A Survey about Blood Bank Policies and Procedures A. WAHEED From the Wesley Medicul Center. Wichitu. Kunsus
A questionnaire about h l d bank policies and procedures was prepared and sent out to 170 hospitals across the nation, 50 per cent responded. There is wide variation in both technical and nontechnical policies and procedures. Serum is separated from the original tube within 8 hours by 68 per cent of the hospitals and In 32 per cent serum is never separated from the original tube. Auto-control is included by 66 per cent of hospitals in at least one phase of the antibody testing, 34 per cent do not include auto-control in any phase. D" testing of the recipient is done in 85 per cent of the hospitals and in IS per cent Rho type is determined by the immediate spin reactions alone. Slide type is the only method used to determine ABO group of cells of the recipients in 10 per cent of the hospitals, 18 per cent use serum-cell suspension, 10 per cent use the applicator stick method and only 62 per cent w washed spline-cell suspension routinely. Compatibility testing between a recipient and a donor vary from a one-tube major crossmatch to a three-tube major crossmatch and minor crossmatch.
TRADITIONALLY the blood bank has been considered as the most sensitive section of the clinical laboratory. Test results reported from other sections of the laboratory can be reviewed, questioned or challenged by the physician, who can order tests to be repeated or, still worse, can even ignore them. When it comes to blood bank, the physician's role is limited once a transfusion has been ordered. Many highly complicated and technical considerations have to be taken care of by the blood bank alone. The technologist performing and signing his name to a crossmatch is primarily responsible for the safety and compatibility of the subsequent transfusion. If a technologist makes a mistake there is seldom a way of finding out until it is too late. For these reasons, blood bank technologists Received for publication June 10. 1977: accepted July 30, 1977.
are required to adhere to the rigid policies and procedures. Those responsible for designing these policies try to ensure that if the policies and procedures are followed carefully, there should be no complications. The American Association of Blood Banks (AABB),* College of American Pathologists (CAP) and regulatory agencies have set up specific guidelines and standards which their affiliated institutes must follow. Additionally there are numerous situations for which each blood bank has to set its own policies and procedures. Policies and procedures in all blood banks are designed toward one goal; to transfuse the right blood to the right patient as safely as possible. It has been observed that policies and procedures vary to a great extent from one blood bank to another. In their concern for the safety of the patient, some blood banks have set up rules which could be considered unnecessary. A survey comprised of 20 questions about blood bank policies and procedures was prepared and sent out to 170 hospitals across the nation in April, 1977. All of these blood banks were institutional members of AABB and names were picked at random from the 1976-1977 AABB Membership Directory.:' Response to the questionnaire was very favorable, with 50 per cent of the questionnaires being returned within three weeks. Responding institutions ranged in size from a 120-bed hospital transfusing 155 units per years to a 1,500bed hospital which reported having transfused more than 30,000 units last year. Responding hospitals represented 35 states in the continental United States.
0041-1132-78-0700-0482-0075 0 J. B. Lippincott Co. Transfusion July-August 1978
482
Volume 18 Number 4
Volume 18
483
BLOOD BANK SURVEY
Number 4
Results The data indicates that there is a wide variation in the policies and procedures of blood banks across the nation. In many instances direct contradiction in policies may be seen. Separating serum and cells from the original tube is a case in point. In 68 per cent of the hospitals serum must be separated from the clot within eight hours of collection and placed in a separate properly labeled tube. In 32 per cent of the hospitals serum is never separated from the original tube. It is interesting to note that AABB Technical Methods and Procedures,' does not provide any guidelines in this regard. It has been suggested that complement deterioration is more rapid in serum left in contact with the clotted blood than in separated serum.> Not separating serum from the clot has the advantage of eliminating a potentially disastrous source of error. ABO und Rh Determination
In order to determine ABO group of cells of the patient, 62 per cent of the responding hospitals use washed saline-cell suspension of the patient's cells, 10 per cent use the applicator stick method and 18 per cent use serum-cell
suspension (Table I). Use of the serum-cell suspension has been known to cause problems in the determination of ABO and Rh group due to the presence of group specific substances, rouleaux and cold reacting agglutinin^.^ Anti-A,B is used with every patient's cells, regardless of ABO group in 70 per cent of the responding hospitals. In 16 per cent of the hospitals only Group 0 patients are tested with anti-A,B (Table I). At least 1 1 hospitals indicated that they test Group 0 patients with anti-A,B only if there is a discrepancy in the cell and serum tests, which is in accordance with AABB standards.* It was interesting to note that 3 of these 1 1 hospitals use slide type as the only method for determining ABO group of cells. Only 10 per cent of the hospitals use the slide type as the only method for this purpose. To determine Rho type of the patients, 85 per cent of the hospitals do D" testing if the immediate spin is negative with anti-D. A full 15 per cent determine Rho type of the recipients only on the bases of immediate spin reaction with anti-D and Rho control (Table I ) . This policy allows not having to decide whether a DU positive should be transfused with only Rho negative blood or could be safely transfused with Rho positive blood. On the other
Table 1. Results of a Nationwide Survey about Blood Bank Policies and Procedures (April, 1977)
Questions
Choices
Percentage of Responding Hospitals
A. Routine method to determine forward ABO type of the recipient
a. b. c. d.
