ElinF

Well, luckily I had posted this question on here a few months ago, and basically used what one of the members here posted. I asked how we were to go about this, and are we supposed to test each cell for every antigen noted to confirm if they are really positive or negative for the antigen?? We know the system is in working condition because we are QC-ing that and we have never done QC on panels, nor do a lot of people, including our reference lab. She seemed leery of that, and wanted me to confirm with the reference lab, but we did not get cited.

I know, right! However, it is dumb, but we still have to do it. I just posted a comment last night- I had a joint commission surveyor ask me if I QC'ed our panel cells and she was surprised that we didn't! She was giving me all sorts of grief so I answered with basically what John said earlier. She still wanted me to check with my reference lab, which I did and they were surprised as well, as they do not QC them either... We did not get cited. interesting.

We were recently surveyed by the Joint Commission. She actually asked me why we don't QC our panels. I was at a loss for words, because I had just posted this question like a month ago and NO ONE said they QC'ed their panels. I actually gave her an answer that some of you guys gave and she seemed ok with that, but leery. She told me to check with our reference lab (which they don't either). We didn't get cited, but I was just surprised! Anyways, thought I would share.

So we had an oncology patient come in through our ER from out of town. He had MDS and had had several transfusions before. The tech typed him as O Pos. Unfortunately the tech who did this had trouble with the back type. (Front typing as an O, back typing as an A) So she cooled the back type and retested. She did not do an auto control and the patient happened to have a strong cold, making her back type look like an O. She was happy, had matching front and back types, and went on her way. Patient subsequently received O Postive Red cells and O positive platelets. After receiving the platelets, temp spiked and the patient was indeed hemolysing. Bilirubin only got up to 2.5 or something, but he did not have that prior. Still not good. So I get back from maternity leave and here about this case and start looking into it. Of course it has been a while so we have no specimen left... I am looking at all the retesting done on the patient from the transfusion reaction and i keep seeing this pre-incubated results for his type. He ends up being a weak sub group of A. Meanwhile, we received records from another facility that tells us all this, and indeed he is a weak sub group of A. So my question is what caused the HTR? O pos blood would have been fine and if he got O platelets, the little bit of anti-A in those would have been most likely A1 anyways, so i can't figure this out. Plus usually you can give any type of platelets. He did not have any antibodies, at least none that we could detect (ab screen was done 2 times, once prior to the trxn and once again afterwards as a check). It was also weird on the TRXN work up the tech that worked it up did a DAT and it was negative (pre and post). Is that possible? So, I am just not sure what went on here. He is from out of town, so we might never see him again, but I guess I want to be prepared if we ever do. Could a cold ab cause this? Do immunosuppressed patients tend to react more? Any thoughts?

I have had good responses so far. I pretty much just say they have a very special blood type and that seems to work. People like it when they are noted as special - I am not saying they aren't, but if you say the word special it sticks! Even if the patient doesn't remember their card, they might possibily say something to the nurse regarding their "special blood type" which scares them and then that could tip us off to start searching for some history. Anything that helps right? haha

We have a database though our reference lab that we can look at (which doesn't include DOBs- stupid!) but it is a start. What kind of cover sheet are you talking about? Could you email me an example? faire@sjrmc.com In our computer system we have a place for all those questions...recently transfused, pregnant in last 3 months etc, but I often wonder how accuate that actually is and I usually don't go by that. I try to send patient's cards, but sometimes that is hard to keep up on.

We do them on all RH negative moms and O Positive Moms. I wish we could drop the O positive moms because I too don't think they really do anything if the DAT is positive on a baby due to ABO incompatiblity. But definitely on cords of all RH= moms.

We would screen and cross 2 units of blood to be ready for the patient if the antibody screen is positive.

That is a good thought. We do RH phenotyping when we have an RH antibody, and we get so few of these Weak D patients that it wouldn't be that big of a deal. I will bring that up. So if they are Weak D Type 2 are they treated any different than partial D? Partial D patients have a higher chance of forming anti-D right? Would we suggest Rhogam for patients that are the DcE haplotype? I need to educate myself on the details of weak D.

We do not do RH phenotyping on our Weak D patients, so I wouldn't know.

