Brenda K Hutson

I have worked in 5 other Hospitals (prior to current one); 3 of them large, major Medical Centers; other 2 mid-size (400 beds). Everywhere I have worked (and everything I have read) states that one should NEVER use any Cord Blood Testing for transfusion purposes! Why? Having been in Management positions in several of my jobs and thus receiving all of the Error Reports (whatever your Institution calls them); performing Audits, etc., I can tell you that by far, the worst place for labeling errors of specimens occurs in L&D! And we are not talking occassional errors. What I think frequently occurs is that the MD obtains the cord specimen; hands off the unlabeled tube; the Nurse takes the tube "somewhere" and puts "a" label on it; it is then passed off to someone else (usually outside of L&D) to put some Infant identification on the specimen. It is frightening the # and type of errors that come out of there (makes you wonder how many people go home with their own babies!...Ha Ha..just kidding). So while there may be mixed feelings on testing a specimen from the baby (though that is also something I have done everywhere else I have worked; until now), I feel very strongly about the Cord Specimen issue. Brenda

The "reason" (in my mind) is that just because there is an antibody in the maternal circulation, does not necessarily mean it is in the baby (mom could have it from a previous pregnancy or transfusion (snd yes, I have both seen, and performed neonatal heelsticks). Brenda

No reverse type on Neonatal Specimen (usually say until 4 mos). Would never transfuse based on Cord Blood Testing; always require a heelstick (unless Nurse gets blood from a line). Thanks! Brenda

A Form still needs to go out with the units (have always used the same Form as for crossmatched; just may not have ALL of the information when uncrossmatched goes out). So however your Institution provides vitals (on the Form; in the patient's records; etc.) should be the same. When trying to decide when to switch the patient to their own type, you might want to take into consideration what type of anticoagulant the transfused uncrossmatched units are suspended in. For example, are you giving Adsol Units such that you do not have to be concerned about a lot of incompatible plasma now circulating, or CPDA-1 which depending on how many units you give, could leave a lot of Anti-A,B in the patient's circulation? (i.e. patient group A; multiple group O uncrossmatched units given)? Brenda Hutson QUOTE=mia9941;44201]Two questions Re:Emergency Release 1. How are transfusions vitals performed and recoreded during transfusion with uxm'd blood? Is this not a TJC reg? 2. At what point, do you convert to type specific blood in a massive bleed? OK. Three questions.

So is this the same Form that you normally have attached to units, or does it "look" different? And it sounds like you are saying that is a Form that comes back to you? Thanks, Brenda Hutson

So trying to clarify all of these "1 Form for Multiple Units" responses.... So, for example; if you initially send the Form out and there are 2 units listed on the Form; the MD signs it and returns it. But then they need 4 more uncrossmatched untis....most seem to be saying ALL units are documented on that 1 Form?? So do you just ADD the unit numbers (stickers from back of units; hand-written; whatever) to the already-signed Form? I guess my "problem" with that is it almost seems like fraud (maybe not exact word I am looking for) to add information to a Form that has already been signed by someone??? Brenda Hutson

As I mentioned previously, I have moved from Calif. (where I worked 30 years in all med-large Urban areas with multiple Donor Centers), to Rural Maine. We have NO Distribution Center in our state (we get it from Massachusetts). Problems include: 1. Costly and time-consuming to get blood products "urgently" 2. Have to place Orders for following day, by 7pm the evening before 3. Because of 1 & 2 and not wanting to be caught short, we try to keep certain levels; but ALL of the Hospitals in Maine struggle with a lot of wasted products (especially RBCs and Platelets) 4. Certain Hospitals have been designated as Overstock Hospitals; given "extra" stock in case smaller ones need it. 5. Larger Hospitals expected to "help out" smaller Hospitals by taking in their short-dated units when called; but then that sets us up to waste even more products; so now the larger Hospitals are starting to decline those units. Just wondering if anyone else in a scenario such as this has come up with a "system" in your area/state whereby all of the Hospitals can communicate with each other (without it taking up a lot of anyone's time) to "assist" each other in getting the short-dated units transferred and used (win-win situation)?? Thanks, Brenda Hutson, CLS(ASCP)SBB

Is this a Sickle Cell patient? If YES, the standard protocol is to give total pheno-matched once they have started making antibodies (to prevent them from making more; which can make transfusion difficult when a SS patient comes into the ER in Sickle Cell crisis; once had such a patient with a hemoglobin of 2.6 who had multiple antibodies, including hrB). If not a SS patient (and even if they are), why would you not perform rule-outs for the other major alloantibodies, just as you would any other patient (i.e. panels; select cells; etc.)? So maybe I am not sure what/why you are asking? Brenda Hutson