Washed saline-cell suspension (tube type) Applicator stick method (tube type) Serum-cell suspension (tube type) Only slide type
62 10 18 10
B. Use of anti-A,B
a. All patients routinely tested with anti-A,B b. Only group 0 patients routinely tested with anti-A,B c. Group 0 patients tested with anti-A,B only when there is a discrepancy on the forward and reverse grouping
70
a. Only immediate spin with anti-D b. If immediate spin is negative, carry through DUstage only c. If immediate spin is negative, carry through 0" and also test with anti-CDE d. If patient is D-negative, DUpositive test with saline anti-D
15
C. Routine determination of Rho type of a recipient
D. In testing patient cells with anti-D control tube include
a. 22% albumin b. 30% albumin c. Special Rho control antiserum
16 14
69 11 5
16 4
80
484
Transfusion July-August 1978
WAHEED
hand this policy could put considerable strain on the supply of Rho-negative blood. A rather surprising result was that over 80 per cent of the hospitals are using special Rho control antiserum as their control with anti-D (Table 1). This reagent has been marketed only recently and its wide use seems to indicate that a vast majority of the blood banks are doing a remarkable job at keeping up with the recent developments. Antibody Screen and Crossmatch
The antibody screen in a vast majority of the hospitals (90%) consists of saline room temperature and albumin 37 C to antiglobulin phase. Only 66 per cent of these hospitals include auto-control in at least one phase of the
antibody screen, 34 per cent do not include auto-control in any phase of the antibody screen (Table 2). Table 2 indicates that 34 per cent of the hospitals do both a major and a minor crossmatch. Of those doing only major crossmatch, 18 per cent require that the ABO group of the donor be rechecked in conjunction with the crossmatch. Some of the hospitals indicated that they do only immediate spin minor crossmatch to ensure that the identical ABO type is being crossmatched. The majority of the blood banks (55%) don’t require minor crossmatch or recheck of the donor ABO group in conjunction with the crossmatch. The major crossmatch in most of the hospitals (80%) consists of two tubes, a saline room temperature tube and an albumin 37 C to antiglobulin tube (Table 2).
Table 2. Results of a Nationwide Survey about Blood Bank Policies and Procedures (April, 1977) Percentage of Responding Hospitals
Questions
Choices
A. Compatibility testing on a patient includes
a. Major and minor crossmatch b. Only major crossmatch with ABO group of donor rechecked in conjunction with the crossmatch c. Only major crossmatch, A 6 0 group of donor not rechecked at the time of crossmatch
6 . Routine major crossmatch includes
C. Auto control
a. One tube major crossmatch, Saline Room Temperature (SRT) converted to Albumin 37 C to antiglobulin (Alb-AHG) b. One tube major crossmatch, Alb-AHG c. Two tube major crossmatch, SRT and Alb-AHG d. Three tube major crossmatch, SRT, Alb-AHG and Saline 37 C to antiglobulin a. Auto control is included in each phase of the antibody screen b. Auto control included only in the Alb-AHG phase of the antibody screen c. Auto control not included in any phase of the antibody screen
D. Routine antibody screen on a patient serum includes
a. b. c. d. e.
