Brenda K Hutson

I am going to call Immucor torrow (today is Sunday), but just curious; has anyone else had problems with the current Lot numbers of anti-Fyb Antisera from Immucor? We have tried 2 different lot numbers; and 2 different heterozygous panel cells. The Positive Control is only macroscopically W+ at best (can actually appear to be negative). Thanks, Brenda Hutson, CLS(ASCP)SBB

The alarms we check daily, are the unit's own integrated alarm. The centralized system is checked and calibrated by the company. Both probes (refrigerator/freezer internal probes) and centralized system probes, are suspended in the same liquid. If the unit's alarm was sounding but not the centralized system, we would know there was a problem. And I don't believe it isn't that the centralized system is not monitoring temps. except for once every 4 hours; but rather that it just documents that temp. (even if within acceptable limits) every 4 hours; unless it reaches one of the alarm set-points inbetween that 4 hour time-frame; then it alarms and takes temps for as long as it takes to get back into the acceptable temperature range. Brenda Hutson

Just a note regarding "who" is allowed to pick up blood products. I have worked places where all blood was sent via pneumatic tube; I have also worked places where only Nursing was allowed to pick up blood; and where I am at now, a Transporter (non-professional) or Nurse can pick up blood (but they must all have been trained on the process). We have the person picking up the blood, perform a read-back from the document attached to the bag (Transfusion Form that will go on patient's chart), while the Tech. compares that to the computer, the unit itself, the pick-up card and the Tag attached to the unit. While it is safe to say the Transporters almost certainly have NO idea what types are compatible, etc., what we get from this is that the Tech. is "hearing" what is read back and hopefully they would notice if something they heard, did not match something they see (not saying that happens 100 % anywhere; but it is the protocol). We have then never had problems with Transport not taking it to the correct location. On the other hand, I can say that at one place I worked where only Nursing could pick up the blood, this did not seem to me to ensure more safety. Just one example of that which I recall was a patient who needed Irradiated blood products. The Tech. had missed that and handed out a non-irradiated product. Upon follow-up with the Nurse (given that upon chart review, I did see that the MD clearly requested Irradiated Products), the Nurse stated that they saw the unit was CMV- and thought that was the same as Irradiated! And for places that Issue through the pneumatic tube (which I have done other places; and which I plan to implement here), you will not have anyone performing a read-back. So it will be important to come up with very strict guidelines for this process to help ensure things are caught (though if guideleines are not followed, well ????). Lesson learned...... Brenda Hutson

Hi, Just a comment on #3; no Lab witness if Nursing collects and labels specimen; and the fact that you see a fair # of labeling ommissiona/errors with Nurse collect specimens. Your comparison about Nursing giving meds w/o a witness; so why for a Lab blood draw, is well taken. That being said, I think the majority of misdrawn/mislabeled specimens in our Facility are also Nurse drawn. They do then often hand them to the phlebotomist who "witnessed" the draw, to label them. But if it were me, I personally would not want to label blood someone else drew; especially given their seemingly lower standards in this area. So while your rationale is sensible, all you can control is specimens coming to your dept. And I try to have tight requirements for specimens for the BB (more so than the rest of the Lab) and would thus prefer "at the very least" that a phlebotomist witness Nurse drawn specimens. Brenda Hutson

I would like to get a feel for what others are doing on an issue. When you receive orders for a Type and Screen with Crossmatch, do you automatically crossmatch the blood products, or wait until they actually come to pick it up (and/or call to say they are coming)? If you wait, what method of crossmatching do you perform (electronic; tube I.S.)? If they only order a Type and Screen (say for pre-op) but the Antibody Screen is positive, do you: call to notify them the screen is positive and ask if they want blood crossmatched; automatically antigen screen and crossmatch a certain number of units; neither?? For those that have a policy to automatically crossmatch antigen negative units on patients with antibodies, even if not ordered (i.e. for pre-op): Which has been more cost effective: Not performing crossmatches until they actually come for the blood (or call to say they are coming) but automatically crossmatching X # of units for patients with antibodies (even if crossmatch was not initially ordered), or, crossmatching what is ordered (not knowing if it will ever be picked up or not)? Has anyone who changed to crossmatching only when actually ready to transfuse, have you documented a change in your C:T Ratio? Thanks, Brenda Hutson, CLS(ASCP)SBB

