Second Sample for ABO/Rh for patients w/o historical type

[woebegone1997]

We are about to implement the second sample requirement for ABO/Rh for patients without historical records. AABB hosted an audioconference on this topic some time last year, and again stressed this during its recent audioconference on changes to the 30th ed of the Standards. We have piloted a small subsection of our hospital for a few months, and are implementing the system hospital-system wide. Previously for a patient without a historical ABO/Rh, we just had a second tech repeat the ABO/Rh with different reagents. Now when we get a T/S sample from a patient without a historical ABO/Rh, we send back to the floor the request (and a tube!) for a second sample. The pilot was relatively pain-free; how well this works with the rest of the hospital, we will have to see. For instance, we had one nurse draw two samples at the same time to "facilitate the process," but unfortunately the process requires two separate phlebotomies. :-(

Our issue is this: our transfusion service also supplies blood to a couple of small hospitals that do not have their own blood banks; we receive PAT (preadmission testing) samples via courier and send crossmatched units on the day of surgery by courier. We do not accept "outside" records and our MISs are not integrated, so we will likely need second samples for most of these patients on the day of surgery. Is there anyone dealing with the same issue? What strategies have you implemented, or are you considering?

Edited April 1, 2016 by woebegone1997
add tag

[pinktoptube]

What standard are you referring to? I reviewed the 30th ed of the Standards and do not see a requirement for that the second type must be a second draw. Not sure where I missed this.

[AMcCord]

A barrier method is also acceptable. Can your small neighbors without blood banks use a barrier method? (Blood Loc, Final Check, etc).

[QCDan]

 

We started sending the floors Tan top EDTA tubes that only the blood bank stocks (so we know it is a second draw and not just a tube of blood the RN had in her pocket) along with a label that needs to be applied at bed side.

5.16.2.2 is the standard that includes the statement about the 2nd current sample

[goodchild]

3 hours ago, QCDan said:

 

We started sending the floors Tan top EDTA tubes that only the blood bank stocks (so we know it is a second draw and not just a tube of blood the RN had in her pocket) along with a label that needs to be applied at bed side.

5.16.2.2 is the standard that includes the statement about the 2nd current sample

I've been really pondering this idea. Having unique tubes for Retypes.

[woebegone1997]

To elaborate, AABB 5.16.2.2 has been modified from the 29th ed to the 30th ed.

No change:

Part 1) "Testing a second current sample." 

Part 2) "Comparison with previous records."

Change:

Part 3) "Retesting the same sample if patient identification was verified using an electronic identification system or another process validated to reduce the risk of misidentification."

From the recent AABB audioconference on the changes to the 30th ed., the push was definitely for the second current sample. We are doing something similar to what QCDan said: we send a tube and a different colored label. Again, our issue is what to do with the small hospitals for whom we provide testing and blood products.

[woebegone1997]

5 hours ago, AMcCord said:

A barrier method is also acceptable. Can your small neighbors without blood banks use a barrier method? (Blood Loc, Final Check, etc).

Can you please elaborate? I'm not sure what this means.

[Teristella]

On ‎4‎/‎1‎/‎2016 at 10:53 AM, woebegone1997 said:

Our issue is this: our transfusion service also supplies blood to a couple of small hospitals that do not have their own blood banks; we receive PAT (preadmission testing) samples via courier and send crossmatched units on the day of surgery by courier. We do not accept "outside" records and our MISs are not integrated, so we will likely need second samples for most of these patients on the day of surgery. Is there anyone dealing with the same issue? What strategies have you implemented, or are you considering?

Well, in short, we do whatever we can to avoid sticking the patient a second time. If you can get your OR to go alone with it, a second sample the day of surgery would be great, but it sounds like you are shipping blood to other facilities. Would you really want to wait for a second sample before you ship the blood over, or would you be shipping the blood over on the condition that they get you a confirm tube? What would you then do if they don't match?

In our case, we do not re-stick the patient the day of surgery (or floor patients, but that's another story) except in specific circumstances. Our policy is written to allow us to give 'universal' group blood products if a confirm is not drawn, as the whole point of the new standard is to prevent ABO mismatch due to misidentification... we get around it by saying that no one is getting anything but group O products without a confirm, and nothing but AB plasma.

