Townsend

We've used Chek Lab for labels in the past..... phone is (630) 896-0574, fax (630) 896-0665, for orders call (888) 870-7979. cheklab@xnet.com - 208 East Benton ST, PO Box 4455, Aurora, IL 60507 We also recently switched to the Typesafe seg device from Typenex. It was cheaper than the hematype and the techs seem to like the product better. Stephanie Townsend, MT (ASCP)SBB

We are using cpt code 86905 and billing per antigen/ per unit typed. We investigated this last year and found a reference in AABB's "Billing and Reimbursement / Frequently asked questions". The original question was regarding billing for matching units for sickle cell patients. You may still be able to pull this up on AABB's website. Stephanie Townsend, MT (ASCP)SBB

We actually do both... the units that we need that are "complete" phenotypically similar (Rh, K, Duffy, Kidd, S/s) come from the ARC Reference Lab (we do not have the supply to search for those kinds of units). Most of the Rh and K neg only units are screened in-house. I must admit that it has become very time consuming to provide blood for these patients, but at least none of us are worried about job security!!! And jcdayaz - you should never feel bad about some of these subjects being "out of your league". We all have our strengths and different experiences; some are Reference Lab specialists, while others come from children's hospitals or community blood banks. It's great to see the wealth of knowledge that the combination can bring to the forum! Stephanie Townsend, MT(ASCP)SBB

Thanks for the suggestion Malcom! I'm sure you understand the frustration of trying to provide units for "needy" Transfusion Services like us.:tongue: We actually only give Fya negative (not Fyb neg) to those who type Fy(a-b-). We have been sending our patients who type Fy(a+b-) for the GATA box mutation - most of them have come back positive so we can drop the Fyb neg requirement. Glad to hear that others recommend this policy. Stephanie Townsend, MT(ASCP)SBB

We are a children's hospital and have the same sickle protocol as aakupaku, Kate, and clmergen: RBC matched for Rh antigens and K, until the patient makes an antibody, at which point we begin also matching for Duffy, Kidd, and S/s. The blood is fresh (7 days or less) and sickle negative. Currently we have about 35 sickle patients that are exchanged 2-8 units every 3-5 weeks, depending on the patient's size, Hgb S level, Hct. So they total approximately 150 red cell units per month (half are some combo of C/c/E/K neg and the other half have antibodies requiring about 5-8 antigens negative per unit). We now have almost 300 sickle and thalassemia patient phenotypes that we keep in a spreadsheet! The key is to collaborate with the physicians, sickle and apheresis nurses, transfusion service, and blood supplier. Our local ARC has done a lot of recruiting for our sickle patients. They're "looking" for those black donors who are Rh pos, but C/E negative (Ro) so that we can try to salvage our Onegative blood supply. After years of tweeking, the process currently in place is moving pretty smoothly, and we just keep getting busier (and more complex antibody workups). Stephanie Townsend, MT(ASCP)SBB:rolleyes:

Terri, We do not routinely irradiate for our sickle cell patients. The hem/onc physicians are aware of our protocol, which were established by our Medical Director and approved by those attending physicians, as well as the Transfusion Committee physicians. If a clinician orders blood on a patient requesting something other than our established protocols (i.e. irradiated for a sickle patient), the tech clarifies with the ordering clinician and explains our protocol. If they still insist, we would refert them to our Med Director (and honor the irradiated request temporarily if she's not immediately available). They only time a sickle patient would receive irradiated blood is after they have been placed on a potential BMT list (currently SIB BMTs). At which point they would receive irradiated, leukoreduced, sickle negative, and CMV negative (if pt and donor test CMV neg or testing hasn't been done yet). I am not aware of any contraindication for irradiating blood for sickle patients. Any directed donation for a sickle patient would be irradiated as it would be for any other patient. Stephanie Townsend, MT (ASCP)SBB