Having worked in 6 different places, let me answer some of these questions from what I see as "best practices" in my own experience: 1. Hospital Courier or Pnematic Tube. A Hospital Courier would not impact the Lab staffing (would be part of another department; so robbing Peter to pay Paul). The Pneumatic Tube would still require staff to Issue the unit(s) in the computer, bag them up and send in pneumatic tube. Not so sure either of those save time. One thing that may save time though depends on whether or not you use coolers (i.e. for OR)? If so, you could have the coolers (and whatever cold inserts they use; would recommend a standard type rather than bags of ice which are more subjective) stay up in the OR. Then you could send the units in the pneumatic tube (with temp. monitors in them; and yes, it works) and the OR can place them in the coolers (you would probably want to call them as soon as you tube it in that scenario). But packing coolers can be time-consuming; so that might be a place to cut back. 2. Specimens drawn by both phlebotomy and Nursing. 3. Same here; if the Nurse does a line draw, phlebotomy has to witness it. 4. Not positive; but think phlebotomy. 5. Depends on your protocols for this one. Where I am at now, we don't have to do any further work. We are moving towards a 2nd blood draw. At another place, when we did this, an OR transporter often brought that 2nd specimen at the same time they came to pick up blood products (so time saved if they never have to pick them up; which you can get an idea of from your C:T ratio). If you use electronic crossmatch, you could choose to perform this when blood is actually needed (on Nursing Units or OR). Could perhaps choose to crossmatch ahead for OR cases that tend to use blood products; and definitely for outpatient transfusions. Perhaps limit pre-crossmatching for OR, to those patients with antibodies. Brenda Hutson

Same for us; but doing a 2nd, different type of crossmatch (GEL vs Tube) seems to warrant a charge in my opinion. Brenda Hutson

Ok, siding with both Liz and David. Technically, you are correct David, you do not have to perform an Antibody Screen to transfuse FFP. That being said, I agree with (and have followed at 6 Insitutions) Liz's suggesting one should request a Type and Screen be performed. I agree that these patients often also need RBCs at some point; and I also agree with the workflow (not only in the Blood Bank, but for Nurses and Physicians who place orders; it is difficult enough to get them to order a Type and Screen correctly; let's not confuse them further). Just my opinion.... Brenda Hutson

So I noticed a couple of people asking about the ability (and/or validity) of charging for 2 crossmatches if this is required; both I.S. and Coombs. For some, it may not be a huge issue (i.e. they perform tube coombs crossmatches) while for others (i.e. my Institution) who use GEL, the I.S. Crossmatch is a totally separate test then. According to our I.S. guru with regard to our Blood Bank LIS (HCLL) when I asked her about the ability to charge for both, her response was: HCLL has logic to send out a charge for the actual type of crossmatch test performed – IS or Coombs But the question (for me) still remains; can we (legally) charge 2 separate crossmatch charges? Would love to hear what the rest of you have decided on that aspect of this issue. Thanks, Brenda Hutson

Prior to my coming to my current Institution, that is exactly what they did; they made the assumption. Sorry, I am old school; I will not assume anything. And if you run the abbreviated Passive D Panel (designated on antigrams), it certainly does not take that long. I believe in my 4 years here, we did have 1 person who had something other than just Passive D. Also, when you are talking about an antibody that can hit 2 of the 3 screening cells (I say can because I have certainly seen many instances where the Antibody Screen is Negative, and/or only 1 of the cells, ususually the R2R2 is Positive), that does not leave much room for noticing anything else (only leaves 1 cell). My biggest reason for promoting doing it is this; if you don't and you miss the early formation of a new alloantibody in this pregnant woman such that it affects future pregnancies, seems to me there may be some liability issues there (not saying there are; just a thought I have). But even if no liability, I would not feel I was doing my best "service" for this patient to not follow-up on any potential antibody that could affect future pregnancies. At the first place I worked, there was a woman who had an abortion her first pregnancy. She made Anti-K at that time. At the time I left, she had had about 7 miscarriages due to the antibody (her husband was K homozygous). So who is to say that when you obtain 2+ reactions on Screening Cells I and II on an Rh Negative woman who received Rhogam, that there is not something new underneath? So it becomes a game of statistics then; what are the "chances" they made something new. I personally would not want to take any chance with a woman's potential to have future pregnancies. But that is just where I am coming from.... Brenda Hutson, CLS(ASCP)SBB

Are you saying (when you say they only want to record the temp. every 4 hours), that this centralized system would not "detect" an out-of-range temperature and alarm? I would assume not, as that would kind of defeat the purpose of a centralized system. I think it is saying just that; that it will just "document" the temp. every 4 hours. Provided it will always detect your alarm set-points (which should be at least 0.5 above the lowest acceptable temp. and 0.5 below the highest acceptable temp.), and alarm (which in our case, is an automated phone call from the system, alerting us), I think you are ok. We do not use the temp. charts except the couple of instances where there was a problem with the centralized system itself; then our protocol is to immediately place charts on our equipment. Brenda Hutson, CLS(ASCP)SBB