For the most part we may 'waste' 2 to 4 O pos units a week on patients who are other blood types, but the staff here are not particularly cooperative with us and it's a small price to pay for ease of workflow. Most patients are O pos or A pos so we do not really hesitate to set up a couple of O pos.

In the event the patient is Rh negative we do try to get a confirm tube the day of surgery if blood products are requested. If they aren't, we don't bother confirming the patient.

In any case, if the patient is continuing to use beyond the initially ordered products and we haven't confirmed, we generally bug the OR to get us some kind of sample. If the patient is bleeding more than they anticipate they usually are ordering TEG testing from us anyway so we just confirm off those tubes.

[pinktoptube]

3 hours ago, woebegone1997 said:

To elaborate, AABB 5.16.2.2 has been modified from the 29th ed to the 30th ed.

No change:

Part 1) "Testing a second current sample." 

Part 2) "Comparison with previous records."

Change:

Part 3) "Retesting the same sample if patient identification was verified using an electronic identification system or another process validated to reduce the risk of misidentification."

From the recent AABB audioconference on the changes to the 30th ed., the push was definitely for the second current sample. We are doing something similar to what QCDan said: we send a tube and a different colored label. Again, our issue is what to do with the small hospitals for whom we provide testing and blood products.

I see. We've always used an electronic system or a two check system for sample acceptability, which meets Part 3. Something another site I worked at use to do was retyping a CBC tube or another main lab tube collected at a different time or by another phlebotomist.

[AMcCord]

17 hours ago, woebegone1997 said:

Can you please elaborate? I'm not sure what this means.

To use a barrier method.............

When the patient is draw for blood bank, an armband with an alpha code is placed on the patient's wrist/ankle. At bedside, stickers with the alpha code are placed on the patient specimen as it is labeled. A 'tail' with more of the alpha code stickers is usually on the armband and is detached from the band once the phlebotomy/labeling process is complete. The tail is attached to the specimen tube with an adhesive. The specimen with its attached 'tail' comes to blood bank. Blood Bank processes the specimen, documenting the alpha ID characters. When the unit is tagged up, the alpha characters do NOT appear on the patient reports or the unit tags and should not appear anywhere on the patient chart, nurse's hand, paper towel on the bed table, etc. - only on the patient's armband, the patient's sample and in blood bank records. When the unit is checked out it is placed in a special plastic bag with a hole in it for attaching the Blood Loc or Final Check lock. The combination set on the lock is the alpha characters on the patient's blood bank ID band. Once the unit reaches the bedside, that lock is the 'barrier' that is intended to stop mistransfusion. An ID check is performed in the usual way plus the alpha characters from the blood bank armband are dialed into the lock on the transport bag to release the blood for transfusion. If the lock doesn't open with the characters on the patient's armband - potentially wrong patient and hard stop until the problem is investigated by blood bank.  Can the armband be cut off? Of course, but you have to have a strong policy that spells out that blood bank can move the band if needed but that it cannot be cut off until a specified time (72 hours after its placed, when the patient is discharged, etc.) Can they cut the transport bag open? Of course, but you have to have a strong policy that forbids it and disciplinary action spelled out if it happens. We've been using Final Check for over 18 months and have not had a single bag cut open - including surgery amazingly! We lose less than a handful of bracelets a year - we've worked very hard with staff education to make sure that the armbands are untouchable. The system works. Regulatory requirements are met. Patient safety requirements for our facility are met. (We also ID patients with hand held devices and print specimen labels at bedside. The lock is on top of that.)

.....So the small hospital uses the Blood Loc or Final Check band when a specimen is drawn for blood products. The hospital providing the crossmatch services and blood products receives the specimen ID'd with the lock alpha code and the 'tail' from the ID band attached. Blood is tagged/issued in the usual way by the hospital providing the crossmatch/product. The lock code is documented in blood bank records. Once it is received on the other end, the small hospital IDs the patient following the accepted SOP and then opens the lock on the transport bag, at the patient bedside, using the alpha combination on the patient's armband. Barrier method has been utilized.

 

 

[ElinF]

If we find we don't have history on any crossmatch patient (or type and screen that could turn into a crossmatch) we search for another tube we may have the lab (samples from the past week).  Other than that we had to start accepting draws from all over the hospital with the nurse's identification (which was hard for us small lab blood bankers to do...we want to control it all!)   If needed we then send the phlebotomist out and get a 2nd tube (which we usually use as the crossmatch tube and the nurse draw as the confirmation tube.) 