We do the same. We eliminated the "least incompatible" and now just call them either compatible or incompatible. We are very lucky to have an involved TS Medical Director who usually talks to the physician in these cases. It is almost always a (sickle) patient with a warm autoantibody, so the physicians involved are pretty familiar with these cases. We also attach a form that says "Transfuse with caution" and warns the nurse of the complex antibody presentation and the incompatible crossmatch results Stephanie Townsend, MT(ASCP)SBB

We also have patient's of all ages on ECMO, even a couple of H1N1 patients this fall. Prime blood is based on weight: 1-10kg: 3 CPD rbc and 1 plasma 11-30kg: 3 CPD rbc and 2 plasma >30kg (including adults): 2 CPD and 2 Adsol rbc and 2 plasma All prime blood is less than 7 days old, Sickle negative, Leukoreduced. You may find some institutions that also irradiate blood for ECMO, but currently we do not. We keep at least 4 units of fresh CPD ready to go for an emergent ECMO prime on hand at all times. The prime blood is issued all at once and placed in a cooler for transport only. By this time, it is almost NEVER returned, as the ECMO team is ready to go by the time they pick up the blood products. Once the patient is on ECMO, extra blood is crossmatched for maintenance as ordered by the physician. These units are adsol rbc, less than 7 days old and also sickle neg, LR. We also ensure adequate platelets are available if needed. All blood is kept in the Transfusion Service until ordered/requested by the clinicians. We can send blood up to the floors via the pneumatic tube system, so maintenance blood products can be sent relatively quickly. Stephanie Townsend, MT(ASCP)SBB

Hi trisram, You should check your blood bank SOPs to make sure that there is a detailed procedure on how to handle neonatal testing and blood administration. Since this is a proficiency/competency test, you should be able to find the answers in your procedure manuals. If not, you should definitely bring this up with your supervisor to ensure that your policies and procedures cover this. With that said, it is good that you are looking for more information on the theory behind the testing - that is the purpose of postings like this one! Just make sure that you are not looking for answers to your test alone - these would vary by institution. Good luck..... I hope that you find that you enjoy working in the blood bank!

We perform only IgG DATs on any neonatal patient - that is any patient under 4 months of age. Any patient 4 months and older gets a Poly DAT.

Oops, that did not display well, let me try again: For patients under 10kg: 1 RBC, 1 (pediatric size) PLASMA, 1 PLT PHER For patients 10-40kg: 2 RBC, 1 PLASMA, 1 PLT PHER For patients >40kg: 4 RBC, 2 PLASMA, 1 PLT PHER Sorry about that, cut and paste did not work:p Stephanie Townsend, MT(ASCP)SBB

I was about to ask the same thing regardiing MTP in pediatrics! I am the TS Manager from Nationwide Children's Hospital (Columbus, Ohio), a level I trauma/burn center. We have been reviewing our MTP procedure recently and are about to make some changes. The original policy called for red cells/plasma/plts in an approx 1:1:1 ratio based on the patient's dose. Once instituted by the physician, components would be prepared based on patient's weight. The problem is, once we were called, we had a lot of questions - can they wait for us to aliquot the doses, do they need whole units? etc. We will soon be making the change to predetermined "packs" based on patient weight instead of doses/kg: Patient weight Red cells per pack Plasma per pack Platelets per pack <10 kg 1 unit 1 ped FFP 1 pheresis 10-40 kg 2 units 1 plasma (FZP or PFP) 1 pheresis >40 kg 4 units 2 units (FZP or PFP) 1 pheresis Now the blood bank tech will know exactly what to prepare, and the clinicians will know exactly what to expect once the protocol has been activated. We hope to institute the above packs after the first of the year. Our only problem now is how to get everyone outside of the blood bank educated. The trauma team is on board and has a great deal of resources for educating their own staff, but we run into problems getting the ICU physicians as well as the OR (esp anesthesiology) educated on the protocol. Stephanie Townsend, MT(ASCP)SBB:rolleyes:

We also leave it on 24/7 without any problems after years of use.

