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Edited June 3, 201510 yr by RollSlow10

The smaller hospitals may be able to utilize these reagents BUT how many have the expertise to do so and evaluate the results especially when these pts are few and far between?  Also, many of the Medical Directors in these smaller institutions are not real strong in advanced BB evaluations . . .

 

My $0.02

You may want to reach out to these hospitals and see what kind of testing they are doing to resolve WAAs.  For example - are they repeating the screen in saline if they suspect a WAA or do they just send it to you?  

Supervising in a large facility (525 bed), I decided to routinely sent WAA to reference lab. Didn't have staffing to deal with complex time-consuming antibody identification workups!

We routinely send warm atuos that we cannot resolve in tube to our reference laboratory.  For reasons already mentioned (staff/medical director expertise) and time.  We simply do not have the staff to allocate to them.   As far as insurance companies go- I dont think there is (if any) fee-for-service type reimbursements happening.  I think most things fall under a DRG type of system.  That being said we can bill for whatever we want- however the insurance companies only pay so much (especially Medicaid and Medicare which encompasses many of our patients).  On patients like this- we probably take a loss. 

We also send out WAA work-ups to our reference lab. The competency and proficiency committments are also very labor/staff intensive to cover all 3 shifts. If we have one tech covering the Blood Bank and 1 or 2 trauma codes come in such as GSW, there is no way the only tech could spend hours adsorbing one patient's plasma / cells. Also, for allogeneic adsorptions, you have to have a supply of cells for that too readily available. Not expense driven for us to send these out.

Speaking with our small neighbors in mind (and a few not so small), many of the small facilities probably don't have a technical supervisor with proficiency in these kinds of methods, much less maintaining staff with competency. Many have such a tight staffing situation that just doing a basic antibody ID is stressful (it can be a stressor here if it's a busy day). In fact most of our small neighbors don't do any kind of antibody workups - if the antibody screen is positive or the crossmatch doesn't work, out it goes to the reference lab. I know of quite a few facilities that don't even do moderately complex antibody IDs. They don't keep the antisera or multiple ID panels on hand to do them as a cost cutting measure. Reagents for advanced methods aren't even on the radar screen. I don't keep DTT, though I do have WARM and chloroquine. I'm the only one that uses these methods - keeping other techs proficient would be very difficult/expensive with the volume of special testing we do. The money crunchers may take that away from me before too long. The only reason they haven't up to now is that we are a long way from our reference lab, though our transport options have improved.

 

It's not just the cost of reagents, either. You have to have surveys, if they are available. Those can be very pricey - I'm thinking that the elution survey alone is $800ish per year. If you don't do surveys you have to have some other way to prove you know what you're doing - like sending a split sample to a reference lab a few times a year. That could be even more expensive than a survey. 

 

If your patient is a Medicare or Medicaid patient, you aren't getting reimbursed now. Their diagnosis (DRG) is worth a pre-specified amount of $$$. If they have extra expensive tests done, too bad for your hospital...no more money. Most insurance companies are following the same game plan.

 

So, after rambling on, in answer to your question, if you don't have much volume for these kinds of tests, it is not cost effective for your lab to try to do them. If you do have the volume, it may still not be cost effective. If you don't have much volume, its probably better (safer) for the patients if your lab doesn't try to do them.

Edited August 12, 201410 yr by AMcCord

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Edited June 3, 201510 yr by RollSlow10

Thanks for all the great input. Coming from a larger hospital to a reference lab, the above mentioned reasons all make terrific sense. 

 

Is it common practice for the physician ordering blood for a warm auto to have to sign a least incompatible slip or a facsimile thereof? In most of the hospitals I have worked, this is the case.

 

Thanks again for the input.

I believe this is true (at least any place I have ever worked)

I believe this is true (at least any place I have ever worked)

 

I would hope that the medical director clears it, if nothing else.

Thanks for all the great input. Coming from a larger hospital to a reference lab, the above mentioned reasons all make terrific sense. 

 

Is it common practice for the physician ordering blood for a warm auto to have to sign a least incompatible slip or a facsimile thereof? In most of the hospitals I have worked, this is the case.

 

Thanks again for the input.

When I worked in a reference lab, we would inform the hospital that the blood was incompatible, then it was up to the hospital to follow their procedures for transfusion.  We did not ask for physician acknowledgement directly.

AMcCord hit the nail on the head.  Hospitals are not reimbursed for the complex workups, we just eat the cost.  And there are many places that no longer have dedicated Blood Bankers, especially on evenings and nights.

 

Everyone is so focused on the bottom line, the turn around times, getting the work out the door faster many of us send WAAs to the reference labs simply because we lack the time and expertise to do it right.

 

Sad but true, $$$ drive a lot of decisions in the labs now days.  

When I took over as technical supervisor this small facility was not doing any antibody work-ups at all...everything went to reference.  Our pathologist covers many small hospitals accross the state so we only see him infrequently.  I discussed this with him, along with a cost analysis of what we were paying reference and how mush it would cost to work up the "simple" ones in house.

 

The decision was made that when I was "available" I would work them up in-house and otherwise they would be sent out.  I have the techs call me if they get a positive screen and I then make the decision on sending it out or holding it for me to work-up.

 

Saved ~$25,000 in reference charges in 12 months.....

 

I do not do any elutions, absorpions or antigen typing.. I send that all out.  Only one of me and not enough time to do everything...

When I took over as technical supervisor this small facility was not doing any antibody work-ups at all...everything went to reference.  Our pathologist covers many small hospitals accross the state so we only see him infrequently.  I discussed this with him, along with a cost analysis of what we were paying reference and how mush it would cost to work up the "simple" ones in house.

 

The decision was made that when I was "available" I would work them up in-house and otherwise they would be sent out.  I have the techs call me if they get a positive screen and I then make the decision on sending it out or holding it for me to work-up.

 

Saved ~$25,000 in reference charges in 12 months.....

 

I do not do any elutions, absorpions or antigen typing.. I send that all out.  Only one of me and not enough time to do everything...

I bet your evaluations have looked pretty good since then!

We have been sending out any WAA that we can't rule out antibodies with saline tube testing but we are thinking of doing PEG adsorptions when needed instead of sending them out.  At least that way maybe we don't have to keep the WARM reagent which expires fairly fast for the amount we use it.  We are far from our reference lab.  Any advice on PEG adsorptions?