Hi All!

I'm a new user and I just love this site! Its really helpful.

 

I'd like to pick your brains of when you make the decision to send out to a reference lab? I guess in particular with Warms and Colds.

We are a small blood bank, we primarily use the ECHO and have gel and tube as back up.  We don't do anything fancier then elutions.  We always send out patients that are reactive with all cells, DAT pos etc.  

  

For example my current facility wants to send out all positive autocontrols, and DATs regardless of the activity in the panels. 

 

Any input is appreciated!

As a Reference Manager, the answer is as early as possible, as quickly as possible.

 

So many hospitals try their best to test a sample to death (and they do so meaning well), but with little hope of getting any meaningful answers, and then send it to a Reference Laboratory, when the work becomes really urgent (either for clinical, bed blocking or financial reasons - or sometimes for no real reason at all for the urgency), and that is just not fair on the staff in that Laboratory.

 

Yes, of course we sometimes get stuff that should never have been sent to us in the first place (at least, by any self-respecting hospital laboratory), but, rather that than putting unnecessary pressure on the Reference Laboratory staff, when they could have been working on a less urgent sample.  The thing is, until we work on these samples, we do not know just how long it will take to get an answer, or how long it will take to get compatible/suitable blood.

 

END OF, I HOPE, A FAIRLY FRIENDLY RANT!

Point taken Malcom, and trust me with most of these patients I want to send them to the experts asap! 

So if you don't mind may I give you a scenario?

ECHO all positive, gel all negative with a 2+ auto control, dat 2+, eluate was a panagluttinin, units were full crossmatch compatible. Should that patient be sent out?  

I can't give you info anything as great as Malcolm can but I will say that I am finding recently that the methodology can create some problems- we are now Echo users and the Echo is super sensitive. Frequently our tube backup will be negative but we think there is something going on and we can find no compatible units. But our Reference lab always starts with tube and only goes to GEL (no Echo) if the tube results from the specimen we send are positive. So now we don't send much because if they start with tube and get negative results, that's the end of it unless we insist on an eluate (pos DAT under 3 months since last transfusion etc) or full phenotyping of the patient at least. Basically, we now call and "negotiate" what we want done based on our current problem. Tons of fun

Thanks Karrieb61, that's a huge problem for me too.  ECHO has been pumping out a lot of junk for us and I'm nervous its going to end up not being junk one day and disregarded.  The people here don't trust the instrument and instantly repeat any positive screen in gel without running a panel. If the screen is negative in gel, they call it negative, their argument being "well if we didn't have ECHO then we would of called it negative." Super frustrating for everyone because I'm insisting on more work before calling it negative.  

My apologies RaeRae251, I didn't see your earlier post with the scenario until this morning.

 

I must be up front and say that I am not a great fan of ECHO, as I think that it is over-sensitive and does detect a lot of junk.  Certainly, the hospitals in my area that do use it used to send in a lot of samples in which we could find nothing.

 

In the scenario you give, I don't see the point of sending the sample.  I have a lot more faith in gel (although no one technique/technology is absolutely perfect), and your findings suggest that there is an auto-antibody present, and nothing else.  When your own findings are so clear cut, it is most unlikely that any Reference Laboratory will find anything else - certainly nothing that is clinically significant - and so I would be happy to give those compatible units myself - THIS TIME.

 

The reason for the caveat is that, if the 2 units are transfused, then, obviously, there is a chance that your patient may produce one or more alloantibodies, but it is also well known that a transfusion to a person with an auto-antibody can lead to the exacerbation and strengthening of that auto-antibody, making the investigation more difficult the next time.

 

In the circumstances, I would ask for another sample within, say, a week, and if the serology has changed (either there are alloantibodies present, or the auto-antibody has strengthened, and will no longer allow for underlying alloantibodies to be ruled out), I would then send in a sample to the reference Laboratory (as na index sample), even if the patient does not require another transfusion at that time.

RaeRae251 and anyone else reading this for Echo -interest. We finally got a few weeks of equivocal results "corrected" with a new lot of Indicator cells and Immucor is telling me that they think the equiv. results had something to do with the donor mix in some lots. Whatever, all I know is that now things are much, much better. I didn't have a choice of new technologies here for political reasons but would probably have not chosen manual gel as it would still constrict our second and third shift techs from working in other parts of the lab due to the clock watching. We are way toosmall for a Provue and my experiences with the Provue is that there is frequent downtime due to mechanical issues. So for our volume and convenience of crosstrained 2nd and 3rd shift people, Echo was a good choice. We are certainly struggling with the What to Do When xxxx Happens but nothing is perfect. Now its a matter of slowly convincing a few older techs to trust it and stop running to the tube every time the Echo presents them with a challenge. I am at least insisting that even if we have a nonspecific antibody on the Echo that crossmatches be done on it so we have the same level of sensitivity for the donor units/patients.

