Dropping AHG crossmatches

[John C. Staley]

Wow Malcolm, :disbelief I go to Canada on holiday for a few weeks and I come back and find news like this. Best of luck to you and I hope the insurance company doesn't put up too much of a fight.

As for the IS crossmatch, I had the same problem getting it initiated about 15-20 years ago but the difference was the push back came from the transfusion medical director. My staff couldn't wait. I seem to remember it was a few e-mails shared with the medical director from John Judd that finally encouraged her to see the light. In compromise, I agreed to go with a 3 cell antibody screen. That seemed to ease her mind as well.

[Malcolm Needs ☆]

Thanks John.

[Eagle Eye]

Malcolm, Find a way to come to US and stay with us, 1 week in each state/place by then your home will be ready!!

Thanks John.

[Malcolm Needs ☆]

Malcolm, Find a way to come to US and stay with us, 1 week in each state/place by then your home will be ready!![/quote

That's a lovely thought, for which I thank you, but we are going in to our long-term rented accommodation at the ned of next week, and I have to think of Harry's schooling and Dee and my work, otherwise..............!!!!!!!!!!!!!!!!!

[mhc]

I was way behind in reading BBT and came upon this thread- so happy to see that you and your family are safe, Malcolm!!

Just to add my 2 cents to the discussion- dont forget to do a thorough process validation and computer validation (if applicable) before you implement your new process. Involve the staff with this- it will help them see that the process will work and is safe in your lab.

Melanie

[Mabel Adams]

I missed this news too! Glad you are OK, Malcolm.

We have a small hospital joining our systemt that is doing full crossmatches on everyone so I appreciate this information to share with them.

To further convince them, I would like to add up all of our collective years of experience with not doing IAT crossmatches on our patients and also how many times you have seen a patient negatively affected by this policy. Between my experience elsewhere and the techs here we have about 30 years of collective experience with this without a single negative outcome. Anyone else wish to share your experience?

[tbostock]

Same as Mabel. Thousands of transfusions with not a single negative outcome. Change is uncomfortable, but sometimes you just have to do it and support and understand the unease in your staff. I went through it when we dropped AHG crossmatches, and then when we went to electronic crossmatches, changed LIS systems, then when we moved to a new hospital, then when we "leaned" our new lab, then when we automated (Tango), then when we started making syringes for neonates, etc. Some techs handle new things very well, and others just about shut down.

[Liz]

Evrybody that goes that route experiences the same angst. If it is OK with the FDA and the other regulatory agencies (AABB,CAP) there should be no qualms about it. This has been an acceptable practice for over 20 yrs. but I can't tell you where to find literature to make your staff feel any better. I'm hoping to go with the e-xm and get a BB vending machine for the pt care areas - that is making my staff nervous.

Do you know anyone who uses the vending machine, if so, where is it placed and who has access?

Thank you.

[Malcolm Needs ☆]

Hi Liz,

A friend of mine, Julie Staves, uses these at the John Ratcliffe Hospital in Oxford.

I'll try to get her to join the group/site and answer your question from a UK point-of-view.

[Liz]

.

Many a true word is spoken in jest Phil. We have just had a fire at home (care of a very kind neighbour and a deep fat fryer) that has made (hopefully, temporarily) 20 families homeless, including my own (hence I haven't been on here much for the last week or so), and I fear that most of my old papers may well have suffered from water damage, amongst them the one by Boral and Henry.

On the other hand, I attach an article I put together about 12 years ago now (it's also in the library section) that cites a lot of these papaers and may help ElinF to pursuade her staff that it is not dangerous to perform the immediate spin X-M under the circumstances described.

I hope a) I can attach it and that it is of some help.

Best wishes,

Malcolm[ATTACH]644[/ATTACH]

I just read this. OMG!!!! I hope that no one was hurt. Do you mean homeless as its all burnt down?? Really, where are you staying?

[Malcolm Needs ☆]

I just read this. OMG!!!! I hope that no one was hurt. Do you mean homeless as its all burnt down?? Really, where are you staying?

Hi Liz,

No one was hurt, but my son Harry had to jump out of the first floor window to escape. Typical of a thirteen-year-old, this has not left him traumatised in any way; you would think that it is an everyday occurrance!

