Brenda K Hutson

Ok, while you look up EGA...I will look up pedantic! LOL I stand corrected......genes. Thanks for responding. Brenda

So you said nothing stands out with medications...i.e. no IvIgG? Had a patient at one place I worked that kept hemolyzing like that and we could not get anything out of the eluate. We decided to "try" transfusing with Jka Negative Units (did not have a non-transfused sample to type) and no more hemolysis (or could be Jkb). Just another random thought in an otherwise bizzare case. Brenda Hutson

Would like to hear what part you don't agree with.....I am always open to discussion. Thanks Malcolm, Brenda

I have taught through the years that one should "never" assume something is a Cold Agglutinin unless they prove it (with a cold panel; i.e. Screening Cells, Auto, Cord and whatever Reverse Cells the patient is Negative for). I even have a story of a place with a similar protocol to what you discuss (though much worse). When I was a Reference Lab Supervisor, we received a "very" hemolyzed specimen on a patient who had a hemolytic transfusion reaction. The Hospital sent their panel work. They did run a panel; and it was a perfect pattern of an Anti-E; but their Policy (and I can only hope they misunderstood it) was that they should try to perwarm it away and if it went away, it was not significant. A week later, we received another hemolyzed specimen from the same Hospital (different patient). This time the patient had a perfect E and c; but again, they managed to prewarm them away (which is another pet peeve of mine.....trust me, I have seen many clinically significant antibodies prewarmed away...by good Techs.; even in large, prestigious Medical Centers....so I tend to be very anti-prewarm except in the right hands). Anyway, I called their Medical Director and told her they needed to "cease and desist" with prewarming before they killed someone (not to mention, teach their Techs. how to perform basic Antibody ID). Your Policy is not "that" bad in that your supervisor is saying you have first ruled-out major alloantibodies. But let me tell you another problem (sorry to belabor the point). If you use GEL, know that I have seen "many" instances of Kidd group antibodies that not only do not react with any heterozygous cells; but do not even react with "all" homozygous cells. So just saying you ruled everything out, doesn't necessarily mean you did. Not only have I seen that in Hospitals I have worked in; but also in work-ups sent to us at the Reference Lab from Hospitals that used GEL but did not know of this potential problem. So, I have also taught through the years that even when you think you have ruled everything out, you need to look at your positive reactions and see "what do all of those cells have in common?" You might run into some surprises. Brenda

To me, it would be easier to just give the Rhogam and say the Rh type is "unable to determine at this time." As far as the dose of Rhogam....you will still do the Fetal Screen (since you are saying the baby "may" be Weak D Positive). Brenda

Depends on where you work and what your resources are. It would be "nice" to give R1R1 to a patient with anti-E or anti-c who is negative for the other; or to give R2R2 to a patient with anti-e or anti-C who is negative for the other. But especially with the R2R2 units...you are taking valuable resources from patients with anti-e if your patient just has an anti-C (and some Donor Facilities won't give that up unless you have an anti-e). While it is true they may go on to make the other antibody; it is not a high enough frequency that we have done it most places I have worked. Brenda Hutson

Here are my experiences with refrigerators in the OR: 1. The OR staff was responsible for taking temps. every day (I think one of the Technicians); but when we found that they were falsifying data, we pulled the refrigerators (i.e. forgot to take temps. one day...so took off chart next day). We caught it when we went to change the charts one week and they had not filled in temps. for the previous day. After we changed the chart (so they did not have the previous chart available to falsify), temps. for the previous day still showed up on the log) 2. If you store >1 patient in the refrigerator at a time, there is the "very real" risk of pulling the wrong patient and transfusing the blood; especially in an urgent situation. I have seen it happen. Brenda Hutson

I agree the EGA Treatment seems like the quickest method if you "really" want to distinguish Weak D from Rh Negative. But even easier is to just administer Rhogam (be on the safe side). I think this Medical Director was concerned because one of his staff had used EGA; but did not use appropriate controls (and I personally had never used EGA for this purpose so did not know what to say to him). And what would be logical controls for this? One Reference Lab told me they only use Negative Controls for EGA Testing (said they have actually seen Negative Controls come up Positive)...but I would want a Positive Control (since I don't use it where I currently am; can't recall if the use of controls is "recommended;" or "required"). Another Reference Lab said they would use an Rh Positive Cell as a Positive Control. But this Medical Director was questioning this; thinking that "if" you are going to do this; should not the Positive Control be a Weak D Positive Cell? I think his concern being that they called this baby an Rh Negative based on the EGA Typing (w/o proper controls) so did not give Rhogam. I would be concerned about that also; but didn't have "absolute" answers to give him as far as the controls. Thanks, Brenda Hutson

