. We have been doing this for about 18 months and it works well - generally the only patients who cannot be redrawn are the pre-admits. We even redraw the ED patients if we cannot find a hematology specimen from a different venipuncture.

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We do a second type on everyone who has no historical type at any of our 4 facilities, unless they type as goup O.

Usually we can find a hematology or chem specimen that was drawn at a different time, so we use that. Pre-ops have to be done the morning of surgery. The cardiac ORs have gotten pretty good about calling and checking before they send someone to pick up blood. For pediatric OR they usually draw the 2nd sample after the child is under anesthesia (if it is a young child) and bring the sample when they come to pick up blood. The runner just waits while we do it. Its really quick because all we do is a forward type and Rh.

We do the same as DOGLOVER. However, i've always disagreed with the exclusion group O patients. I believe they should be retyped as well in case FFP is required. I realize the probability of HTR is low from incompatible plasma transfusion, yet I would still hate to give O FFP to a non O patient that was mistyped as O due to an identification error.

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We do not perform a second type at the moment. I do have one question for those who do - how often do you need to get a new sample on the patient because a second sample from Hemo or Chem is not available?

:boogie:

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Our policy is to perform a repeat ABO on a 2nd tube from a separate venipuncture if no historical record exists. The idea is to have a second check of patient ID and specimen labeling starting from scratch so identification errors will be caught - 2 tubes drawn at the same time (eg sharing the heme tube drawn from the ER rainbow, or antsy anesthesiologist drawing both in OR at once) would not be acceptable. We moved to this requirement to decrease wrong blood in tube events as well as to be compliant with the electronic crossmatch regs. We do not use any of the secondary blood bank armband systems/barcode scanners at bedside.

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  • 1 year later...

How would I set this up for a retype in MediTech 5.65 going to 5.66? We use a seperate BB band and have barcoded Hospital ID bands and would like to go to barcodded BB bands and use the TAR system in MediTech but that will take some time and money to set up.

So in the mean time I want to test out a double draw/double type system. We do a lot of prenatal type and screens that will not have the opportunity for redraws. Also alot of Baby Types. So if I set up a "Previous History?" question and the answer "No" reflexes an "ABO/Rh Retype" I get a lot of unwanted test orders.

Could I tie the refex order in to the XM order? But that would not help if the patient just got FFP.

So how are other Meditech 5.65 lab handling this? Thanks

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We do not perform a second type at the moment. I do have one question for those who do - how often do you need to get a new sample on the patient because a second sample from Hemo or Chem is not available?

:boogie:

At our facility, 25% of patients for whom a Type and Screen is requested, have no historical blood type on file.  As part of our protocol (because we use TYPENEX and the ID band CODE number is integrated into the computer result entry protocol), we don't use specimens from Heme/Chem.

 

In a previous facility, I recall that about 16% of those patients had a hematology specimen that we could use in Blood Bank that had been collected by a different venipuncture.

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How would I set this up for a retype in MediTech 5.65 going to 5.66? We use a seperate BB band and have barcoded Hospital ID bands and would like to go to barcodded BB bands and use the TAR system in MediTech but that will take some time and money to set up.

So in the mean time I want to test out a double draw/double type system. We do a lot of prenatal type and screens that will not have the opportunity for redraws. Also alot of Baby Types. So if I set up a "Previous History?" question and the answer "No" reflexes an "ABO/Rh Retype" I get a lot of unwanted test orders.

Could I tie the refex order in to the XM order? But that would not help if the patient just got FFP.

So how are other Meditech 5.65 lab handling this? Thanks

 

 

Our Type and Screen test in configured in Meditech with an anti-A,B test in Line#1.  If there is no blood type on file (our BBK specimen collection label is configured to print a historical blood type...we don't have to look it up in Meditech), we test the uncentrifuged blood sample with anti-A,B.  That test result is entered in Meditech, saved and filed.  If the anti-A,B test was agglutinated (a positive result), the test CONFIRM is reflexed on a new blood sample request (Using the LIS Enter/Edit Order Group Dictionary).  As a result, specimen collection labels are automatically printed on the phlebotomy label printer.  There is a separate blood type calculation (BTU) created for the test CONFIRM.  Type and Screen uses (BT).

 

If the anti-A,B test is not agglutinated, Meditech relexes the test CONFIRMO (BTO), that is added the same specimen and when filed with the Type and Screen test results generates the second ABO grouping blood type.  A second venipuncture/separate specimen number is not required for our protocol.

 

Whenever blood components are requested, Meditech is configured to automatically add a Type and Screen to that request (in the absence of a current Type and Screen) at our facility.

 

This protocol is limited to Type and Screen only, we do not do this for prenatal ABO/Rh typing.

Edited by Dansket
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How would I set this up for a retype in MediTech 5.65 going to 5.66? We use a seperate BB band and have barcoded Hospital ID bands and would like to go to barcodded BB bands and use the TAR system in MediTech but that will take some time and money to set up.

So in the mean time I want to test out a double draw/double type system. We do a lot of prenatal type and screens that will not have the opportunity for redraws. Also alot of Baby Types. So if I set up a "Previous History?" question and the answer "No" reflexes an "ABO/Rh Retype" I get a lot of unwanted test orders.

Could I tie the refex order in to the XM order? But that would not help if the patient just got FFP.