We had a little fire damage in our flat, but extensive smoke and water damage from the falt that was gutted two floors above us. All our ceilings came down and we lost most of our furnature. Miraculously, all of my blood transfusion books (including those signed by their various authors, e.g. Race and Sanger, Mollison, Anstee and Issitt, Daniels, Daniels and Bromilow, Reid and Lomas-Francis. etc) and all of my old papers (including Boral and Henry!) could be salvaged (as could my collection of Wisden cricket books).

We have been staying as the guests of the building insurers in a hotel for a month (bed and breakfast only), which means that I have had to buy three evening meals a night (so we have been eating from the carvery every night, as this was the cheapest, but, believe me, eating a roast everyday for a month tends to put you off roast dinners for a while; as the Bard wrote, "If music be the food of love, give me excess, so the appetite may sicken and so die").

As of the day before yesterday, we moved into long-term rented accommodation (again, at the expense of the building insurers), which, as it happens, is in the block of flats in front of our own, and is a mirror image of our own, so it is not too bad (except that we are having to sleep on a matress on the floor until the new beds arrive).

They reckon that we will be out of our own place for a minimum of 6 months (more likely a year), and it is going to cost the insurers about £1 million to everything right, but, every cloud has a silver lining, when we go back in, all the electrics, decorating etc will have been done for us, without me having to lift a finger, which is very important to me, as I am useless at do-it-yourself!!!!!!!!!!

[Liz]

Malcolm, what happened is very serious!! Thank God you are all safe and sound. And you are taking it very well. You live in a civilsed country and this is shocking! Oh my goodness. Welcome back from that disatrous situation!! You and your family have proven yourselves to be very solid. and you have a lucky star.

[Liz]

I am very proud of Harry!!! that is what youngsters do, but again.. in a civilzed country!?? wow!! Bravo!! (nothing broken, right? )

- - - Updated - - -

Do you get to pick the new furniture ????

[Malcolm Needs ☆]

Nothing broken and yes.

[JulieSt]

Hi Everyone

I'm the Julie who Malcolm has asked to join in this conversation.

I'll admit I didn't know this was here - you will probably seeing a lot more of me!

I'll comment on the thread:

We moved over from full AHG crossmatches about 12 years ago and went straight for electronic issue. Like others we experienced some resistance from the lab staff. They were mostly worried about - is it safe? and what would happen if something went wrong.

We did a lot of 'information sessions' for the staff - I went through why we wanted to do it, what evidence was out there for doing it, etc etc. I also got the consultant to come along and answer questions and re-assure them that as long as they followed the laboratory SOP then they were covered for anything going wrong.

The 2 were doubtful staff (even after this) I involved in week of duplicate running. This meant they could see upfront just what was involved etc. They ended up being 'champions' of EI!

Regarding vending machines - I was involved in the development of the first vending machine system in the UK back in 2004-5. We have been using the system ( with multiple fridges) since early 2006 and really wouldn't go back.

We've gone for putting them in theatre (OR) and have them in all our main theatres.

I said at the beginning that I was concerned about portering staff doing the issuing ( and I still stand by that today) - so the staff we have doing the issuing are mainly ODP (Operating department practititioners) and theatre nurses.

I did initially train all the anaesthetic consultants ( because they insisted they'd use it) but I wouldn't do that again. I've only ever had 1 Anaesthetist issue blood and he only did it to see how easy it was!

Hope this helps - happy to answer questions on this....

We did publish our initial work on remote issue/vending machines. If its appropriate to I'll see if I can attach a copy!

[Liz]

Welcome Julie to our abode and thank you for the post.

Your approach sounds doable and shows that you have put a lot of thought into it before actually venturing.

The OR is a good way to go and to have control, rather than the open-access refrigerator.

Who of the blood bank staff have access to replenish the vending machine, and how often do you do that. I assume it is linked to your HIS/ LIS/BIS so that you can follow more or less every move. and who does check who accessed it?

What kind of barrier do you use at the bedside for pt id prior to transfusion?

Thank you

Liz

[Eagle Eye]

I would like to ask more questions: (sorry but your system looks good so we want more information)

how often do you rotate the inventory?

Are you occupying too many units?

Is your wastage up because of these?

Is the machine able to print transfusion tag?

I am sure your lab system is interfaced so---1) the machine would not issue unit for the patient with history of antibody 2) patient whose type and screen is not complete 3) for uncrossmatch---machine uses the logic ---issue O Neg to child bearing age female??

