Need opinions...Giving Ag neg units vs. antibody "rule-out"

[tupton]

Hello all,

 

I have encountered some controversy regarding a few of our patients that have historical antibodies.  As a general policy, at our facility a patient that exhibits a positice Ab screen must have an Ab ID.  Normally, we do our own identifications which includes antibody rule--outs using at least 2 cells, preferably 1 that is homozygous (when applicable).

 

However, we have had a couple patients recently that didn't quite fit the criteria.

 

Example:  Patient has a historical Anti-D and Anti-C.  Using our panel cells, Anti-D and Anti-C were confirmed (again), with 2 stray reactions in gel.  Autocontrol was positive.  DAT was negative.  Reviewing these 2 stray reactions, based on my experience, they looked kinda "funny."  I suspected some proteins in this patient's system were causing the stray reactions (patient was on chemotherapy).  All clinically significant antibodies were ruled out using at least 2 panel cells, EXCEPT for Kell.  I could only find 1 rule-out cell.

 

So, instead of sending this patient to the Refence Lab to investigate the stray reactions, I (as supervisor of the department), screened units that were negative for C and Kell (as a precaution).  Both units were XM compatible through AHG and transfused without incident.

 

Later, another tech (who happened to be the supervisor before me) questioned this strategy.  She claims this patient should have been sent to the IRL from the begining.  I disagree.  In my opinion, she is being to strict.  Even if we would have positively identified an anti-Kell, we still would have given Kell-neg units!  Clinically, either way results in the same outcome, the difference being using my approach saved at least a $500 Reference Lab bill and the patient got their blood at least 24 hours sooner.

 

My Lab Director responded to the other tech's request and a sample was sent to the IRL anyway.  The results from the IRL confirmed Anti-D and Anti-C.

 

So, did I do the right thing? Is this a decision that should be based on judgement or policy?

 

Thanks for the replies!

 

Tom

[Mabel Adams]

If this policy is defined in your SOPs you should follow them.  In my opinion, what you did was entirely logical and safe.  It may have even prevented a presumably K neg patient that is known to make antibodies from being exposed to the K antigen and making anti-K as well.  If you had a patient with multiple antibodies even the IRL may not be able to rule out everything and may suggest using antigen negative units for specificities that they can't rule out.  Lastly, you give blood every day to patients that have had anti-K ruled out using only one single dose K pos cell, because this is the case with every patient with a negative antibody screen.  They don't even get the advantage of an AHG xm (most places) which your patient got.

 

You could also check with your IRL and see how many K+ cells they require to rule it out.  They may require only one.

 

Afterthought: be careful of turf wars with ex-supervisors.    Look for ways for everyone to save face.   

[goodchild]

I would have done the exact same thing under the circumstances you described. Sending a sample to the reference lab seems like a waste of their (reference lab & patient's) time and an unnecessary expense.

Ortho was just talking about "antibodies of undetermined specificity" with gel testing on their webpage this month and how it is the most commonly observed antibody. At our institution we result any AUS-related results as Inconclusive so we can have a record that there have been serological problems with that patient.

[DOGLOVER]

Thats basically what I would have done. Do you only have one panel? Do you save outdatedd panels for selected cells, so that you could find more than one "rule-out" cell. That is a great help, as long as you run appropriate QC.

[SMILLER]

I agree with the others.  Besides being an unnecessary expense, sending this one to a reference lab would result in a delay of having blood available.

 

Scott

[tupton]

Thats basically what I would have done. Do you only have one panel? Do you save outdatedd panels for selected cells, so that you could find more than one "rule-out" cell. That is a great help, as long as you run appropriate QC.

 

We use 2 0.8% panels and we keep outdated panels (up to 4 months) for rule-outs.  QC is performed when the expired panels are used.

[cthherbal ☆]

I would have done the same as you. In fact I did this week on a patient with anti-E, -K -HLA (historical) and only the K cells reacted on straight panel in gel. E reacted with ficin-treated only. 2 extra E, K neg cells reacted but everything ruled out and E, K neg units were full XM compatible.