I don't think that product is available from Quotient any longer? Brenda

Couldn't tell from the original post; if you are doing these things "at the time you get an exsanguinating patient;" or, if they are done ahead of time? Labeling the Unit Tag with Unit Information; placing Uncrossmatched Stickers on blood and Tags; Pulling Segments; having an Uncrossmatched Release Form (for MD signature) all ready to go....would obviously save a lot of time. These can all be done ahead of time. As far as patient identification....unfortunately, not every Hospital has a system for even obtaining a "John Doe" type of identification for these patients in time to label the paperwork. One Trauma Center I worked at requires this (some type of patient identifier; in the computer) for release of Trauma Units. This is because in auditing patient charts, there were too many examples of Chart Copies either not making it to the Charts; or going on the wrong patient's chart. The FDA noted this. The busier your ED/Trauma facility, the more room for error like this to occur (i.e. maybe you have multiple trauma patients come in at once). Brenda Hutson

We use Thermolyne Type 12200 Dry-Bath. Have rarely had any problems. Brenda Hutson, CLS(ASCP)SBB

Sorry....EDTA Glycine Acid; and yes, it functions as chloroquine (and I think; at least in this country, is now more widely used than chloroquine). Thanks, Brenda Sorry....EDTA Glycine Acid; and yes, it functions as chloroquine (and I think; at least in this country, is now more widely used than chloroquine). Thanks, Brenda

I received an e-mail from a former Medical Director, asking me a question for which I do not know the answer. I have not used EGA in awhile (last couple of places used Generalists so we didn't get that technical). His question had to do with using EGA on Cord Cells with a Positive DAT (mom O NEG; baby A NEG; Anti-A eluted) to go through to the Weak D phase (vs. resulting it as "unable to determine at this time" and giving Rhogam to be on the safe side). I know when I worked there, we ran Positive and Negative Controls for the Antigens we treated (but we did not use EGA for this purpose). I can't recall now if the Manufacturer's Inserts "recommends" both Positive and Negative Controls; or whether it is a "must?" In asking a couple of technical experts, I received different replies: 1. 1 Reference Lab stated they don't use it for this purpose simply because they don't usually get cord work-ups; but they don't see why you couldn't. They said they just use a Negative Control for any Antigen they are typing after EGA Treatment (said in their experience, they have seen problems with the Negative Control coming up Positive for some reason). They "accept" the Manufacturer's statement as far as which Antigens have been proven to be destroyed by EGA. 2. A 2nd Reference Lab said you could use EGA for this purpose but that you should run a Positive Control; and that Positive Control should be an Rh Positive Cell. The Medical Director is questioning whether a known Weak D Positive Cell would be required to be tested as the Positive Control (which would be tough unless you had frozen Weak D Cells around). What are your thoughts....and do any of you use EGA for this purpose (and if yes, what controls do you run)? Thanks, Brenda Hutson, CLS(ASCP)SBB

Ok, so I set my filters like this (several times): Show topic Type (All Topics) Sort By (Last Post) Sort Direction (Descending Z-A) Time Fram (Show All) Remember Filters But everytime I go to Hot Topics (and want to view everything....I have missed a lot); all that comes up are the last 2-3 Posts. What do I have to do to see ALL previous Posts? Thanks, Brenda

We just had our X-Ray Irradiator (Raycell) set-up day before yesterday....and I was trained to use it yesterday (so I will train my staff). But myself and my Leads had also gone to another Hospital that uses it, about a year ago. Here are the pros and cons (with my limited knowledge): X-Ray Pro: 1. Don't have all of that extra regulation of using cesium (and that is a big deal); lots involved as you know X-Ray Con: 1. I am told (inclduing by the Vendor installing our Irradiator) that there is much more maintenance (i.e. more downtime) with the X-Ray Irradiator. Also told that by the Hospital that we went to last year; as well as another local Hospital that uses the cesium Irradiator (which is almost never down). Not sure about other Pros and Cons....those seem to be the 2 biggest differences by my understanding. Brenda Hutson, CLS(ASCP)SBB

