kirkaw

We have a patient who received many units of group/type specific red cells in Jan. of this year. At that time, his antibody screen was negative. His group and type is A, Rh positive using monoclonal typing reagents. The anti-D reactions have been 2+ and 3+. His current specimen shows an anti-E in the plasma and a panagglutinin in the eluate tested in gel, with stronger reactions in the D+ cells. His eluate tested in tube shows a clear anti-D pattern. Could this be a D variant? Auto-anti-D? Should he get Rh negative red cells? Thanks!

Am I correct in following that this lady got 7 units of blood in a 6-week period before the 1st febrile reaction? Could this hemolysis be drug induced?

I don't know of a standard requiring that blood products be issued in a plastic bag. If Joint Commission sites you with a deficiency, I believe they will cite the standard that they feel you are violating. I had a Joint Commission inspection last July and we do not issue blood products in plastic bags and we were not cited. In fact, the inspector did not even ask about it, even though she witnessed blood being dispensed and she watched a transfusion.

I am in this exact same situation - we are opening another 'campus' of our hospital but I do not think it will have it's own tax ID #. Does this affect what the state's requirements might be? And when you say state requirements, where do I look for those, Health and Human services? I feel that I can validate by testing samples at our main campus and then at this new campus. We will not be using automation, just manual gel and tube testing at the new campus.

I don't know the answer to your question. both inspectors had full access to all our records, policies & procedures and results.

Mabel, what is your CPOE system and does this order from the MD cross to your blood bank computer system automatically?

We do almost exactly as mollyredone does. Our emergency release form that the requesting MD signs is a 2 part/carbon copy form so that one copy is retained in the blood bank and one goes on the patient's chart.

I love this discussion! I am caught in the same dilemma. However, I view it in terms cost/benefit. If I do not use expired cells, there is a chance that I cannot positively identify many antibodies in my lab. We cannot afford to keep 6 indate panels for selected cells. If I only use indate panel cells for ruling out, then I have to either send many specimens to a reference lab for definitive ID or supply antigen negative blood for any antigens that cannot be ruled out using indate cells. Either option is VERY expensive. My mentor said that at her hospital, they did a study and determined that panel cells within a certain number of days of expiration (I can't remember the # of days) were viable for use doing rule outs. Her policy is to use reagent cells within that time frame and then discard. (I do not know her sample size for the study). I am leaning towards this option. I simply cannot afford to completely discontinue the use of expired cells for ruling out. Nor have I been cited by a regulatory agency (JCAHO,AABB) for doing so.

Greetings, Does anyone send blood to inpatient units via a pneumatic tube system. If so, do you have a document that accompanies the unit that nursing fills out, verifying that the unit was inpsected upon receipt and found to be OK? What regulatory agencies would govern such a practice? I cannot find a suitable reference in the AABB standards. Would this fall under all standards/CFR references for blood transport? Thanks!

1-10 C here too. I actually require units issued in a cooler for the OR to be maintained at 1-6C, as I have been told that in that situation, the blood is being temporarily stored (in the OR) instead of transported. However, we also send blood to the dialysis units and to our outpatient oncology units in small coolers. These units are being transported and not stored, so the 1-10 C rule applies.

For those of you who have Generalists manning blood bank during evening and night shifts, who is on call for them if they have an issue? How long does that person have to call back? If the 1st responder doesn't call in that time, who is the 2nd on call? Thanks, Amelia

Scott, you are correct. Anti-K was never identified, just not ruled out in 2010. Thanks for your input.

Here is a situation that we had last week: A nurse came to get a unit of blood. 40 min. later, she brought the unit back saying they had a problem with the IV. I was prepared to discard the unit since it had been out >30 minutes but my coworker told the nurse that if they could get the IV started correctly AND could get the unit infused within 4 hours of the original time of issue, that they could take it back. I would've thrown the unit away. Based on your policy, what would you have done?