[vilma_mt]

I would have done the same. You were cautious without with causing undue delay in treatment.

[Malcolm Needs ☆]

If it counts for anything, as a Manager of a Reference Laboratory in the UK, I think you did exactly the right thing.

 

I say this because those that work in a Reference Laboratory (at least, on this side of the pond) do exactly the same exams as those working in Hospital Blood Banks (there is nothing magical about us), and so you probably know as much about serology as do those who work in a Reference Laboratory.  The only difference is, perhaps, the experience of seeing unusual cases, and the availability of far more reference cells and sera than are available to the average Hospital Blood Bank staff.

 

If you are confident in the results you have obtained, why send them to a Reference Laboratory for confirmation?  Think about it.  If you were not confident, then you would send all of your samples that give a NEGATIVE screen to a Reference Laboratory as well (and, if any of the hospital staff that my Reference Laboratory happen to read this - don't get any ideas - two or more samples with nothing in at all, and you are struck out!!!!!!!!!!!!!!!!!!!!!!).

[Dansket]

I must disagree to some degree with almost every response (except Mabel's first statement).  Well thought policies and training should prevail, not an opinion in the heat of the moment.  I certainly do not think that the cost of doing business should enter into the decision whether or not to follow the antibody identification protocol.  Tom didn't mention the urgency for blood transfusion in this situation, so I don't know if the patient's conditions supported his actions.

 

We don't re-identify historical antibody for transfusion recipients unless incompatible crossmatches are detected with antigen-negative donor units or antigen-negative screen cells are agglutinated.  Just this one change in policy would save thousands of $$$ annually in Tom's facility and take cost out of the decision equation.   Requiring that this patient receive Kell-negative blood is also an unnecessary cost incurred by such decisions.

 

Regardless, I do agree that the specimen should have been sent to an IRL to confirm Tom's conclusions.

 

As a new BBK supervisor, please consider updating the antibody identification protocol to allow rule out of anti-K with a single heterozygous panel cell (as Mabel said) and communicate this to all your staff. 

 

Dan...

[Likewine99]

I agree, I think you did the right thing re: you patient's antibody workup.  I don't agree with your Lab Director stepping in and "siding" with the "other tech" who just happens to be the previous supervisor.

 

Your patient received high quality service from your blood bank, your lab manager however did you and the rest of the blood bank a terrible disservice by intervening in a discussion between 2 staff members.  

 

He/she has basically allowed the former BB sup to continue to make decisions that are no longer in their scope of responsibility.  YOU are the supervisor now.  You get 10 Blood Bankers in a room for a discussion and what do you get, 10 different answers

 

Mabel is correct, turf wars with ex-supervisors stepping back into bench positions are difficult so be careful.  I do have to ask though, does your lab director make it a practice to help the other depts make pt care decisions?

[Malcolm Needs ☆]

I must disagree to some degree with almost every response (except Mabel's first statement).  Well thought policies and training should prevail, not an opinion in the heat of the moment.  I certainly do not think that the cost of doing business should enter into the decision whether or not to follow the antibody identification protocol.  Tom didn't mention the urgency for blood transfusion in this situation, so I don't know if the patient's conditions supported his actions.

 

We don't re-identify historical antibody for transfusion recipients unless incompatible crossmatches are detected with antigen-negative donor units or antigen-negative screen cells are agglutinated.  Just this one change in policy would save thousands of $$$ annually in Tom's facility and take cost out of the decision equation.   Requiring that this patient receive Kell-negative blood is also an unnecessary cost incurred by such decisions.

 

Regardless, I do agree that the specimen should have been sent to an IRL to confirm Tom's conclusions.

 

As a new BBK supervisor, please consider updating the antibody identification protocol to allow rule out of anti-K with a single heterozygous panel cell (as Mabel said) and communicate this to all your staff. 

 

Dan...