SRT and Alb-AHG phases Saline 37 C to antiglobulin and Alb-AHG SRT, Alb-AHG and enzyme Alb-AHG and enzyme Only Alb-AHG
E. Microscopic examination
a. All negative reactions in antiglobulin phase must be examined microscopically b. Microscopic examination not required. Only when macroscopic examination is inconclusive tubes may be examined microscopically c. Microscopic examination not encouraged unless mixed field reaction is suspected
34 11
55
11
2 80 7
62 4 34 90 4 4 1 1
~
~ _ _ _ _ _
78
20 2
Volume 18 Number 4
485
BLOOD BANK SURVEY
Antiglobulin Phase
Of the 80 responding hospitals only six indicated that use of check cells is not required in every tube giving a negative reaction in the antiglobulin phase. They indicated that daily quality control of the antiglobulin serum is considered adequate. It should be remembered that use of the check cells is not required by the AABB Standards.P Microscopic examination of all negative reactions in the antiglobulin phase is required by 78 per cent of the hospitals. A full 20 per cent indicated that microscopic examination is not required and in some instances routine use of the microscope is discouraged (Table 2). Following manufacturer’s directions is a highly recommended policy and most manufacturers of antiglobulin serum require reading reactions both macroscopically and microscopically. Avoiding a very important step in this highly sensitive test could be regarded as not using the test to its full potential. Nontechnical and Administrative Policies
A number of questions in the survey dealt with administrative and nontechnical aspects of blood banking. Some of the more interesting differences are discussed. If the type, antibody screen and crossmatch has been done on a patient by one technologist and another technologist needs to crossmatch some additional units using the same specimen, more than 58 per cent of the hospitals require the second technologist to repeat at least ABO and Rh of the patient (Table 3). Primary concern here seems to be to ensure that the right specimen was being used for the crossmatch. Our data indicates that almost all hospitals requiring repeat ABO and Rh in this situation, also require separation of serum from the original tube as soon as the specimen is collected. Repeat ABO and Rh could, to some extent, ensure that the right specimen was being used, but it could also provide false sense of security to the technologist. Drawing the right specimen from the right patient is the first and perhaps the most important step in compatibility testing. In 63 per cent of the hospitals, only blood bank technologists, other laboratory technologists or specially trained phlebotomists perform this function. However, 17 per cent responded that they would accept a specimen drawn by any blood drawer including students and laboratory aides. If more than one specimen tube has been drawn on a recipient for compatibility testing,
52 per cent of the hospitals require that ABO, Rh and antibody screen be done on only one tube, but serum from the identically labeled tubes can be used for crossmatches without any‘ additional testing. A full 48 per cent of the hospitals require that ABO, Rh and/or antibody screen be done on all tubes used for compatibility testing (Table 3). This policy again, seems to be more for the peace of mind than anything else. If for some reason a technologist can not finish the type and crossmatch in time and has to leave, 48 per cent of the hospitals require that a second technologist must start the work all over again, 24 per cent allow a second technologist to complete the antibody screen and/or crossmatch after the incubation phase and 28 per cent indicated that they have no particular policy in this regard and a second technologist is allowed to make his own decision (Table 3).
