Antigen screening in house vs. ordering from Blood Supplier

[medtechristy]

I'm working on a project in our blood bank to try to improve both cost and time spent antigen screening for units.  When is it more cost effective to order from our supplier vs. screen in house?  We spent several hours screening for both Jkb and M (separately) about a month ago, and also spend lots of time screening for multiple antigens.  I found out it costs us $21 per antigen for historically negative units from our blood supplier and $51 for antigen typed units from our blood supplier.  So I'm in the process of analyzing data and time spent to figure out the best plan / guideline for our transfusion service for screening vs. ordering.  I wanted to reach out and find out from other hospitals, what your policies / parameters / strategies are in this situation.  Thank you in advance for any help you can provide!

Edited February 7, 2016 by medtechristy

[Eagle Eye]

Are you screening for M- units? is anti-M clinically significant or you always give M- units?

your cost per antigen is very good. If I am paying that much I may consider buying from my supplier. It all depends on antigen you are screening for.

eg. anti-S 1 drop of anti-S will cost you $15 (if you are paying $900 for 3ml vial), add controls, frequency of finding units, other supply cost plus tech time.

it would be a good exercise for you to take your Jkb example and add all costs to see what was your cost per unit and compare that to your supplier cost.

By the way your supplier is really giving you good pricing? east cost or west cost?

[medtechristy]

Eagle Eye, yes, we were screening for M neg units.  The patient had an M that was reacting at Coombs phase.  Thank you so much for your response!  We are on the east coast in the panhandle in Florida.

 

[David Saikin]

Since I have a limited blood supply to screen units from, if I am dealing with multiple abs I usually will just call my supplier.  I may screen my units using pt specimen and if I get any negatives I will type them with the reagent antisera.  Depends on how busy I am, multiple abs, and the statistical chance for finding a unit with my inventory.  Screening in house is usually less expensive and the patient can receive transfusion in a shorter time frame than if I have to get blood from my supplier.

[AMcCord]

I'm 150 miles away from my blood supplier with delivery options that require orders be placed by 1330 or 2030 on week days - and obviously sooner if they need to screen units. If I need it stat, I can request a special delivery by volunteer, but I do not want to abuse that option. Weekends and holidays is a whole nother ball game - there is one routine delivery option on weekends, none for holidays. Whether or not I order antigen negative blood from my supplier depends on:

1) Is my patient an outpatient coming into the infusion clinic? Does the patient live in town or nearby? Does the patient drive or does someone have to bring him/her? Does the patient feel lousy, making leaving the house an ordeal? - I will order blood if the patient is local, brings themselves to OIC and it's not a major production for them to come in. OIC schedules patients with known antibodies that fit in that category for the next day automatically to allow us time to bring units in on the next delivery run. Otherwise we screen units. May not find them, but we'll look.

2) Is my patient an inpatient with a very low Hgb? Is the patient's condition unstable? Is the patient scheduled for dismissal after the transfusion? Is the patient scheduled for surgery? Is the patient actively bleeding? - If we answer Yes to any of those questions, we will screen for units.

3) Do we have the necessary antisera? - I stock the major players and in quantities related to how likely we are to use them. In other words, I keep 1 vial of anti-S but multiple vials of anti-c. This allows us to screen units for the majority of patients who need antigen negative blood and keeps outdating as minimal as possible while still stocking the antisera. If I use up the antisera screening or don't have a particular specificity or the price skyrockets (as has happened), then I'm going to have to order units.

4) If multiple antibodies - I do the math. How many units would I have to screen to find units? If it's a large number and I'm busy and the patient is not in dire need - I order them. If the patient is a type that we don't stock many units of - I'll probably end up ordering them.

Lots of things besides pure $$ for us. If you are very close to your blood supplier and/or have more delivery options,  the equations would change.

David's point about using the patient's plasma/serum (if the antibody titer is adequate) to prescreen units is a good one. It could potentially save a lot of antisera.

OK, I've rambled way past enough

 

[tbostock]

Our criteria lately seems to be staffing.  Sometimes it would probably be more cost effective to screen units, but if it takes a tech a couple hours, then other work waits.  So we have to balance that.

Once a week, we screen about 10 type O units on our Tango for the Rh/K antigens.  So we always have some K and E neg units around to grab.

[SMILLER]

Here, similar to David S, above. 

 

Scott

[Teristella]

3 hours ago, tbostock said:

Our criteria lately seems to be staffing.  Sometimes it would probably be more cost effective to screen units, but if it takes a tech a couple hours, then other work waits.  So we have to balance that.

Once a week, we screen about 10 type O units on our Tango for the Rh/K antigens.  So we always have some K and E neg units around to grab.

I like this idea, but was wondering how you decide which to screen (essentially, do you pull from the 'middle' of the shelf expiration-wise) and if you segregate them afterward if they're negative, or just tag them? We use hang tags that aren't really visible if the units are on the shelf, but I don't like the idea of having another 'set' of units to worry about rotating weekly (we already rotate trauma units, liquid plasma, platelets, antigen negative units on hold, the list goes on!). Maybe we could tag these in a different manner...