So how are other Meditech 5.65 lab handling this? Thanks

 

We do not have anything reflexed. When a patient with no historical type comes in, we attempt to locate a second sample in chem/heme. If we find one, we add a test we designed for this purpose (just a forward BT) to the patient's TS req. There isn't a charge associated with it, it only counts for 'number' purposes for us, but every little bit helps there! We result that using the second specimen. If the patient types as O (or AB for plasma), we don't bother.

 

If we cannot locate a second specimen our actions depend on the situation. If packed cells/plasma are ordered we can either order the retype test and have labels print for a phleb to draw the patient again, or we do not order the test and give group O/AB if the situation is emergent. If no products are ordered we make a note that 'confirmation is needed' and basically wait it out to see if by the time products are ordered we will have another sample. 

 

Most of our patients either have a HX or type as O. For pre-ops, most of the time the blood is not transfused anyway, so we do not hesitate to set up group O even if they are another blood type. If, on the day of surgery, they bleed, we should by then have another sample and can switch to type specific.

Edited by Teristella
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We request a second sample at a different draw time. We try to use chem/heme samples but they are not always available so we send a pink top tube to the unit with a special label that we keep in the department so that we know the nurses aren't drawing this second tube at the same time as the first draw then sending it later. If for some reason we can't get the second sample we crossmatch group O red cells. And we do not charge for testing performed on this second sample. It can be a huuuuuuge pain however trying to get this sample from the nurses and explaining why we need it.

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We perform a second ABO/Rh on ALL patients that do not have a historical type on file. We also use a second tube from a different collection. If the patient has had a CBC or a chemistry test requiring a plain red top, we can usually grab those and do our testing, otherwise, the phlebotomist is sent back to the patient to redraw the specimen. The only time that we do not do this is if the patient only has a ABO/Rh ordered.

When we report a Type and Screen, Crossmatch, etc., we have a test that must be answered called a previous history test (nonchargable), and depending on the answer that the tech enters into that box (no history, prev history with no antibodies, previous history with antibodies) determines if a second type is needed, if no history is entered, then a second type is reflexed, where by the same token if a previous history is entered we do not get a second type reflexed.

This repeat testing is called a confirmatory type, and IS NOT a chargable test since it is a part of the testing required.

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We have tried to make this as invisible as possible to the patient & due to the lack of phlebotomists.  We implemented a no tobacco policy for new hires in Jan & have seen our applicant pool shrink dramatically. So....

Only a type and screen - no recheck

O patient - no recheck

 

Most patients , get a previous specimen from another dept.  @35/ month

We have an aggressive pre admit program, so those patients coming in for surgery that are Non O , get a few drops in a small lav when their IV is set up. 

 

Patients without a previous specimen,and NON O have bag locks from Typenex used.  About 40 units/ month at the most.

 

We transfuse @500 red cells.

We credit the patient for the 2nd type.

 

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We do a second ABO on all T&S that are banded and non O.  We give O if we cannot get a second draw in time.  It is about 20% as well that need to have a draw.  I do not use meditech to reflex a new specimen when needed.  If a patient is non O and has no history we manually order the test and call the phleb as a verbal "attention".  We color the band card with a highlighter if it is an outpatient waiting to come in for a surgery so there is a visual cue not to crossmatch type specific until the type is confirmed.  It is also on our pending list, so we can easily see that it still needs to be done.  We have been doing this for about 1yr and it has been going quite well. We do try to get a specimen from heme/coag before drawing the patient again.

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We use MediTech and also have a reflex test if the history question is answered "No"  Baby Type and DAT testing don't have a history question.  Our prenatal  TS don't require an armband and we just retype with the CBC tube or BB tube.  When they come in to the hospital, of course, they are banded if a TS is ordered.

I would like to move to electronic crossmatching within the year, so we will be implementing the second specimen with a separate draw time "for real". 

Our retype, like someone else mentioned, is just a forward type and Rh.

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  • 4 months later...

How would I set this up for a retype in MediTech 5.65 going to 5.66? We use a seperate BB band and have barcoded Hospital ID bands and would like to go to barcodded BB bands and use the TAR system in MediTech but that will take some time and money to set up.

So in the mean time I want to test out a double draw/double type system. We do a lot of prenatal type and screens that will not have the opportunity for redraws. Also alot of Baby Types. So if I set up a "Previous History?" question and the answer "No" reflexes an "ABO/Rh Retype" I get a lot of unwanted test orders.

Could I tie the refex order in to the XM order? But that would not help if the patient just got FFP.

So how are other Meditech 5.65 lab handling this? Thanks

Just to add to what others have already said... Your prenatals and babies don't need second types unless they are for transfusion, which I assume most of them are not. We built more than just "Yes" and "No" to result the History Check field: No Previous History, Previous History Negative, History of an Antibody, ABO/Rh History Only. Then there is a separate field "Retype Needed?" which is yes/no, with yes reflexing a retype with no charge attached. The tech has to look at the situation and decide if a retype is needed. We have the OB docs order "Type" and "Antibody Screen" as 2 tests for prenatals (instead of "Type and Screen" which is for possible transfusions). And a type on a baby is a different order because it was built to include the weak D results if needed. Those don't have the "Retype Needed?" field at all.

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