Conclusions
Results of this survey tend to indicate that there is a wide variation in policies and procedures amongst blood banks across the nation. Some of the variations could be attributed to the differences in style, size, work load and area of specialization. Blood bank policies and procedures can be expected to reflect each area of specialization. The present survey did not take these factors into consideration, but this is an area which certainly needs further exploration. In general it seems that blood banks could be grouped into two distinct categories. One group tends to be rather cautious in its approach. They tend to check patient’s and donor’s group and Rh at several stages, use the most sensitive techniques available, even if they are more time consuming. They include as many tests in their routine procedure as possible. The second group tends to be rather liberal in their approach. They do not seem to be doing any additional testing than that required by AABB Standards.z Repeat testing of the specimens is kept at minimum. Reliance seems to be on the correct identification and blood group determination on initial testing. The purpose of this survey was not to
486
Transfusion
WAHEED
pass any judgments, and any attempt at doing so would require much more data than available. The present survey did not touch the important areas of quality control, transfusion policies, prenatal care, cornponent therapy, efficiency of the procedures in terms of number of crossmatches
July-August 1978
per time period per technologist and cost to the patient per transfusion. It should be remembered though that basic function of the blood bank is to provide the most compatible transfusions as efficiently as possible. As long as a blood bank is doing this job it should not be
Table 3. Results of a Nationwide Survey about Blood Bank Policies and Procedures (April, 1977) Percentage of Responding Hospitals
Questions
Choices
A. If more than one specimen is drawn on a patient at one time (as in the case of an open heart surgery)
a. ABO, Rh and antibody screen are done on all tubes used for crossmatch or other purposes b. ABO, Rh and antibody screen are done on only one tube and serum from identically labelled tubes can be used for crossmatch and other purposes c. ABO, Rh and antibody screen are done on only one tube and serum from other tubes can be used after doing ABO and Rh only ____
~~
_
_
_
_
_
_
_
_
_
_
_
~
a. ABO and Rh type b. ABO, Rh and antibody screen c. No repeat type or screen required
C. Under certain circumstances it may not be possible for a technologist to finish hidher work. What is your policy regarding these situation9
a. If one technologist starts type and crossmatch work on a patient, he/she has to finish it; at no stage of antibody screen and/or crossmatch can another technologist take over and finish the work, even if that means starting all over again b. One technologist can take over the work of another technologist at any stage of antibody screen and/or crossmatch . One technologist may perform the type, antibody screen and/or crossmatch through all steps leading to incubation phase. Once incubation is in progress, a second technologist may then complete the 37 C to antiglobulin phase No particular policy in this regard. Technologists are allowed to make their own decision
D. Fatigue and overwork can often lead to clerical and technical errors. How do you relate this to the technologist work-load?
~~
52 16
~
8. If type and antibody screen are done by one technologist, and a second technologist has to crossmatch some additional units, using the same specimen, helshe must also repeat
~
32
45 13 42
48 12
12 28
~
a. Technologists are required to work on only one patient at a time and only after ABO and Rh have been determined and antibody screen and crossmatches are incubating can a technologist start working on another patient b. Technologists can do the type, antibody screen and crossmatches on more than one patient at a time c. Technologists are assigned work according to their experience and ability
20 52 28
Volume 18 Number 4
BLOOD BANK SURVEY
criticized for not doing a particular test or not following a particular policy. It is easy to get too involved in endless academic considerations and lose speed, economy and efficiency along the line. It is hoped that this survey provided some useful information about the blood bank operations across the nation and would serve as a base for more surveys along the same line.
References 1. American Association of Blood Banks: Technical
2. 3. 4.
Acknowledgments The author is grateful to Ms. Julie Cox and Ms. Mary Jane Wooten for their advice and encouragement throughout this study. The author also wishes to thank Mr. John Moulds of Gamma Biological. Ms. Karen Waldorf of Wichita Regional Red Cross, Ms. Janis Nossaman, Mr. Joe Siemens, Mr. Ted Street, Ms. Theresa Parker and Ms. Ronda Moore of Wesley Medical Center for their assistance. Special appreciation is extended to Ms. Bonnie Kendall for secretarial help.
5.
Methods and Procedures, 6th Ed. W. V. Miller, Ed. Washington, D.C. 1974. -: Standards for Blood Banks and Transfusion Services, 8th ed. H. A. Oberman, Ed. Washington, D.C. 1976. : Membership Directory: 1976- 1977, Washington, D.C. 1976. Beattie, K. M.: Discrepancies in ABO Blood Grouping. I n : A Seminar on Problems Encountered in Pretransfusion Tests. AABB. 1972, p. 129. Issitt, P. D.. and Issitt. C. H.: Applied Blood Group Serology, 2nd ed. Oxnard. California, Spectra Biologicals, 1975, p. 52.