Thanks Malcolm; and thanks for the essay (which I will read; I look forward to it). And yes, I can see how that would be the primary issue; using up antigen-negative units for patients who don't really require them. For me (at least in my current position), we are not a big Hospital so this would not be a frequent request. My staff have been told that in the event our Supplier cannot provide pheno-matched at a particular time, we will have to go the adsorption route. Thanks again, Brenda Hutson

Just wondering, for those of you who give out Emergency Uncrossmatched blood requiring a Physician's signature (accepting responsibility, etc. etc.).... Do you require 1 Form for each pick-up (i.e. maybe they come for 2 units initially); so if they come for more uncrossmatched before Type/Screen/Crossmatch complete, would need to sign another Form....or Do you do a "1 Form fits All?" So in a given episode (i.e. of bleeding), if the MD signs a Form, they can just keep coming for more uncrossmatched RBCs without having to sign another Form? I personally feel the need to document the unit numbers on the Form being sent with the blood for Physician signature; thus requiring 1 Form each time they request Uncrossmatched RBCs.....but would like to know what others do. Thanks, Brenda Hutson, CLS(ASCP)SBB

Everywhere I have worked (until now), we have approached Neonatal Work-Ups as follows: 1. Perform initial Type and Screen on heelstick from infant 2. Check for Anti-A,B in baby if mom Group O and baby non-group O. 3. If Antibody Screen Positive, can use mom's plasma/serum for Antibody ID (rather than exsanguinating the baby). In my current job, they don't even ask for a specimen on the baby (or say, well, they did a Type and Coombs on the Cord); they do everything with the mom's specimen. I think that: 1. Important to know infant's ABO/Rh (and never transfuse based on Cord results) 2. Need to see what is going on in baby; not just what you might find in mom (that may or may not be affecting the baby) Your thoughts and/or experience?? Thanks, Brenda Hutson, CLS(ASCP)SBB

Thanks for weighing in on that Malcolm; have been undecided for years! Brenda

It isn't pretty! Basically, they don't really care about trying to do it correctly; they know the Lab and Nursing will "fix" things for them. In my last place, we spend so much time every day; cancelling duplicate orders, calling to ask Nursing to Order a Type and Screen because the MD only ordered crossmatches; etc. Could the Physicians have "seen" what was done and what needed to be done? Absolutely! I even offered to make a little "cheat sheet" to place by every Nursing station computer for Physicians to use; was told (by my Medical Director) that they would not bother to look at that either. Very frustrating; wasted our time, the Nurses time, the phlebotomist's time. In my current place, they created different "rules" in their Hospital computer system such that Physicians are 'forced" to do things more appropriately. Problem is, it is restricting the Lab in some ways so may need to be changed. I know, not what you wanted to hear! Brenda Hutson, CLS(ASCP)SBB

And I am that "someone" who does the tedious work here....that is part of why I am going to change the Policy to only give IRR to patients who need it per their diagnosis (and for whom we can charge). Brenda Hutson

Google cGMP... Brenda

As stated by others, only have to give c- or e-; and obviously, c- much easier to find (would not recommend Rh NEG blood). Not sure why this patient will have to have 2 visits for ongoing transfusions? Can you not perform their work within 3 days of transfusion? Also, wondering why you were giving this patient pheno matched blood? And why you would have expected another Hospital to do so? There are only certain scenarios (in my experience) in which one "prophylactically" gives a patient partial or complete phenotypically matched units. Brenda Hutson, CLS(ASCP)SBB

See red below... Brenda Hutson It took awhile for me to be convinced to switch from performing adsorptions on these patients, to giving complete pheno-matched; but there is NO WAY I would only match for Rh and K on Warm Auto patients, while not doing Adsorption studies! Again, it is a different scenario than Sickle Cell patients; you are expecting a negative screen while only matching for Rh and K.

Malcolm, allow me to clarify: I am talking about complete pheno-matched (Rh, K, Kidd, Duffy and Ss; mixed feelings about M). When I mentioned this to someone locally, they brought up the issue of just matching for Rh and K; as per Sickle-Cell Protocol. But I told them they are NOT the same; that in the Sickle Cell patient, you are only matching for Rh and K, while still performing Antibody Screens (and work-ups if necessary); then matching for everything if an antibody is made. With Warm Autos, you would have no way of knowing whether the patient had made any new antibodies; so it would not be safe to only match partially if you are not doing a work-up. So to clarify, I guess I am asking who gives "complete" pheno-matched instead of doing time-consuming, expensive adsorptions "as per your Institutional protocol" for repeating antibody ID. I used to be a "purist" (as one well-known Immunohematologist called me) in that I felt they should always be worked up. But she hated doing Differential (Allogeneic) Adsorptions and opted instead to attempt a complete phenotype the first time they got an "untransfused patient" (or you could do retic separation); likely with partial EGA treatment; then just supply pheno-matched. So, I have kind of moved in that direction and just wondered about others...since the Reference Lab my new Hospital uses, gave a little "push back" when I discussed this with them. And what would be the "advantage" of doing the adsorption studies? You will adsorb out a High if doing a Differential Adsorption....you might catch a Low now and then.... Would love your feedback on all of that Malcolm (as well as others). Brenda Hutson, CLS(ASCP)SBB