Cliff, Would love to come to site every day, but had a tough year last year (mom had stroke....I had surgery....we moved into a new Hospital). It just "is what it is." Again today I tried to look at Hot Topics and it is only showing the last 2 posts. I tried to change the filter to ask to see everything; but that didn't work. Used to be I just clicked on Hot Topics and got a long list of posts. What am I doing wrong? Also, is there a place I can go to on this website to learn about all of the changes that have taken place on this site so I can better navigate it? Thanks, Brenda Hutson

Ok Cliff, It has been awhile since I have had time to go to this website....and it is completely different. I get confused everytime I come on now. Todays problem (my problem ) is that when I try to look at Hot Topics, it only brings up 1 topic. Why does it not show me ALL previous posts as it used to? Thanks, Brenda Hutson

Ah, this is along the lines of my recently posted Thread under Hot Topics....who should be responsible to ensure there is an "Order to Transfuse." My predecessor here set it up so that the Transfusion Order printed out in the Blood Bank. That had been a thorn in my side in my 2 years here; as I had never done it anywhere else and do not feel it is the responsibility of the Transfusion Service to confirm the Order to Transfuse. In fact, the Standards and Technical Manual clearly reference this to the Transfusionist. But as with other things (as I have learned through the years), the more you are willing to do for Nursing....the more they will let you do. I had already told the Director of Nursing that I was going to discontinue this printout as soon as I got a chance (we just moved into a new Hospital). That was ok with her until a Nurse transfused a couple of weeks ago, without a written Order from Physician (she said he told her verbally; and he later put the order in). So Nursing wanted to know why the "Transfusion Service Issued blood when there was no Order to Transfuse?!" Of course they did.....we had taken on some of the owness of their responsibility; so now they could blame us! This has made my battle more difficult but I think it is one I have finally won. The compromise (to assist Nursing to remember what is in their Policy and is their responsibility) is: 1. An added space on the pick-up Form where the Nurse must write the Name of the Physician Ordering the Transfusion, and must Sign her/his Name to attest that they checked the Order 2. Added wording on the Blood Chart Copy where there was already a space for the 2 Nurses identifying the patient to sign; also stating that they checked that there is an Order to Transfuse. Brenda Hutson, CLS(ASCP)SBB

Yes, there are Techs. like that everywhere (and it seems to be becoming even more difficult to find experienced, knowledgeable staff with a good work ethic). So, what I resorted to years ago (and about 3 Hospitals ago) is a little thing called "accountability." You don't do your job (or don't do it correctly), and you get written up. You get written up enough....and there will be consequences (and though it is extra work on my part, I manage to find ways to track almost every/any aspect of a task that is supposed to be done). Once staff know you can track things back to them; and once they know there are ramifications....sadly, for "some" people, that is the only thing that will get them to do their jobs correctly. And I can tell you this in all honesty (not at all meant as a reflection on me)....but when I have started at a new place (in-charge) and seen all of the above....and "forced" improvement (sometimes with kicking and screaming from some staff); I can say with all honesty that in every place I have left, the staff honestly thanked me at the end for "raising their standards." They may have fought me all the way....but they could see the difference in their work performance after time and were actually proud of themselves. That makes it worth it! Another problem I have encountered is people who are just trained "how" to do something (or "what" to do); not the "why" or theory behind it. I always teach by principles because my philosophy is that if someone understands why they do things the way they do, they are much less likely to forget steps; to recognize when something is not right; and to be able to trouble-shoot problems when they do encounter them. People that are just taught "what" to do, are errors waiting to happen (and will not understand when you try to correct them, because they were never taught that way in the first place). But again, there are 2 types of workers; those who may have been taught that way but have the motivation to want to understand what they are doing and to do a good job; and are willing to learn and understand what they were never taught; and those who just want a paycheck. And unfortunately, they don't teach work ethic much anymore.....do they? Brenda Hutson, CLS(ASCP)SBB

Differs depending on where I have worked. Rhogam in Blood Bank, everywhere I have worked (note: now a form that can be intramuscular or IV; so a little confusing to contrast that with WinRho). Larger Facilities I worked at, also stored the Clotting Factors. Brenda Hutson

Wow...sorry everyone; guess I have not replied to responses since this website changed and I see I made a mess of it! Was trying to respond to people's individual posts... Brenda