A. Waheed. Student, Blood Bank Specialty Program. Wesley Medical Center, 550 North Hillside, Wichita, Kansas 67214.
A questionnaire about h l d bank policies and procedures was prepared and sent out to 170 hospitals across the nation, 50 per cent responded. There is wide variation in both technical and nontechnical policies and procedures. Serum is separated from the original tube within 8 hours by 68 per cent of the hospitals and In 32 per cent serum is never separated from the original tube. Auto-control is included by 66 per cent of hospitals in at least one phase of the antibody testing, 34 per cent do not include auto-control in any phase. D" testing of the recipient is done in 85 per cent of the hospitals and in IS per cent Rho type is determined by the immediate spin reactions alone. Slide type is the only method used to determine ABO group of cells of the recipients in 10 per cent of the hospitals, 18 per cent use serum-cell suspension, 10 per cent use the applicator stick method and only 62 per cent w washed spline-cell suspension routinely. Compatibility testing between a recipient and a donor vary from a one-tube major crossmatch to a three-tube major crossmatch and minor crossmatch.
TRADITIONALLY the blood bank has been considered as the most sensitive section of the clinical laboratory. Test results reported from other sections of the laboratory can be reviewed, questioned or challenged by the physician, who can order tests to be repeated or, still worse, can even ignore them. When it comes to blood bank, the physician's role is limited once a transfusion has been ordered. Many highly complicated and technical considerations have to be taken care of by the blood bank alone. The technologist performing and signing his name to a crossmatch is primarily responsible for the safety and compatibility of the subsequent transfusion. If a technologist makes a mistake there is seldom a way of finding out until it is too late. For these reasons, blood bank technologists Received for publication June 10. 1977: accepted July 30, 1977.
are required to adhere to the rigid policies and procedures. Those responsible for designing these policies try to ensure that if the policies and procedures are followed carefully, there should be no complications. The American Association of Blood Banks (AABB),* College of American Pathologists (CAP) and regulatory agencies have set up specific guidelines and standards which their affiliated institutes must follow. Additionally there are numerous situations for which each blood bank has to set its own policies and procedures. Policies and procedures in all blood banks are designed toward one goal; to transfuse the right blood to the right patient as safely as possible. It has been observed that policies and procedures vary to a great extent from one blood bank to another. In their concern for the safety of the patient, some blood banks have set up rules which could be considered unnecessary. A survey comprised of 20 questions about blood bank policies and procedures was prepared and sent out to 170 hospitals across the nation in April, 1977. All of these blood banks were institutional members of AABB and names were picked at random from the 1976-1977 AABB Membership Directory.:' Response to the questionnaire was very favorable, with 50 per cent of the questionnaires being returned within three weeks. Responding institutions ranged in size from a 120-bed hospital transfusing 155 units per years to a 1,500bed hospital which reported having transfused more than 30,000 units last year. Responding hospitals represented 35 states in the continental United States.
0041-1132-78-0700-0482-0075 0 J. B. Lippincott Co. Transfusion July-August 1978
482
Volume 18 Number 4
Volume 18
483
BLOOD BANK SURVEY
Number 4
Results The data indicates that there is a wide variation in the policies and procedures of blood banks across the nation. In many instances direct contradiction in policies may be seen. Separating serum and cells from the original tube is a case in point. In 68 per cent of the hospitals serum must be separated from the clot within eight hours of collection and placed in a separate properly labeled tube. In 32 per cent of the hospitals serum is never separated from the original tube. It is interesting to note that AABB Technical Methods and Procedures,' does not provide any guidelines in this regard. It has been suggested that complement deterioration is more rapid in serum left in contact with the clotted blood than in separated serum.> Not separating serum from the clot has the advantage of eliminating a potentially disastrous source of error. ABO und Rh Determination
In order to determine ABO group of cells of the patient, 62 per cent of the responding hospitals use washed saline-cell suspension of the patient's cells, 10 per cent use the applicator stick method and 18 per cent use serum-cell
suspension (Table I). Use of the serum-cell suspension has been known to cause problems in the determination of ABO and Rh group due to the presence of group specific substances, rouleaux and cold reacting agglutinin^.^ Anti-A,B is used with every patient's cells, regardless of ABO group in 70 per cent of the responding hospitals. In 16 per cent of the hospitals only Group 0 patients are tested with anti-A,B (Table I). At least 1 1 hospitals indicated that they test Group 0 patients with anti-A,B only if there is a discrepancy in the cell and serum tests, which is in accordance with AABB standards.* It was interesting to note that 3 of these 1 1 hospitals use slide type as the only method for determining ABO group of cells. Only 10 per cent of the hospitals use the slide type as the only method for this purpose. To determine Rho type of the patients, 85 per cent of the hospitals do D" testing if the immediate spin is negative with anti-D. A full 15 per cent determine Rho type of the recipients only on the bases of immediate spin reaction with anti-D and Rho control (Table I ) . This policy allows not having to decide whether a DU positive should be transfused with only Rho negative blood or could be safely transfused with Rho positive blood. On the other
Table 1. Results of a Nationwide Survey about Blood Bank Policies and Procedures (April, 1977)
Questions
Choices
Percentage of Responding Hospitals
A. Routine method to determine forward ABO type of the recipient
a. b. c. d.