Were any of you at the AABB meeting in New Orleans? I attended a session "Ask the FDA" where this exact question was addressed - "does the TS that performs reconstituted whole blood only rarely need to be FDA registered?" They were very clear in they're response - YES! According to them, it does not matter how often you perform this component preparation; it is manufacturing a blood component. The other thing that was brought up at the session was - "if your TS only performs this on such rare occasions, how do you determine that you're staff is competent in the procedure?" If anyone has any ideas how to maintain staff competency on rare procedures like this, please speak up! This was never addressed in any of our inspections (AABB, CAP, or FDA), but that doesn't mean that it never will be.

That would be great if we knew that. Malcom, do you normally get this information from your blood supplier?

Just a few things to keep in mind, hope they help, - If the transfusionist is pulling blood into a syringe themselves prior to administering, make sure that the blood is filtered first. You may want to consider supplying a syringe with an inline standard blood filter (charter medical makes some). We have had cases where a whole unit or bag aliquot was pulled into a syringe by anesthesia and (we think) not filtered first. - Make sure that you are giving O red blood cells to neonates with possible maternal ABO antibodies, unless you are performing testing for the presence of anti-A and/or anti-B at the AHG phase, which most places would not routinely do. (see AABB Standard 5.16.2) You are doing the right thing by coming up with a procedure and solution now for those rare cases when a neonatal transfusion may be required. Scrambling during this urgency is the last thing you'll want to have to do when the time comes!

Good point! We will also further investigate any weak reactivity - maybe molecular testing as well. All of our typings so far are much stronger in gel (at least 2+, usually 4+) and almost exclusively on our sickle cell patients. (lots of variant antigens)

We also just got done with all of our validation for gel ag typing, so far so good. We're using the same procedure as Swede's posting. We're using the MTS Rh phenotyping card and monoclonal C/E/c/e cards, and the IAT phase antisera with IgG cards for the rest fo the major antigens. Our only observation thus far is to beware of "hazy" reactions in the gel column. You'll find one example of a hazy column in Ortho's interpretation guide; usually seen with high levels of plasma proteins. We washed the cells and repeated testing and saw less haziness, but it didn't go away completely. When in doubt, you can always confirm in tube. Just make sure that techs don't interpret this as a positive result without further investigation - both of our cases were indeed negative for the ag being tested.

We also use a sterile connection device and make either bag or syringe aliquots from plateletpheresis units. The standard dose we use is 5ml/kg, occasionally the physician will order 10ml/kg. More than a double-dose is usually approved by our TS Med Director first (unless the need is obvious - OR or massively bleeding pt). We have not filled a "volume-reduced" request in quite some time. Again, this would only be after approval from the Med Dir. We only go to random platelets when a specific type of plateletpheresis is not available. We've created 3 different orders, transfuse plt syringe, transfuse plt bag, transfuse whole platelet. Each order has a price that is adjusted for the approx amount - syringe price about 1/4 of a whole apheresis unit, bag aliq equal to about 1/2 of an apheresis unit. It's not perfect, but we feel it is the best way to get our money's worth while being fair to the patient. There may also be some hospitals that bill by volume, which we do not do currently.

Someday, we'll be doing molecular typing on each patient and donor............. until then..... We used to re-confirm everything that we received, but years ago switched to the following policies: -Unconfirmed units sent by the red cross do not have an attached tie tag when the unit is received. A fax is sent to us with the "historical" antigen typing results. Once we place these into our inventory, we place a label (created in house) that lists the negative antigens. It also states that these typing results have not been confirmed and are historical only. We use these units without retyping in-house for patients that have NOT formed the corresponding antibody (ie, phenotypically similar for our sickle cell patients- C, and/or, E, K neg). Any patient who has made the antibody will have a unit that has either been confirmed by the red cross, or that has been retyped in our BB. -Confirmed units are sent with an attached tie tag from our supplier. We DO NOT reconfirm these units after we receive them. When we add the antigen negative info into our LIS, we add a comment "Antigen types confirmed by ARC" so that we can track who has performed the antigen typing. We have the option of ordering units confirmed or unconfirmed - obviously confirmed is more expensive, so we try not to get these unless we do not have the antisera available to type them ourselves. Hope this helps!