Brenda Here (Michigan, US), we receive an order for a test or product from the hospital system. Once the product is tagged and available, we call the unit to let them know. Typically a transporter brings a written order slip when they come to pick up the product. It includes, among other things, the reason for transfusion, the type of product and the unique BB armband number (that matches the number on the unit tag, specimen used for T&S and armband on patient.) FDA, JCAHO has never had a problem with these being inadequate for "confirming an order". Indeed, BB here has had to take over functions which you would expect to be monitored by other areas. Our OR dept. could not handle proper tracking of bone and other transplant tissue, so we have to stock, issue and track it using our BB system. Scott This is how they order in our system: Under Transfuse they select which product they want. The Nursing to Administer is automatically selected along with 0.9% NaCl. They then have to check the Set up [Product] and put in if it's stat/routine, how many units, the reason why. Then the order is electronically signed and submitted. When this happens Nursing gets their order to transfuse and Blood Bank gets a requisition printed to set up whatever product they ordered. The problem we encounter is that the doctor's forget they have check Set Up so Nursing gets an order, but Blood Bank never does. Then Nursing calls asking if the blood is ready and we reply "we never got an order." So we've had some delays in patient care because of that. as already a statement that said "I HAVE IDENTIFIED INTENDED REIPIENT AND COMPARED THIS WITH BLOOD LABEL AND WITH THE UNIT IDENTIFICATION;"so I am adding to that; AND HAVE CONFIRMED THAT THERE IS AN ORDER TO TRANSFUSE." There are then 2 spaces for the 2 Nurses to sign and date. Also, 3 things regarding your statement that Inspectors wanted to know how you were making sure Nursing was doing their job: 1. We do follow units to the floors a few times a year and audit their process 2. By adding to our pick-up slip (which is what we have done other places," a line for the Physician "requesting the Transfusion;"' (or something along those lines), that has been our confirmation; and that is then the Name we enter in the computer when we Issue the Product. 3. I can tell you that in 2 places where our Transfusion Chart Copy Forms were actuallyduplicate, carbon forms, we would get the 2nd copy back for the purpose of auditing completion by Nursing. At one place, we were cited by the FDA because there were too many incomplete Forms. I went to Nursing administration and we continued to Audit and return incomplete Forms....which improved the process some, but still not to the extent the FDA wanted....so we were cited the next Inspection again (only this time, the CEO made the Nursing Administrator come to the closing meeting). Because after all, what else can we do? At some point, Nursing should be made by "their" Management to follow "their" protocols; and they should audit those protocols. It just seems to me that the Blood Bank is having to be the gate-keeper for more and more of the Nursing processes. But I have no doubt you feel my pain.....as we all do; so thanks so much for your response! Brenda "There was a case years ago here where the state came in to review a surgical case that went bad. Had nothing to do with the Blood Bank, but when they scrutinized this case they told us that now it would be our job to make sure the nurses did theirs. From then on, we get a printout of their order for blood in the Blood Bank and we match it to what goes out. As you say above, I agree that it's not our place to make sure the order is there. But ever since then even Joint Commission inspectors have asked me "how do your techs in the Blood Bank confirm the order to transfuse?". Since we made this change we have had 3 or 4 instances where the nurse sent us a request for a second unit of blood for a single unit order that was already complete. Very sad that their carelessness has to become our problem. Some Blood Banks that do not want to get the actual printed order will put a statement on the request form that is signed by the nurse with items checked off: Order verified Consent verified Pre-transfusion vital signs performed At least then you are covering your Blood Bank staff if an extra unit is issued; you had a signed document from a licensed RN to back you up. I feel your pain on this one Brenda.