I have never heard of that protocol (performing a coombs crossmatch due to a weak backtype). There can be many perfectly "normal" reasons for a weak backtype (i.e. age; bone marrow transplants; and yes, immunodeficiency). However, you are still performing some type of coombs Antibody Screen, so I personally would not initiate a policy like this. But if there is anyone out there doing this, I would be interested in your rationale.... Brenda Hutson, CLS(ASCP)SBB

1. As far as initiating a delayed transfusion reaction, that is an Institutional protocol. Historically, most places I have worked do so. Was Anti-Jka eluted? I don't want to make any assumptions. Identified could just meant he plasma/serum. I do see the MF DAT; but again, do not want to make an assumption. If not in the eluate, would not initiate a delayed Transfusion Reaction. 2. For recently transfused patient with WAA: a. 1st, I am assuming you have identified it as being a WAA? b. You can actually approach it 1 of 2 ways; you can perform the differential adsorption, or, you can elect to give phenotypically matched RBCs (assuming you are able to obtain the complete phenotype either by typing a pre-transfusion specimen, or, successful EGA or Chloroquine treatment). And that too is an Institutional Policy. My experience has varied with that, depending on the # of WAA patients you get, and the availability of phenotyped units. When I worked at a large Institution that constantly had warm autoantibodies, as well as very sick patients (would get patients from all over the world), it was not feasible to limit patients to phenotypically matched. So we performed allogeneic (differential) adsorptions. Where I am now, we always try to get that phenotype and give matched blood to save the time and expense of the adsorptions. 3. Not sure I totally follow your 3rd question. Are you asking if that statement is an acceptable conclusion for documentation purposes? If that is your question, I think it can be simplified to something like: Anti-XYZ reacting with homozygous cells only. Brenda Hutson, CLS(ASCP)SBB

I am in the process of changing our SOP to address this exact issue. What it "will" say is that anytime a positive antibody screen is obtained, the Physician should be notified ASAP. If it is a pre-op for the following day, staff must contact the Physician (can call answering service in evening) both to notify them, and to inquire as to whether they would now like to change the order from a Type and Screen to a Type and Screen and Crossmatch. Even if they do not, depending on what the antibody(ies) is and/or the nature of the surgery (thus the chance of them using blood), we may elect to at least have antigen screened units avaialable. Obviously I have not yet thought out all of the scenarios; nor all of the specifics, but it is "coming soon to an SOP near you!" While you may very well have some Physicians get upset with you for calling to notify them, I promise you that the ones who get upset the next day when their patient is on the table needing to be transfused and it is at this point you choose to "spring it on them," will make you realize that not only is it safer for the patient, but it is the lesser of 2 evils with the Physicians as well. You can't please everyone! Just make patient safety your highest priority and let that guide your decisions (as well as any regulatory considerations). Brenda Hutson

If your desk is "out in the Lab" and is not in a closed off office, I also side with your Manager. I have worked places that were even stricter than that. At one place, I had my own office (with a door that shut and everything) but that office was out in the Lab so the Manager would not let me have any food/drinks in there. They kind of had an imaginary line drawn; where the floor in the hallway met with the floor to the Lab; once you stepped over that threshold "anywhere," it was considered a clean zone. Have also worked places where if you bring your lunch (for example; from the cafeteria) through the Lab to get to the Lab breakroom, you are expected to cover your food while walking through. There are different degrees of strictness but I have never worked somewhere in which my desk was in the "Lab Area," open space (regardless of how far away I felt I was from testing) where they would allow eating or drinking. I have known a couple of people (1 Resident and 1 Technologist) who got hepatitis at work. Sorry, just my opinion. Brenda Hutson

Most of the patients I have seen share cards are from Labor and Delivery. Brenda

I think it is safe to say that everyone initial encounters push-back when changes are made that will affect their workload. What you have to perhaps help back you though is the fact that the regulatory agencies are moving in the direction of increased patient safety (2nd blood draws; barcoded armbands; etc). The CAP checklist even specifically makes reference to a 2nd blood draw (as an example of what types of processes can be used to ensure a specimen from the correct patient was drawn and tested). And certainly your Hospital Risk Management Dept. might be able to support you. In actuality, the Phlebotomy Manager is all for it (of course it is his staff that will be doing all of the running around; nevertheless.......). So I have Lab support (Phlebotomy Manager, Lab Director, Lab Manager, Medical Director) that will hopefully assist in this effort. I have not done a cost analysis for electronic crossmatch, however, I can tell you by having used it for many years at 2 different Institutions that it saves a LOT of time! It is wonderful! Good Luck on both! Brenda

