MVRBC SOP Changes

1. MVRBC SOP Changes That will affect Client Hospitals October, 2011 TAC Meeting

2. Effective DATE Monday, September 19th

3. Antibody Screens • All antibody ID samples will receive a Room Temperature 30 minute antibody screen • Performed to catch any cold reactive antibodies including autoantibodies • All antibody ID samples will receive a screen with PeG or LISS in addition to the RT screen. • Allows us to view another perspective on antibody reactivity. • Not all antibodies will react with every method.

4. Antibody Identification • Techs will be testing FULL 10-11 cell panels on patients with previously identified antibodies. • Prior practice was to choose selected cells to rule in antibody with one cell and choose cells to rule out other clinically significant antibodies. • Will allow MVRBC to better provide for client hospitals by testing with complete panels. • Minimizes chances that an antibody will be missed, such as an antibody to a low frequency antigen.

5. DAT / Elution Testing • All Antibody ID Samples will receive a DAT • MVRBC wants to meet our patient’s need by providing the most complete workup • All positive DAT / AHG positive autocontrols will have an eluate performed regardless of the transfusion history • Prior practice was to perform an eluate if the patient has been transfused within the last three months. • Can be a safety issue – How accurate is the transfusion history we receive? Have they been treated at another hospital we don’t know about?

6. Absorption on Eluates • Eluates will only be adsorbed if the patient has been transfused within 21 days • Prior process was to absorb if the patient had been transfused within 3 months. • TM 16th ed. States that an antibody will typically be produced by 14-21 days after transfusion at which point it will be detected in plasma.

7. Antibody Titers • Will see Antibody Score reported with titer results. • Weak reactivity often extends beyond a 1+ which is the cut off for reporting antibody titers. • The score is calculated based on strength of reactivity of each tube. • The score can increase without the antibody titer increasing – Indicating antib0dy production or possible clinical significance • Dr. Marshall has written a letter describing the additional information being reported with antibody titers. • A copy of the letter will be available from Ronelle.

8. Critical Values • MVRBC staff will begin reporting and documenting who they spoke with for values that are considered critical values to MVRBC. • Each hospital is recommended to follow your own policy / procedures. • Some of the more common critical values include the following: • Positive DAT • Critical Antib0dy Titer (≥ 16, increase of 2 dilutions or a score of 10 points) • Percent compatibility of < 10% based on patient’s antibodies

9. Antigen Testing on Tail Segments • A new form will be faxed if you send tail segments from your inventory for antigen testing • This form (Z-132) provides verification for the hospitals that the testing was performed • Considered similar to the antigen typing tag attached to units issued to your facility

10. Double Red Blood Cells • Antigen typing on double red cells will now be typed individually and charged for testing performed. • Prior practice was to antigen type one unit and label both parts of the unit as antigen negative • Resulted in ONE antigen type fee • As a safety concern, the new practice will require BOTH parts to be tested and labeled as test results indicated • Resulting in an antigen testing fee for each unit ordered

11. Effective DATE Monday, November 7th

12. Final Consult Reports • Beginning Monday, November 7thfinal consult reports will not be faxed to each hospital. • The report will be placed in an envelope and sent with PMD courier to appropriate hospital • Refining process to meet our clients needs • We recognize the extra work that is involved each time a report is issued

13. Questions / Comments?