We had a patient for whom an anti-Jkb and (presumed) anti-Kn was identified by the Red Cross in 2010. At that time, they could not rule out anti-K and it was recommended that we transfuse red cells negative for Jkb and K. The patient has come in again and although some of her gel-crossmatched units were incompatible (neg for K and Jkb), K can be ruled out on her antibody screen. Is it ok to now drop the K- restriction? Or should we honor that forever and ever, Amen? Thanks.

I was told by my JCAHO inspector last year that the person who signs as the reviewer has to be the person that is listed on your CLIA certificate. However, our process mirrors Ann's.

These are great questions and suggestions everyone, Thanks! To answer Dansket's questions, I do have my own cost center, and since my blood budget is so large, it sticks out like a sore thumb. We use a 2-cell screen, do not do IgG crossmatches on everyone and do employ electronic crossmatches. Out biggest waste is platelets; we outdate about 7/month. It's something I've been working on for months! Since we don't have a transfusion committee, I'm using this as leaverage to get one started to address just these types of issues. I feel that my predecessor addressed many of the other cost savings, like consolidated shipments, negotiating better pricing through a 3-year contract with our (single) blood supplier and we do make our own Provue controls. I just got a good deal on some Immucor reagents but have not investigated Quotient or BioRad. Thanks for that tip. I know that we have a contract with Ortho, so I need to find out how restrictive that is.

I am in the process of re-organizing our procedure manuals. I have decided to have 3 manuals, 1 each for Quality Assurance, Technical Procedures and Inventory Management. I have constructed flow charts for use following a positive antibody screen. One is for a standard positive (panel, selected cells, antigen typing, etc) and the other is for when there is a positive auto-control. Our techs seem to love flow charts!

David, We're licensed for about 375 beds. We have a provue that we use for type and screens and gel crossmatches. We transfuse about 800 units of red cells/month. We also have a heart program, usually 1 or 2 cases per day, although we did 15 cases in a week 2 weeks ago. Unfortunately, we do not have an active transfusion committee. Hope that helps. Thanks for the input.

Hi All, I have just come from a meeting where our CEO has 'mandated' a 8-10% reduction in expenses due to decreased reimbursement from Medicare and Medicaid. (57% of our inpatient business is Medicare patients). What is everyone doing to cut costs? Are you decreasing your inventory at all? Renegotiating contracts? How about use of rare antisera? We stock anti-M, anti-N and anti-Lea to antigen type patients even though we do not give antigen negative blood for these antigens. Should I stop stocking it? Looking for any way possible to meet the mandate. Thanks for the input.

I am curious about the tube method folks are using as a follow-up when your gel antibody screen is positive and gel antibody panel is negative. Do you use enhancement; if so what kind? We have these same phenomena at hour hospital. I have seen it occur with screening cells that are getting old and could possibly be contaminated. So I have techs re-run the antibody screen with fresh screening cells (same lot # if we have it) and if negative, then we call the antibody screen negative. If it is still positive, we say 'positive antibody screen, negative panel; issue Coombs crossmatch compatible red cells.'

Thanks Phil. I'll remember that and do the testing before I give to the student to test.

This is so awesome that this was up for discussion today! I was just looking for a recipe for creating a positive DAT. I was going to do what Malcolm suggested. Do I have to incubate that or just combine and give to the student to test?

AABB Standard 6.1.4 says an 'authorized individual' should perform policy review. Does anyone have techs review procedures for completeness and/or clarity and have them make recommendations for change to the blood bank supervisor? Is this a permissable way to accomplish the review? I still have the medical director review policies and procedures biannually, but I thought it might be a good idea to have the folks that used the procedures review them.

I have decided to go with BDI. What I did not understand to start with is that Rhogam is a different product than Rhophylac. I have been getting the latter. Regardless, BDI has given me a better price. I know that our pharmacy already orders from them, so I feel that they are a reputable vendor.

DeeMc, I would adhere to whatever rule applies to whatever cooler you are using. If you are using an OR cooler that is designated 'temporary storage' then units need to be kept at 1-6 even if they are returned within an hour.