My techs do not like doing gel ABORH for crossmatches because it takes to long if they don't have history. So we have kept with tube for those patients- and luckily not run into any problems...yet. but good point. And the reason we went to gel for prenatals was to hopefully curtail some of this mess. Right now our policy on the weaker D reactions in gel is to perform a weak D to confirm (as our weak D testing in gel is in the process of being validated- mainly because we don't see that many weak D patients. I have about 10 1-2+ reactions so far in 4 years...). But if they are 1 or 2+ in gel, and it is so sensitive, I am so scared that one of these weaker patients is going to form anti-D. I think we should just tube all our ABOs (as we are not automatued yet) and just to IS on all the Rhs. But that probably won't happen. I don't know.

sorry, more questions on this issue! So we have been using Gel for 4 years now and thought we had our weak D problems figured out. OB calls the other day and says they had a patient that was historical Rh negative. We reported RH positive. Repeat testing showed in tube she was weak D positive and the Rh was 3+ in gel so we called her rh Positive. Explained this to the nurse and she understood. In reading other threads on this issue everyone says to just drop the weak D testing. Well, we really don't do "weak D testing" - we do Gel. So my question is do we just go back to doing Tube ABORHs on all prenatals instead of gel (and just report the D at IS). This is what we do on crossmatch patients. The weak D patients are usually so strong in gel we don't even know they are "weak D" because of the strength of the reaction? The staff will love this change because I have talked endlessly how ABOs in gel will be the solution to our problems!.

What is the best way to archive the hematology QC data for recall during inspections? We have tried hard drives, flash drives, etc but there is always a potential problem and we have had data lost. Any suggestions on how other facilities store their data? Thanks!

We do prenatal ABORH testing in Gel so most of our Weak D patients come out as 3+ positive. She would not be a canidate for Rhogam and as long as her AB screen ins negative we wouldn't do any other work on her.

I have always wondered about the QC on panels thing, but never had the guts to ask! I am glad not many other people do it.

I love reading Malcom's answers...

I see another thread on this topic so I will read through that. Sorry!

This may be dunb, but does anyone QC their panel cells? I saw the thread about using Expired reagent panel cells, and this question was brought up by one of our staff. We QC everything else, but honestly not panel cells. Do you QC all 11, or just 1? Never really thought about this. They just work...

So we are thinking of going to Electronic crossmatches. What are your opinions on this. I am so used to AHG crossmatches, it may take some getting used to mentally! What qualifies a patient for electronic XM? Neg screen, history...what else? any tips on validating? I think we are just going to look at a years worth of crossmatches and pull data from there... Although it will save on cost, it makes me nervous. I know we are behind on the times!

I have seen the halo reactions and the hazy reactions and these are not it. These positive results are usually 1+ and are very believable. We have LISS and use that for tube if we need to. Thank you for all your suggestions! Unfortunately I am finding that it will usually be looked at on a case by case basis.

We use Micro ID typing systems from ortho. I want to say that it is mostly screen cell 2 as well, but sometimes it is 1 and 2. Usually only 1+ or so, but you can't ignore that. We don't have the ability to enzyme pre-treat. I suppose we are getting pretty good a these since we are starting to get them more often. We never really used to get these in this abundance, it seems like in the last year or so it has really increased. Speaking of natural anti-E we had a pregnant woman form anti-E so we were concerned with her titers the whole pregnancy. They never went up but the funny thing is her husband was big E negative, she was obviously big E neg.....sooooo how could the baby be big E positive giving mom the opportunity to produce Anti-E. Well, the baby was big E neg too and mom just had anti-E for whatever reason. (And we ruled out the possibility of a possible switch-a-roo on the father as she was close friends with one of the techs). So that was interesting. I did learn at a Red Cross event that naturally occurring big E has been seen during pregnancy. I was like viola! there's my answer!

We do not yet do electronic crossmatches, so we always do AHG crossmatches. Most of the time our units are compatible. It is just the screen cells that are positive.

Thank you so much. At least I can tell them that they are not alone!

Ok, we have recently been getting burned by this annoying issue. Can I get procedure suggestions I can give to my staff to deal with this. They always ask me and we always have to feel our way though it. Basically we get a positive gel screen. Do a gel ABID panel. Sometimes positive with no clear pattern (is it an antibody, or the start of one or not?) sometimes negative, however we don't want to ignore the positive screen. We then usually go to an immediate spin tube screen then refrigerated for 10 minutes to identify any colds. And then rule out. Sometimes we repeat with new specimen, but mostly it does the same. Is this all we should be doing? Is this good enough? I am so afraid we are going to get complacent with this misc reactivity and miss something and I truly do not want to do that obviously, but we have had like 6 of these since Christmas (we are a small lab) and I am afraid it is desensitizing people to true positive results. Any suggestions would be helpful! Thanks! elin

thanks! i will look at that!