RaeRae251, I would also say it depends on what your reference lab is going to do.  Not all RLs are created equal.  I would not send the sample in your example.  Our local RL doesn't use gel or solid phase, so it's not uncommon to get a response of "we couldn't replicate your reactions."

Thanks for all the input.

Malcom, I felt the exact same way.

Karrie, ECHO said the same thing to me, and we too are having better results with our current lot.  But what I made a stink about was that we have 2 ECHOs and the results weren't the same on the newer ECHO with the same lot of reagents which to me felt like an analyzer problem not a lot problem.  Its too bad because three or four years ago, ECHO didn't have these problems, at least not like it is now.

CMCDCHI, excellent point because I had no history on that patient, and I got her test results faxed from ARC where she had her testing done four days earlier and they called her negative most likely because they used gel or tube.  

RaeRae251 - you didn't mention anything about transfusion history. We are a midsized hospital and I only send out when I have to - (sorry Malcom). 

If your patient has not been recently transfused and you can rule out all the common clinically significant antibodies, cross matches are negative... why send it out?

If I recall correctly 9% of the population is walking around with a positive DAT, completely benign. I wouldn't send out any cold reacting antibody if I can get around it, certainly if the patient hasn't been transfused. I definitely won't send out a sample where the auto control is the only positive reaction and the DAT is negative.

Now, if the patient has been recently transfused, that is an entirely different scenario and great care must be taken not to overlook any developing antibodies (IgM). But, we use different techniques (GEL, LISS, PEG, and my favorite - 4 drops with no enhancement - yes, I'm older than most).

I guess what I'm attempting to say is, we have no "cut and dried" formula for sending out specimens, each case is different. Patient safety first, but follow up with common sense.

Just my 2 cents....

Liz

Yes Liz D, I can see from where you are coming, and I do, to a large extent agree with what you say, however, what I want to avoid, if possible, is the kind of scenario that happened to me on Saturday/Sunday.

 

I was on-call for the Reference Laboratory, and had already worked on three DAT positive samples for some 7 hours 45 minutes, none of which could be considered clinically urgent (in terms of life or death), but all needed work performed that notwithstanding.  I then got called at 02.45 for work on an in-patient at a hospital, who's Hb had dropped to 44gL^-1, positive DAT, and who had become symptomatic and required transfusion.  The sample did not arrive until 04.30, by which time the situation had become clinically urgent.

 

Now, as this last patient had been an in patient for a few days (following a road traffic accident), I would have thought that it would have been noticed, some time before 02.45, that his Hb had been dropping, and that he had a positive DAT (with an auto-antibody), that the hospital Blood bank were not going to be able to sort out themselves whether or not there were any underlying alloantibodies and, therefore, a sample should have been sent to us earlier, so that we could have worked on it at a more civilised hour, and under a good deal less pressure, before the situation became clinically urgent.

I agree, I wonder why that positive DAT wasn't detected on admit? I see your point.

If it makes you feel better, I presently have 2 patients being worked on in our local reference lab (neither is urgent...)

Hi Liz,

The patient wasn't recently transfused but was having a c-section if I remember correctly.  I get the that patient specific problems, everyone wants a flow chart but they don;t understand that some patients wont fit into that flow chart and their knowledge has to kick in.

I'm stuck somewhere in between not wanting to do too much or too little, and not wasting time like Malcom said.

I always think that the Boy Scout motto is a good thing...'be prepared'. If I have a patient that looks like they are going to be a problem and there is a possibly that they might need to be transfused, I send the sample in to the reference lab. We follow a path similar to what Liz has described, but if things aren't falling neatly into place with the workup early on, the sample goes out. If a weekend or holiday is approaching, we send it out so that we (and the reference lab on-call staff) don't have to struggle with something that could have been a routine workup plus we will have more options available for getting blood products to us.

 

If my workup turns out OK, if the patient is transferred - I always have the option to call the reference lab and tell them that the specimen on the way is no longer needed. BUT if this is a patient that I will be seeing again in the near future, I don't cancel the workup. That gives me and the reference lab baseline information for that patient (phenotype, etc.)

Brilliant comment AMcCord!