This is how they order in our system: Under Transfuse they select which product they want. The Nursing to Administer is automatically selected along with 0.9% NaCl. They then have to check the Set up [Product] and put in if it's stat/routine, how many units, the reason why. Then the order is electronically signed and submitted. When this happens Nursing gets their order to transfuse and Blood Bank gets a requisition printed to set up whatever product they ordered. The problem we encounter is that the doctor's forget they have check Set Up so Nursing gets an order, but Blood Bank never does. Then Nursing calls asking if the blood is ready and we reply "we never got an order." So we've had some delays in patient care because of that. as already a statement that said "I HAVE IDENTIFIED INTENDED REIPIENT AND COMPARED THIS WITH BLOOD LABEL AND WITH THE UNIT IDENTIFICATION;"so I am adding to that; AND HAVE CONFIRMED THAT THERE IS AN ORDER TO TRANSFUSE." There are then 2 spaces for the 2 Nurses to sign and date. Also, 3 things regarding your statement that Inspectors wanted to know how you were making sure Nursing was doing their job: 1. We do follow units to the floors a few times a year and audit their process 2. By adding to our pick-up slip (which is what we have done other places," a line for the Physician "requesting the Transfusion;"' (or something along those lines), that has been our confirmation; and that is then the Name we enter in the computer when we Issue the Product. 3. I can tell you that in 2 places where our Transfusion Chart Copy Forms were actuallyduplicate, carbon forms, we would get the 2nd copy back for the purpose of auditing completion by Nursing. At one place, we were cited by the FDA because there were too many incomplete Forms. I went to Nursing administration and we continued to Audit and return incomplete Forms....which improved the process some, but still not to the extent the FDA wanted....so we were cited the next Inspection again (only this time, the CEO made the Nursing Administrator come to the closing meeting). Because after all, what else can we do? At some point, Nursing should be made by "their" Management to follow "their" protocols; and they should audit those protocols. It just seems to me that the Blood Bank is having to be the gate-keeper for more and more of the Nursing processes. But I have no doubt you feel my pain.....as we all do; so thanks so much for your response! Brenda "There was a case years ago here where the state came in to review a surgical case that went bad. Had nothing to do with the Blood Bank, but when they scrutinized this case they told us that now it would be our job to make sure the nurses did theirs. From then on, we get a printout of their order for blood in the Blood Bank and we match it to what goes out. As you say above, I agree that it's not our place to make sure the order is there. But ever since then even Joint Commission inspectors have asked me "how do your techs in the Blood Bank confirm the order to transfuse?". Since we made this change we have had 3 or 4 instances where the nurse sent us a request for a second unit of blood for a single unit order that was already complete. Very sad that their carelessness has to become our problem. Some Blood Banks that do not want to get the actual printed order will put a statement on the request form that is signed by the nurse with items checked off: Order verified Consent verified Pre-transfusion vital signs performed At least then you are covering your Blood Bank staff if an extra unit is issued; you had a signed document from a licensed RN to back you up. I feel your pain on this one Brenda.

as already a statement that said "I HAVE IDENTIFIED INTENDED REIPIENT AND COMPARED THIS WITH BLOOD LABEL AND WITH THE UNIT IDENTIFICATION;"so I am adding to that; AND HAVE CONFIRMED THAT THERE IS AN ORDER TO TRANSFUSE." There are then 2 spaces for the 2 Nurses to sign and date. Also, 3 things regarding your statement that Inspectors wanted to know how you were making sure Nursing was doing their job: 1. We do follow units to the floors a few times a year and audit their process 2. By adding to our pick-up slip (which is what we have done other places," a line for the Physician "requesting the Transfusion;"' (or something along those lines), that has been our confirmation; and that is then the Name we enter in the computer when we Issue the Product. 3. I can tell you that in 2 places where our Transfusion Chart Copy Forms were actuallyduplicate, carbon forms, we would get the 2nd copy back for the purpose of auditing completion by Nursing. At one place, we were cited by the FDA because there were too many incomplete Forms. I went to Nursing administration and we continued to Audit and return incomplete Forms....which improved the process some, but still not to the extent the FDA wanted....so we were cited the next Inspection again (only this time, the CEO made the Nursing Administrator come to the closing meeting). Because after all, what else can we do? At some point, Nursing should be made by "their" Management to follow "their" protocols; and they should audit those protocols. It just seems to me that the Blood Bank is having to be the gate-keeper for more and more of the Nursing processes. But I have no doubt you feel my pain.....as we all do; so thanks so much for your response! Brenda "There was a case years ago here where the state came in to review a surgical case that went bad. Had nothing to do with the Blood Bank, but when they scrutinized this case they told us that now it would be our job to make sure the nurses did theirs. From then on, we get a printout of their order for blood in the Blood Bank and we match it to what goes out. As you say above, I agree that it's not our place to make sure the order is there. But ever since then even Joint Commission inspectors have asked me "how do your techs in the Blood Bank confirm the order to transfuse?". Since we made this change we have had 3 or 4 instances where the nurse sent us a request for a second unit of blood for a single unit order that was already complete. Very sad that their carelessness has to become our problem. Some Blood Banks that do not want to get the actual printed order will put a statement on the request form that is signed by the nurse with items checked off: Order verified Consent verified Pre-transfusion vital signs performed At least then you are covering your Blood Bank staff if an extra unit is issued; you had a signed document from a licensed RN to back you up. I feel your pain on this one Brenda.