Thanks

[PAWHITTECAR]

Malcolm,

Sorry to hear about your house..hope everything works out ok. Thanks for the "ammunition". I have just taken a position a technical supervisor is a small(~150 bed) hospital. It is crazy the stuff that is in this procedure manual and that is being done. Du testing on every Rh negative always. Yes 60 year old men getting a Du every three days. And AHG crossmatches for every unit. Those were the first 2 things to go..lucky for me the lab manager and the pathologist that is "medical director" both realize I know a little about blood bank and are letting me make the changes needed.

Now if I can just get all these procedures updated by January when CAP is expected....Some haven't been "revised" since 1992...

Wish Me Luck,

Trish

[R1R2]

Malcolm,

Sorry to hear about your house..hope everything works out ok. Thanks for the "ammunition". I have just taken a position a technical supervisor is a small(~150 bed) hospital. It is crazy the stuff that is in this procedure manual and that is being done. Du testing on every Rh negative always. Yes 60 year old men getting a Du every three days. And AHG crossmatches for every unit. Those were the first 2 things to go..lucky for me the lab manager and the pathologist that is "medical director" both realize I know a little about blood bank and are letting me make the changes needed.

Now if I can just get all these procedures updated by January when CAP is expected....Some haven't been "revised" since 1992...

Wish Me Luck,

Trish

Sounds like a great challenge! Good Luck to you!

[PAWHITTECAR]

Sounds like a great challenge! Good Luck to you!

Thanks I'm sure you guys will be getting a lot a questions from me...I have already used several posts as a "resource" in getting some items addressed.

[JulieSt]

Hi Liz,

In answer to your questions - I've given access to all the staff in the blood bank to allow for restocking. This includes our support staff.

We check stock levels visually (by checking on the inventory on the manager PC) twice a day ( probably restock 1 fridge or other everyday but not each fridge daily)

On mondays and fridays - we swap out the stock which has less then 7 days life left so we can ensure we use it and it doesn't get wasted. This is i usually the less used groups ( especially B neg and ABs)

The system has an alarm level (which is settable by the lab leads) which means if the level of any group drops below that level - the system alarms in the lab prompting us to restock. This works well - most of the theatre staff are also happy to scan in the stock if we send it down to them when someone is bleeding.

The system is totally controlled by IT - we've a bi directional interface with our LIS which means patients for who you don't want to issue remotely ( like those with antibodies and those who have recently had a transplant) can simply be blocked.

It also means we can select who gets access ( they use a barcode on their staff ID badge to log on) and what they have access to. We have been known to redraw access if someone keeps doing things wrong ( or hasn't used the system for 6 months so they have to have retraining)

regarding bedside transfusion - we also have It there too. We have PDAs at the bedside which are used to scan the patient ID wristband (which has a barcode on it) and the blood products (again we put barcodes on them too). If the blood isn't issued to that patient is alarms (loudly!) and so prevents them transfusing.

We transfuse 28,000 units of red cells in a year - and this is used for all but a handful each year ( the handful which aren't done correctly are chased to fine out why - usually things like the PDA wasn't charged or the HIS wouldn't print out a wristband)

You probably think by now that we have loads of IT - well we do!

Hope that helps

Julie

[JulieSt]

No problem with questions ( I'm really proud of our system so really don't mind)

Inventory - we swap out of the fridge when its got 7 days life left. checking this on mondays and fridays ( so not too much work)

The number of units we stock in the fridges is dependent on the usage in that area - initially I looked at what they'd used in that area in the last 6 months and the mix of groups. Then aimed to stock a weeks worth of stock. This has reduced over time because we've found they use less blood if they know its there but not issued!

My wastage hasn't gone up ( runs at just under 1% )

Yes the system has a printer which prints out the tag - it then asks the user to scan the unit and tag within a short time (15 s) to check they right tag is attached to the unit

Yes you're right the system is bidirectionally interface to the lab system.

It blocks automatically those patients not suitable for electronic issue ( so antibodies, samples not completely reported etc etc)

for Emergency stock (uncrossmatched blood) - it has a button to get emergency stock ( you can choose to just let them have O neg for this or give them the choice of O pos as well) I give them access to both ( as we've spent years training that if you know the patient is Rh pos then give O pos emergency stock) - this works well and reduces the use of O neg in these situations. We've only ever 1 person take O pos when they should have given O neg ( but that was when a trained nurse lent their access badge to an untrained unqualified support worker!)

Hope that helps