[Teristella]

I guess I could answer the actual post! We, like Terri, tend to go with the flow, and most of it depends on staffing and workload. If we have time we'll screen for single antigens or multiples if the combo isn't too difficult. Of course we never screen for e and very, very rarely for c -- it takes about three hours for us to get antigen negative units so we would order those STAT if we needed and screen in the meantime if things were dire.

 

We don't have stringent rules, sometimes I come in on Monday and cringe when I see techs ordered Fya neg, K neg units when it wasn't particularly busy. Maybe that's the former reference lab tech in me, I spent quite a few days doing antigen typing on donors for eight hours straight.

[Malcolm Needs ☆]

In the UK, all the units are typed for C, c, E, e and K (as well as, of course, for ABO and D!).

[goodchild]

This is an excerpt from the Preanalytical section of our donor unit antigen typing procedure:

• Check the “Special Products” shelf prior to testing or requesting products from the supplier – they may be available in the inventory.
• Notify the patient’s caregiver any time crossmatches are ordered and antigen-negative blood products have to be acquired from the supplier or tested in the inventory so they are aware of the delay in the availability of blood.
  • Document communication with the caregiver in the specimen comments.
• If the patient’s physician determines the delay in obtaining antigen-negative blood products would be detrimental to the patient, blood products may be released through the emergency release procedure.
• Determine whether blood products should be obtained from the blood supplier or if they can be obtained from antigen-typing units in the inventory. Consider the 
  • Priority of the transfusion order.
  • Rarity of the phenotype required.
  • Workload in the transfusion service.
  • Turnaround time for antigen-typing units in the inventory compared to the turnaround time for obtaining the products from the blood supplier.

We keep donor units with less common, known phenotypes and >7 day out-dates on a segregated shelf by type and expiration.

We do >100 in-house non-ABO/D antigen types a month and acquire a bit less than that from the blood supplier. We're about 10 miles from our supplier.

Edited February 9, 2016 by goodchild
Distance from supplier

[AMcCord]

Stealing some of your ideas from your Preanalytic Ag typing section, Goodchild.

 

"We don't have stringent rules, sometimes I come in on Monday and cringe when I see techs ordered Fya neg, K neg units when it wasn't particularly busy. "....................Me, too. I hate it when someone has screened 8 units for a K negative unit! or ordered E negative O Pos units.

[tbostock]

On ‎2‎/‎9‎/‎2016 at 11:44 AM, Teristella said:

I like this idea, but was wondering how you decide which to screen (essentially, do you pull from the 'middle' of the shelf expiration-wise) and if you segregate them afterward if they're negative, or just tag them? We use hang tags that aren't really visible if the units are on the shelf, but I don't like the idea of having another 'set' of units to worry about rotating weekly (we already rotate trauma units, liquid plasma, platelets, antigen negative units on hold, the list goes on!). Maybe we could tag these in a different manner...

We screen the new ones, so they will be in inventory for a while.  We enter them into our LIS so the techs can search online for E neg units.  We put antigen labels on the units as well.  We don't segregate them, they are just in with the rest of the inventory if needed.

[mcgouc]

We used the percentages of  antigen negative and staffing in deciding rather to screen in-house or order antigen negative until a couple of years ago when our blood center let us have access on their website to the historical antigen types for units in our inventory.   This information made a huge difference in how we handle this situation and the number of antigen types we perform.  At first, the techs were reluctant to use this search feature.  Then a second shift tech had an anti-c.  I told her to try the search and if there weren't any in the historical types to order the antigen negative units.  Our blood center must have been cleaning their shelves of c negative units because 10 of the 20 O positives in our stock were historically c negative.  Unusual situation, but it sold the techs on using the program.  Of course, we confirm the types before crossmatching, but if we happen to find extra antigen negatives in stock, we do segregate with a note as to what the Blood Center found and the unit needs confirmation.  If there are no antigen negative units in stock and we decide to antigen type, we use the antigen positive info to skip typing those units.   

[suhu]

do you use a NEO or ECHO? 

[goodchild]

On 2/11/2016 at 11:41 AM, mcgouc said:

We used the percentages of  antigen negative and staffing in deciding rather to screen in-house or order antigen negative until a couple of years ago when our blood center let us have access on their website to the historical antigen types for units in our inventory.   This information made a huge difference in how we handle this situation and the number of antigen types we perform.  At first, the techs were reluctant to use this search feature.  Then a second shift tech had an anti-c.  I told her to try the search and if there weren't any in the historical types to order the antigen negative units.  Our blood center must have been cleaning their shelves of c negative units because 10 of the 20 O positives in our stock were historically c negative.  Unusual situation, but it sold the techs on using the program.  Of course, we confirm the types before crossmatching, but if we happen to find extra antigen negatives in stock, we do segregate with a note as to what the Blood Center found and the unit needs confirmation.  If there are no antigen negative units in stock and we decide to antigen type, we use the antigen positive info to skip typing those units.   

I wish our blood supplier would do that.