 

I tend to agree with you Dan that, if your Laboratory SOP states that a sample should be sent to a Reference Laboratory, then one should be sent, BUT I would also say that such an SOP is wrong, if the Laboratory is certain that they have excluded all other antibody specificities.  It seems to me that, under such circumstances, it is duplication of work and, as a Manager of a Reference Laboratory, I can assure you that we tend to be busy enough without being sent samples that contain a single antibody or a simple mixture of antibodies (say, anti-D+C) that the sender is quite capable of working out for themselves and excluding other specificities.

[Joanne P. Scannell]

I agree with Mabel ... you did 'the right thing'.  What did he/she really expect a reference lab to do with this anyway?

 

And, as she reminded, we do 'rule out' clinically significant antibodies with one homozygous (with exceptions, such as Anti-K which doesn't show much dosage anyway) every time we have a negative Antibody Screen.

[goodchild]

I think I see what Dansket is referring to.

 

Because of this one time scenario is this patient going to receive Kell-neg units for all future transfusions?

What would individuals do at their own institutions presented this same scenario? One time only for Kell-neg or is it part of their history now?

[apfelblosm]

FYI- we recently had an anti-K that did show dosage and did only react with the homozygous cells.  We have a reference laboratory here.  We recently just changed our procedures to include ruling out on two heterozygous or one homozygous cell. 

 

We are a 1250 bed, tertiary level 1 trauma center.

 

Thanks!

Jen, MT(ASCP)SBB

[Mabel Adams]

We sometimes enter a comment on the patient's record to give Ag neg units unless we can rule out that specificity adequately.  That way the next person knows why Ag neg units were given but maybe has a different panel and can do a rule out on the later specimen.

 

Although we are all scientists, sometimes this business has as much art as science.  From our antibody screens that can't detect every Ab to a low inc Ag to our abbreviated crossmatches we are always "playing the odds."  It's our job to have enough knowledge to make the right play when the situation is not clearly defined by procedure (as many of the finer points of complex antibody IDs are not).

[BrianD]

Tom, I agree your decision was practical and timely.  Given the situation, there are 3 questions that come to my mind:

1. Who is paying for the IRL testing?  I hope not the patient because this testing seems to have been done in hopes of an EX-supervisor "scoring" points against a newcomer.
2. Has it been established that the patient is Kell negative? 
3. Have you talked with your director to ascertain why he or she felt your decision couldn't be supported?  Your director has established a potentially bad precedent for your transfusion service. 

best of luck.

[galvania]

 

I think I see what Dansket is referring to.

 

Because of this one time scenario is this patient going to receive Kell-neg units for all future transfusions?

What would individuals do at their own institutions presented this same scenario? One time only for Kell-neg or is it part of their history now?

 Patient has known anti-C+D - I would give K- (to a K- patient) regardless of whether you had been able to rule it out or not

[tupton]

I think I see what Dansket is referring to.

 

Because of this one time scenario is this patient going to receive Kell-neg units for all future transfusions?

What would individuals do at their own institutions presented this same scenario? One time only for Kell-neg or is it part of their history now?

 

In this situation this would be a one-time scenario for K-neg units.  However, as Galvania posted, because this patient has already formed 2 antibodies, her chances of forming another are greater.  Thus, giving phenotypically similar units would be advantageous, if at all possible.

[L106]

I would have handled it exactly like tupton.<br /><br />Of course, if your policies/ procedures state that any unexplained reactions must be referred to your Reference Lab, you have to follow your policies/procedures. In the absence of such a policy, it is the supervisor's job to evaluate and select the course of action in "questionable" situations. A lot depends on the supervisor's experience, expertise, and confidence level. (And yes, the "cost of doing business" does have a place in the decision-making process, like it or not.)<br /><br />It is unfortunate that your Lab Director chose to override your decision and send the patient's specimen to the IRL. (Shame on him/her.) However, I hope your Director shared the IRL's results with the tech/former supervisor. Also, the IRL's results should encourage your Director to develop more confidence in and support for you. (It's not pleasant to be challenged or overridden, but you came out smelling like a rose on this one!)<br /><br />