Our computer system requires that we scan a specimen barcode label for any/all testing. And I was almost thinking I agreed with your logic and that I would DC this confirmation type. But here is part of why I do not agree given the way our Institution performs testing at this time. While my future goal (soon) is to go to a 2nd blood draw and electronic crossmatch, what is currently in-use (which to me, is almost worthless given the risk of biased blood banking), is that a specimen from a new patient must have 2 blood types confirmed. However, those 2 types are performed by the same Tech.! Would at least be better to require 2 different Techs but knowing my goal of changes, I did not make that change. That being said then, while scanning the specimen barcode would ensure they pulled the correct specimen, it would not ensure that the initial Tech. had typed the specimen correctly. And yes, the Immediate Spin XM is to detect ABO incompatibility, but if a patient's mis-type is such that other blood types could be compatible with it (i.e. mis-typed as O; so XM O RBCs; but patient really A); while you would be transfusing compatible blood, the mis-type would possibly not be caught until the next specimen. Brenda

Oh, so you do not use the 5 day thawed plasma? We do, so we have a "good chance" of using it on "someone" provided it is returned in a re-usable state. You are correct about the FFP getting down to the cooler temp; but that is just assuming it is picked up as soon as it is thawed and has not been stored in the refrigerator a short time first. But your point is well taken. Brenda

Right after I stated that we repeated the forward type (and in thinking then that someone might follow that up by asking "why"), I thought about the fact that in the places where we performed electronic crossmatch, we certainly did not pull the tube out of the refrigerator and re-type it. I realize that the computer is doing a check (and that you have a 2nd blood draw; but we will soon be getting a 2nd draw but not yet going onto electronic crossmatch); but that would still be the case if you pulled in a unit (into the computer) to perform the crossmatch on your patient and document the results; the computer would still warn you if the types did not match. And of course, the whole purpose of the immediate spin crossmatch is to detect ABO incompatibility. I think that historically, the thought has been more one of a confirmation (however lame, given that there are only so many blood types to choose from) that you pulled the correct specimen from the refrigerator. And I suppose one could also argue that we have not validated our system for the electronic crossmatch (though it is built into it). So as things have "progressed," (i.e. 2nd blood draws; electronic crossmatch; etc), perhaps it is time for us to re-think some of our processes. Anyway, just thought I would throw all of that out before someone else did. Brenda

We are computerized but we still perform a repeat Forward Type when we pull a specimen out of the refrigerator to crossmatched units at a later time. Brenda

Wow, all of that work you went to; only to have a Physician sabotage it?! Unbelievable! That makes the picture even more ominous in that we can't exactly go back and educate every Physician in the field. Your reference to sickle cell patients reminds me of another physician problem; that is when they are presented with patients they do not normally treat; and as such, are not familiar with the standard of practice for their blood products. Add to that, Hospitals that put the diagnosis as the exact symptoms a patient is admitted with (i.e. nausea; dizziness); without mentioning the big problem (bone marrow transplant; leukemia with possible transplant; sickle cell; etc). I have had to tell Physicians what kind of products we needed to provide based on the diagnosis. Then there was the Physician presented with a sickle cell patient (obviously not common for him), who knew "a little;" just enough to mabye mess things up. He insisted on E-C-K- red blood cells (can't recall if he asked for Hemoglobin S NEG). I told him that while that is a common type for those patients, it should not be assumed! That we will type them and give them RBCs lacking the Rh and K antigens they lacked. But that's ok; maybe he will remember that next time around......or not! Brenda

Sorry, read and replied to previous question before seeing this. EGA stands for EDTA-Glycine-Acid. It can be used to dissociate the antibody from the RBCs. Cannot use for Kell system though. Brenda

It is ok with me for you to ask any question (no question is bad except the one not asked out of pride). It means the antisera that you have to take out to the coombs phase of testing (so incubation at 37C; wash; add IgG or Poly AHG; etc). Currently (unless something new has come out that I am not yet aware of), the only "primary" Antigens this would be are Fya, Fyb and s. Brenda

Wow, sounds like you have more than 1 problem on your hands! 1. I would certainly hope you could trust the work of your Techs. such that you would not need to keep repeating the Antibody Screen on the same specimen! 2. A Tech. who cannot understand the simple (Blood Banking 101) requirement of needing a new Antibody Screen only on a new specimen?? Maybe this sounds harsh (and I try not to do this on the website; but feel compelled to make an exception this time), but I would go back to 1 Antibody Screen per specimen, and start the process of eliminating staff who cannot remember that simple rule. We do repeat the Forward type and Rh if we pull a specimen out of the refrigerator (which has already been typed and screened), to XM additional units. Hmmmmm... Brenda Hutson, CLS(ASCP)SBB