Wasn't sure whether to put this under computers or billing.......... Of those of you who use Sunquest, just wondering how (if) you resolve the following... Patients come in prior to surgery and/or outpatient transfusions and are given an account #....once they are then admitted, they are given a new account #. How are you able to use that original specimen for subsequent crossmatches and transfusions, and bill for the work? I have been able to accomplish both of those things at other Institutions, but with other computer systems. Am told this is a "bug" :cries:with Sunquest and that they are aware of it. But still need to find a way around that because we can also not bill for duplicate services (and I certainly don't want all of our surgical patients just presenting for testing on the day of surgery)! Thanks, Brenda Hutson, CLS(ASCP)SBB

Just wondering how many of you transfuse Warm Auto patients with Pheno-Matched RBCs in lieu of performing subsequent work-ups (adsorption studies)? Thanks, Brenda Hutson, CLS(ASCP)SBB

So wanted to see how the rest of you handle this scenario. Unless you work in a Reference Lab and have the luxury of frozen samples of Low Incidence Antibodies, about all we can actually screen units for are Cw and Kpa. According to the AABB Standards, the expectation is that one should screen for antigens for which commercial antisera is availalble. Now, fast forward to relatively small Hospitals in Urban areas..... We recently had a patient with Anti-E,c,K and Kpa. Our Reference Lab is about 2 1/2 hours away with only intermittent shuttle service of specimens. So this weekend (of course, it is always on a weekend) our patient showed up needing blood. We happened to have some units that were E-c-K- in stock, but Kpa untested. The Tech. called wanting to know if she needed to send the units down to the Reference Lab to be typed for Kpa. The thought of that kind of made me sick! A few things came to mind: 1. Was the Kpa currently demonstrable (such that we could at least hope to catch it on the coombs crossmatch) 2. Did the Reference Lab have anything from that unit (pilot tube; segment; etc) that they could use to type from? 3. Given that we cannot type for most Low Incidence Antigens; but just Crossmatch for Compatibility, is it really mandatory in a case like this that we type the units for Kpa? Just curious. Thanks, Brenda Hutson, CLS(ASCP)SBB

It was always my understanding that for "clinically significant" Antibodies for which a commercial Antisera is available, you were expected to screen the units; not just perform crossmatch-fo-compatibility. The antibody is demonstrating W+ only. I know there are some Antibodies for which you just "crossmatch for compatibility" (i.e. Leb, P1, N; sometimes, Lea, M. But Kpa is clinidcally significant and I feel it best to screen." Problem is, we do not store that antisera. But then there is always an argument to be made for the fact that not all panels even have a Kpa+ cell on them; so we could be missing them every day unless they are demonstrable and lead to an incompatible crossmatch. As an aside; I did call the Donor Facility we received the blood from, asking them if they kep the pilot tube so they could screen the unit (we had) for Kpa. First, they said they did not keep pilot tubes. Then I asked, "what about a segment?" They have got to keep something until it expires! Am interested in feedback for this. Thanks Brenda Hutson, MT(ASCP)SBB

1. If all cells positive (becomes more complicated if positive autocontrol; so just referring to panel cells here), perform complete phenotype on patient (if not transfused in past 3 months; or do retic separation if they have) 2. Find a Panel Cell that matches the phenotype of the patient (at least whatever antigens the patient lacks, that cell must also lack; it is ok if the cell is negative for something the patient is positive for) and Test that cell 3. If the cell is non-reactive, you are likely dealing with multiples. Now you just have to start splitting out the possibilities and running combinations that lack the antigens the patient lacks; until you are fortunate enough to get a negative reaction. 4. If phenotypically matched Panel cell is positive, you are likely dealing with a High Incidence. If you were fortunate like me and got a double-negative; i.e. Fy(a-b-), Jk(a-b-), S-s-, etc., you can head in that direction first. If you don't get that and/or that does not pan out, you can run some High Incidence Negative (frozen) cells. If there is a flaw in my protocol, hopefully Malcolm will point it out before I lead everyone astray! Brenda Hutson, MT(ASCP)SBB

I don't think I would accept just a 2nd person witnessing 1 draw. I have seen a lot of biased testing in the Laboratory world; better to have a different person, at a different time, identify and draw the patient from scratch. Just my opinion. Brenda Hutson

I hear what you are saying. You missed your calling; you should be an investigator! Thanks, Brenda