Washed saline-cell suspension (tube type) Applicator stick method (tube type) Serum-cell suspension (tube type) Only slide type
62 10 18 10
B. Use of anti-A,B
a. All patients routinely tested with anti-A,B b. Only group 0 patients routinely tested with anti-A,B c. Group 0 patients tested with anti-A,B only when there is a discrepancy on the forward and reverse grouping
70
a. Only immediate spin with anti-D b. If immediate spin is negative, carry through DUstage only c. If immediate spin is negative, carry through 0" and also test with anti-CDE d. If patient is D-negative, DUpositive test with saline anti-D
15
C. Routine determination of Rho type of a recipient
D. In testing patient cells with anti-D control tube include
a. 22% albumin b. 30% albumin c. Special Rho control antiserum
16 14
69 11 5
16 4
80
484
Transfusion July-August 1978
WAHEED
hand this policy could put considerable strain on the supply of Rho-negative blood. A rather surprising result was that over 80 per cent of the hospitals are using special Rho control antiserum as their control with anti-D (Table 1). This reagent has been marketed only recently and its wide use seems to indicate that a vast majority of the blood banks are doing a remarkable job at keeping up with the recent developments. Antibody Screen and Crossmatch
The antibody screen in a vast majority of the hospitals (90%) consists of saline room temperature and albumin 37 C to antiglobulin phase. Only 66 per cent of these hospitals include auto-control in at least one phase of the
antibody screen, 34 per cent do not include auto-control in any phase of the antibody screen (Table 2). Table 2 indicates that 34 per cent of the hospitals do both a major and a minor crossmatch. Of those doing only major crossmatch, 18 per cent require that the ABO group of the donor be rechecked in conjunction with the crossmatch. Some of the hospitals indicated that they do only immediate spin minor crossmatch to ensure that the identical ABO type is being crossmatched. The majority of the blood banks (55%) don’t require minor crossmatch or recheck of the donor ABO group in conjunction with the crossmatch. The major crossmatch in most of the hospitals (80%) consists of two tubes, a saline room temperature tube and an albumin 37 C to antiglobulin tube (Table 2).
Table 2. Results of a Nationwide Survey about Blood Bank Policies and Procedures (April, 1977) Percentage of Responding Hospitals
Questions
Choices
A. Compatibility testing on a patient includes
a. Major and minor crossmatch b. Only major crossmatch with ABO group of donor rechecked in conjunction with the crossmatch c. Only major crossmatch, A 6 0 group of donor not rechecked at the time of crossmatch
6 . Routine major crossmatch includes
C. Auto control
a. One tube major crossmatch, Saline Room Temperature (SRT) converted to Albumin 37 C to antiglobulin (Alb-AHG) b. One tube major crossmatch, Alb-AHG c. Two tube major crossmatch, SRT and Alb-AHG d. Three tube major crossmatch, SRT, Alb-AHG and Saline 37 C to antiglobulin a. Auto control is included in each phase of the antibody screen b. Auto control included only in the Alb-AHG phase of the antibody screen c. Auto control not included in any phase of the antibody screen
D. Routine antibody screen on a patient serum includes
a. b. c. d. e.