 

If we cannot get a confirming 2nd tube we give universal products until we can get a confirm tube.  If the patient is originally O positive or negative, we don't confirm them with  a 2nd type because they will get O anyways.  (unless they are getting FFP). 

I feel so much more comfortable doing this.  I hated giving blood on just 1 draw ABO results! 

Hope this helps. 

 

 

[R1R2]

On 4/1/2016 at 9:53 AM, woebegone1997 said:

We are about to implement the second sample requirement for ABO/Rh for patients without historical records. AABB hosted an audioconference on this topic some time last year, and again stressed this during its recent audioconference on changes to the 30th ed of the Standards. We have piloted a small subsection of our hospital for a few months, and are implementing the system hospital-system wide. Previously for a patient without a historical ABO/Rh, we just had a second tech repeat the ABO/Rh with different reagents. Now when we get a T/S sample from a patient without a historical ABO/Rh, we send back to the floor the request (and a tube!) for a second sample. The pilot was relatively pain-free; how well this works with the rest of the hospital, we will have to see. For instance, we had one nurse draw two samples at the same time to "facilitate the process," but unfortunately the process requires two separate phlebotomies. :-(

Our issue is this: our transfusion service also supplies blood to a couple of small hospitals that do not have their own blood banks; we receive PAT (preadmission testing) samples via courier and send crossmatched units on the day of surgery by courier. We do not accept "outside" records and our MISs are not integrated, so we will likely need second samples for most of these patients on the day of surgery. Is there anyone dealing with the same issue? What strategies have you implemented, or are you considering?

Can I ask how many RBC units are actually transfused at these small hospitals?

[ANORRIS]

Our LIS person for Meditech has it where if you choose NO history it automatically orderes another ABO/Rh to be drawn with it's own specimen number.  If it was drawn with a mechanical barrier (Mobilab is ours) it orders a repeat ABO/Rh on the same tube.

[woebegone1997]

To update this discussion with our experience since we implemented the second sample...

We are not using mechanical barriers, so for us, the important part of this process is that the second sample must be from a different phlebotomy from the initial ABO/Rh sample. To ensure this, we print a different colored label in the BB when we have get a sample from a patient with no history, and we send it ALREADY AFFIXED TO THE TUBE to the floor. (And yes, we have had to tell nurses that they cannot peel off that label and put it on a tube that they had drawn along with the first sample for convenience, because they knew that they would need a second tube!)

The only exception we made is for trauma. BB management met with Trauma staff, and even they agreed that this was a valuable process, and they wanted to stick with the second sample. To speed things up, as soon as we get the trauma alert and the patient has been registered as anonymous, we send the pre-labeled second sample tube (instead of waiting to receive the first sample). We have been assured that trauma staff WILL NOT take "shortcuts," having been educated that taking such "shortcuts" is a dismissible offense. The patient will get emergency-released blood (O +/- RBC, AB or A plasma according to policy) until we get the second type.

As for the small hospitals for whom we provide blood banking services (R1R2: it varies from a unit a week to no more than several units a week), since most of their patients are scheduled, we have decided to add a comment to their pre-admission testing, when necessary, to prompt them to send a second sample. They provide the courier, so a second sample will be sent to us with the courier on the day of the procedure. The courier will wait while we complete testing on the second sample, and then we will issue type specific products. Cumbersome, and a few minutes delay for the patient, but this is what we came up with to conserve precious universal products.

As with most new processes, there were MANY phone calls with the nursing staff, doctors yelling at my blood bankers, etc. It's been almost a month, and things are settling down. Most of the hospital has gotten onboard and understand that this process will add another measure of safety for the patients.

[pbaker]

Sending a prelabeled tube for nursing to collect would make me really nervous

[woebegone1997]

The label has only the patient's demographics, with room for the nurses to write. The collecting nurse has to document date and time of draw and initials. A second nurse has to verify and document her own initials for verifying. We implemented the second nurse verification after a wrong-blood-in-tube incident. We reject samples that are missing any of these criteria.

[pbaker]

We get totally unlabeled specimens that 2 nurses supposedly verified at the bedside.  Be careful!

[Teristella]

At some point you have to trust nurses if you are going to allow them to draw samples, no? I am not sure I would be comfortable sending a tube that is pre-labeled in any way, but if they are willing to label and verify a draw I see no problems using it.