Has anyone checked out the new edition to Standards (26th edition) on this subject? There were a lot of public comments made during the drafting of the new edition - check them out. The new standard (5.1.8.2.1) reads that "containers (eg, portable coolers) used to transport blood components issued for transfusion shall be qualified and the process validated for the appropriate transport temperature." I'll be looking for this to come up in New Orleans. Hopefully we'll get some further clarification. Currently, we (a hospital TS, not a blood center) issue blood in the Thermosafe medical transporters if the surgeon requires the blood in the OR room or at the bedside - each unit was validated prior to use. If the blood is simply being transported to the patient care unit for transfusion, it is placed in a ziploc or Igloo cooler and the 10 degree limit applies (usually about 30min, but we do take the temp if returned). We have never validated the Igloo coolers since they are not for storage, but maybe we'll have to!

Years ago, we made the change to do fill-volume check daily and cleaning every two weeks. We now only performing cell button calibration upon receipt (prior to use) and after major repairs by Biomed. Biomed also does the tach and timer on a quarterly basis. It does seem like there is a lot of variation in practice, but as long as you have a defined system in place (SOP), I would be surprised to see any problems from AABB or CAP inspections - hopefully I did not speak too soon!

What do you know..... I was reading this posting on Wednesday evening, and who should appear at our door on Thursday morning? That's right, the FDA. We, however, had a very pleasent experience with our investigator. We are a children's hospital Transfusion Service who is FDA registered because of the manipulations that we perform. We do not do any blood collections, so her visit was only about 3 hours long. She was also very knowledgeable (used to work at a donor center - blood preparation) which helped speed up the process. If only all of our inspections were this easy - good luck to all of you when your time comes! Stephanie

I'm the TS Manager at a Children's Hospital with a large sickle cell population. For some time now, we have had a phenotypically similar blood program in place, and have had quite a few patients that fit your exact description. Here are my thoughts: - Have you considered sending this patient to a reference lab for Molecular Testing to obtain a true phenotype? We send samples to our local ARC Reference Lab for a phenotype upon initial diagnosis (to help avoid these situations, where after multiple txns, it's hard to obtain the patient's phenotype). Anything requiring molecular testing is sent on to ARC, Penn-Jersey Ref Lab. We have a lot of patients who have made Warm Autoantibodies that mimic anti-e.......... the question is, is it a true auto-e, or does the patient have a varient e antigen? In that case, the e antigen typing would be positive, but the patient forms an allo-anti-e, against the "traditional" e antigen. Much more common in our sickle cell patients than you'd think. In the meantime, as recommended by our Ref Lab folks, I would try to honor the e and give e neg units until you know whether or not it is allo or auto in nature. -So, based on your results, we would try to obtain blood that is negative for C, e, Fya, S negative which is a "likely phenotype" for these sickle patients. If the e turns out truely to be auto, you may be able to drop the e neg requirement and give units based on the true phenotype. I would suggest matching as much of the phenotype as you can based on blood availability. -As for the flocculation, I too have not heard that particular term. We don't currently do typing in gel, but use it for ABID/AS/DAT/AHG XM. Hope this helps! Stephanie Townsend, MT(ASCP)SBB

Is anyone using the CPT code 86905 instead of 86903? The CMS comments on 86903 allow one antigen screening per unit screened, but what about using 86905? There was an AABB reimbursement question about how to bill for phenotypically matched blood for sickle patients (ie C, E, K neg units) that said to charge 86905 times 3.