SRT and Alb-AHG phases Saline 37 C to antiglobulin and Alb-AHG SRT, Alb-AHG and enzyme Alb-AHG and enzyme Only Alb-AHG
E. Microscopic examination
a. All negative reactions in antiglobulin phase must be examined microscopically b. Microscopic examination not required. Only when macroscopic examination is inconclusive tubes may be examined microscopically c. Microscopic examination not encouraged unless mixed field reaction is suspected
34 11
55
11
2 80 7
62 4 34 90 4 4 1 1
~
~ _ _ _ _ _
78
20 2
Volume 18 Number 4
485
BLOOD BANK SURVEY
Antiglobulin Phase
Of the 80 responding hospitals only six indicated that use of check cells is not required in every tube giving a negative reaction in the antiglobulin phase. They indicated that daily quality control of the antiglobulin serum is considered adequate. It should be remembered that use of the check cells is not required by the AABB Standards.P Microscopic examination of all negative reactions in the antiglobulin phase is required by 78 per cent of the hospitals. A full 20 per cent indicated that microscopic examination is not required and in some instances routine use of the microscope is discouraged (Table 2). Following manufacturer’s directions is a highly recommended policy and most manufacturers of antiglobulin serum require reading reactions both macroscopically and microscopically. Avoiding a very important step in this highly sensitive test could be regarded as not using the test to its full potential. Nontechnical and Administrative Policies
A number of questions in the survey dealt with administrative and nontechnical aspects of blood banking. Some of the more interesting differences are discussed. If the type, antibody screen and crossmatch has been done on a patient by one technologist and another technologist needs to crossmatch some additional units using the same specimen, more than 58 per cent of the hospitals require the second technologist to repeat at least ABO and Rh of the patient (Table 3). Primary concern here seems to be to ensure that the right specimen was being used for the crossmatch. Our data indicates that almost all hospitals requiring repeat ABO and Rh in this situation, also require separation of serum from the original tube as soon as the specimen is collected. Repeat ABO and Rh could, to some extent, ensure that the right specimen was being used, but it could also provide false sense of security to the technologist. Drawing the right specimen from the right patient is the first and perhaps the most important step in compatibility testing. In 63 per cent of the hospitals, only blood bank technologists, other laboratory technologists or specially trained phlebotomists perform this function. However, 17 per cent responded that they would accept a specimen drawn by any blood drawer including students and laboratory aides. If more than one specimen tube has been drawn on a recipient for compatibility testing,
52 per cent of the hospitals require that ABO, Rh and antibody screen be done on only one tube, but serum from the identically labeled tubes can be used for crossmatches without any‘ additional testing. A full 48 per cent of the hospitals require that ABO, Rh and/or antibody screen be done on all tubes used for compatibility testing (Table 3). This policy again, seems to be more for the peace of mind than anything else. If for some reason a technologist can not finish the type and crossmatch in time and has to leave, 48 per cent of the hospitals require that a second technologist must start the work all over again, 24 per cent allow a second technologist to complete the antibody screen and/or crossmatch after the incubation phase and 28 per cent indicated that they have no particular policy in this regard and a second technologist is allowed to make his own decision (Table 3).