 

Have you tried using previously collected samples at all? Using hematology and coag tubes has worked very well for us so far. We are generally able to find a CBC from the previous shift on every patient, with exceptions being patients who were just admitted through the ED that day.

Edited May 3, 2016 by Teristella
Pre-coffee typo :(

[Auntie-D]

Prelabeleed tubes in blood bank is an absolute no no - this is asking for a WBIT incident.

[R1R2]

On ‎4‎/‎29‎/‎2016 at 10:20 AM, woebegone1997 said:

To update this discussion with our experience since we implemented the second sample...

We are not using mechanical barriers, so for us, the important part of this process is that the second sample must be from a different phlebotomy from the initial ABO/Rh sample. To ensure this, we print a different colored label in the BB when we have get a sample from a patient with no history, and we send it ALREADY AFFIXED TO THE TUBE to the floor. (And yes, we have had to tell nurses that they cannot peel off that label and put it on a tube that they had drawn along with the first sample for convenience, because they knew that they would need a second tube!)

The only exception we made is for trauma. BB management met with Trauma staff, and even they agreed that this was a valuable process, and they wanted to stick with the second sample. To speed things up, as soon as we get the trauma alert and the patient has been registered as anonymous, we send the pre-labeled second sample tube (instead of waiting to receive the first sample). We have been assured that trauma staff WILL NOT take "shortcuts," having been educated that taking such "shortcuts" is a dismissible offense. The patient will get emergency-released blood (O +/- RBC, AB or A plasma according to policy) until we get the second type.

As for the small hospitals for whom we provide blood banking services (R1R2: it varies from a unit a week to no more than several units a week), since most of their patients are scheduled, we have decided to add a comment to their pre-admission testing, when necessary, to prompt them to send a second sample. They provide the courier, so a second sample will be sent to us with the courier on the day of the procedure. The courier will wait while we complete testing on the second sample, and then we will issue type specific products. Cumbersome, and a few minutes delay for the patient, but this is what we came up with to conserve precious universal products.

As with most new processes, there were MANY phone calls with the nursing staff, doctors yelling at my blood bankers, etc. It's been almost a month, and things are settling down. Most of the hospital has gotten onboard and understand that this process will add another measure of safety for the patients.

You may want to rethink sending prelabeled tubes to the patient care area.   I can think of at least 3 regulatory agencies that require samples to be labeled in the presence of the patient. 

[KKidd]

As I read 5.16.2.2  It seems like it refers to an electronic crossmatch.  If an immediate spin crossmatch is performed, that will detect ABO incompatibility.  A second type is still a good practice.

[Teristella]

2 hours ago, KKidd said:

As I read 5.16.2.2  It seems like it refers to an electronic crossmatch.  If an immediate spin crossmatch is performed, that will detect ABO incompatibility.  A second type is still a good practice.

It's going to detect ABO incompatibility if the right patient was drawn. Our practices are meant to prevent transfusion of ABO incompatible blood due to wrong blood in tube (WBIT) incidences.

 

Edit: If you are concerned only with patients who qualify for electronic crossmatch then that is slightly different issue, to be sure. I do not think everyone in this thread is using this information for EXM purposes only, though.

 

Edited May 19, 2016 by Teristella
Clarification

[Dansket]

Although we implemented the EXM, all Type and Screens are processed identically, whether or not blood components are requested.  A second venipuncture is done on all patients who do not have a blood type on file (excluding prenatal ABO,Rh and Antibody screen requests) and whose initial blood sample is not agglutinated by anti-A,B.

[cthherbal ☆]

Our policy is similar in that if you're issuing out group O blood in emergency you do not need the second sample. That being said, it sounds as if your patients are not emergencies because they are PAT's and they should certainly be able to send you a 2nd sample prior to you issuing ABO specific products.  Usually a few articles about  mis-transfusions due to WBIT will scare them enough to understand that this is an important patient safety practice. ?

[ElinF]

Could you draw 2 separate blood bank tubes at the time of the PAT testing using a 2nd phlebotomist?  Really It doesn't matter when the 2nd tube is drawn...whether it is the day of surgery or before...

Explanations will have to be done with the patient of course as to why they are being poked twice, but the importance of it should be emphasized...

 

Edited June 8, 2016 by ElinF