Conclusions
Results of this survey tend to indicate that there is a wide variation in policies and procedures amongst blood banks across the nation. Some of the variations could be attributed to the differences in style, size, work load and area of specialization. Blood bank policies and procedures can be expected to reflect each area of specialization. The present survey did not take these factors into consideration, but this is an area which certainly needs further exploration. In general it seems that blood banks could be grouped into two distinct categories. One group tends to be rather cautious in its approach. They tend to check patient’s and donor’s group and Rh at several stages, use the most sensitive techniques available, even if they are more time consuming. They include as many tests in their routine procedure as possible. The second group tends to be rather liberal in their approach. They do not seem to be doing any additional testing than that required by AABB Standards.z Repeat testing of the specimens is kept at minimum. Reliance seems to be on the correct identification and blood group determination on initial testing. The purpose of this survey was not to
486
Transfusion
WAHEED
pass any judgments, and any attempt at doing so would require much more data than available. The present survey did not touch the important areas of quality control, transfusion policies, prenatal care, cornponent therapy, efficiency of the procedures in terms of number of crossmatches
July-August 1978
per time period per technologist and cost to the patient per transfusion. It should be remembered though that basic function of the blood bank is to provide the most compatible transfusions as efficiently as possible. As long as a blood bank is doing this job it should not be
Table 3. Results of a Nationwide Survey about Blood Bank Policies and Procedures (April, 1977) Percentage of Responding Hospitals
Questions
Choices
A. If more than one specimen is drawn on a patient at one time (as in the case of an open heart surgery)
a. ABO, Rh and antibody screen are done on all tubes used for crossmatch or other purposes b. ABO, Rh and antibody screen are done on only one tube and serum from identically labelled tubes can be used for crossmatch and other purposes c. ABO, Rh and antibody screen are done on only one tube and serum from other tubes can be used after doing ABO and Rh only ____
~~
_
_
_
_
_
_
_
_
_
_
_
~
a. ABO and Rh type b. ABO, Rh and antibody screen c. No repeat type or screen required
C. Under certain circumstances it may not be possible for a technologist to finish hidher work. What is your policy regarding these situation9
a. If one technologist starts type and crossmatch work on a patient, he/she has to finish it; at no stage of antibody screen and/or crossmatch can another technologist take over and finish the work, even if that means starting all over again b. One technologist can take over the work of another technologist at any stage of antibody screen and/or crossmatch . One technologist may perform the type, antibody screen and/or crossmatch through all steps leading to incubation phase. Once incubation is in progress, a second technologist may then complete the 37 C to antiglobulin phase No particular policy in this regard. Technologists are allowed to make their own decision
D. Fatigue and overwork can often lead to clerical and technical errors. How do you relate this to the technologist work-load?
~~
52 16
~
8. If type and antibody screen are done by one technologist, and a second technologist has to crossmatch some additional units, using the same specimen, helshe must also repeat
~
32
45 13 42
48 12
12 28
~
a. Technologists are required to work on only one patient at a time and only after ABO and Rh have been determined and antibody screen and crossmatches are incubating can a technologist start working on another patient b. Technologists can do the type, antibody screen and crossmatches on more than one patient at a time c. Technologists are assigned work according to their experience and ability
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Volume 18 Number 4
BLOOD BANK SURVEY
criticized for not doing a particular test or not following a particular policy. It is easy to get too involved in endless academic considerations and lose speed, economy and efficiency along the line. It is hoped that this survey provided some useful information about the blood bank operations across the nation and would serve as a base for more surveys along the same line.
References 1. American Association of Blood Banks: Technical
2. 3. 4.
Acknowledgments The author is grateful to Ms. Julie Cox and Ms. Mary Jane Wooten for their advice and encouragement throughout this study. The author also wishes to thank Mr. John Moulds of Gamma Biological. Ms. Karen Waldorf of Wichita Regional Red Cross, Ms. Janis Nossaman, Mr. Joe Siemens, Mr. Ted Street, Ms. Theresa Parker and Ms. Ronda Moore of Wesley Medical Center for their assistance. Special appreciation is extended to Ms. Bonnie Kendall for secretarial help.
5.
Methods and Procedures, 6th Ed. W. V. Miller, Ed. Washington, D.C. 1974. -: Standards for Blood Banks and Transfusion Services, 8th ed. H. A. Oberman, Ed. Washington, D.C. 1976. : Membership Directory: 1976- 1977, Washington, D.C. 1976. Beattie, K. M.: Discrepancies in ABO Blood Grouping. I n : A Seminar on Problems Encountered in Pretransfusion Tests. AABB. 1972, p. 129. Issitt, P. D.. and Issitt. C. H.: Applied Blood Group Serology, 2nd ed. Oxnard. California, Spectra Biologicals, 1975, p. 52.
A. Waheed. Student, Blood Bank Specialty Program. Wesley Medical Center, 550 North Hillside, Wichita, Kansas 67214.
