Is it possible to incorporate a transfusion service laboratory into a core laboratory?

A transfusion medicine colleague in Texas reports that "efficiency experts" have evaluated her 300 bed hospital to help the facility solve a cash flow problem. One of the 'expert' suggestions was for the laboratory to reduce its workforce by 960 FTE hours every 2 weeks, which equates to 12 FTE's. Since the laboratory FTE allotment is 75 employees (plus 4 pathologists) the proposed cutback represents about a 16-17 percent workforce reduction. At their current staffing level they provide phlebotomy and laboratory services (about 1 million tests per year) to their hospital on a 24 hours per day basis. The hospital has a busy surgery department, a Level 3 trauma center, and a cancer center. The laboratory also serves as a reference lab for many doctor offices, 3 smaller hospitals and 8 clinics. One suggestion for how they should restructure under the weight of staff cuts is to incorporate the transfusion service into the "core lab". This would allow technologists to 'float' from Hematology to Chemistry to Blood Bank and back throughout the day. The inquiring Texan would like to know if anyone has SUCCESSFULLY incorporated a transfusion service laboratory into a core laboratory USING traditional manual TUBE testing methods and technologies? She asks the question that way, because her hospital does NOT have any of the newer blood bank automated testing systems. She would also like to know if anyone has SUCCESSFULLY incorporated a transfusion service laboratory into a core laboratory USING automated blood bank technologies.

The following comments have been received.

ADDENDA Mar. 13, 2006

1. A transfusion service technologist in the US has expressed strong opinions that outside 'efficiency experts' often lack adequate familiarity with the 'ins and outs' and 'stresses' of transfusion service laboratories, which she believes explains why some 'efficiency experts' have recommended that transfusion service laboratories should be 'fit' into a Core Laboratory.  For example, based on outside advice, her hospital created a "Core Lab" more than 6 years ago. The Core Lab includes Chemistry and Hematology in one large room, plus a Blood Bank lab in a different close by room. Two other laboratory sections included Histology and Microbiology, but these sections were not made part of the Core laboratory. Each of the 5 previous lab sections had its own Technical Specialist who was responsible for technical operation as well as bench work. However, a few years ago the staff was "streamlined", which reduced the number of day shift technologists assigned to the Blood Bank to ONE (usually the Technical Specialist) plus a designated backup tech to cover breaks, lunch, and to provide assistance in case workload suddenly become excessive. All of the remaining core laboratorians (except the Technical Specialists) are cross-trained in two or more laboratory disciplines, including Chemistry, Hematology, Blood Bank, or Micro. The Core Lab 'Blood Bank' still uses "traditional testing methods and technologies" (tube testing), rather than automated or semi-automated methods. She believes that the inclusion of the blood bank in the Core lab coupled with the increased use of cross trained technologists has decreased the overall quality of their laboratory, including the quality of their blood bank. She believes that the 'blood bank' technologists feel more insecure in their performance than previously, that they no longer have a true sense of being "Blood Bankers", and that feel like they are part of another department more than the Blood Bank. In addition, the cross trained technologists do not willingly "float" from departments throughout the day until asked.

ADDENDA Mar. 15, 2006

2. A colleague in Spain reports that he was in charge of hematology and blood banking for two years at a 100 bed community hospital which performed about 2000 crossmatches and transfused about 750 units of red cells each year. His lab had one individual who was assigned exclusively to their transfusion service laboratory during the day shift. However, during the afternoon, on nights and on weekends the transfusion service laboratory testing was performed by individuals who were generalists and 'pulled' from their 'urgency laboratory'. The generalists felt uncomfortable with doing transfusion service testing and other banking activities, and even with good training they viewed the task as a burden. The Spanish colleague suggest that those who plan to merge their transfusion service laboratories into Core labs should use automated or semi-automated pre-transfusion testing for ABO/Rh, antibody screen and crossmatching. In his opinion, non-tube testing is easier to perform, easier to read and record, more standardized and can be 'supervised' the next morning by dedicated blood bank staff. He acknowledges that automated pre-transfusion testing may not be practical below a certain workload level.

ADDENDA Mar. 23, 2006

3. The Medical Director of a Transfusion Service in Oregon comments that in his opinion the inclusion of the transfusion service into the core lab is a necessity in his community, because there are not enough 'dedicated' blood bankers to provide 'dedicated' coverage for all the city's major transfusion services. Day shifts at the major hospitals in his town are usually staffed by a mix of dedicated blood bankers and generalists, while off shifts are usually staffed mostly by generalists. This system has been in place for more than ten years, and he believes that the quality of transfusion medicine in this town is 'first rate'. He adds that "Having a cross-trained staff that can help cover sick days and vacation is an enormous benefit, and is particularly useful in emergencies when sudden service demands require an immediate influx of experienced personnel. Training and maintenance of proficiency are admittedly a bit more of a challenge in the core lab model, but can be managed if the skill set is limited to those tasks that are truly essential. We try to focus the training of our generalists on common tasks that need to be available at all hours (pre-transfusion testing, crossmatching, product preparation and dispensing components.) Excluding more esoteric skills from the generalist's initial training allows them to be more focused and reduces the stress that some feel when working in the transfusion service." In addition, he also states "One advantage of this model that bears mentioning is that generalists may be more comfortable with automated testing than dedicated blood bankers. We recently implemented automated pre-transfusion testing, and our generalists were very enthusiastic about the new technology. Comfort levels with operating and maintaining automated testing instruments were high among our generalists and they were very helpful in championing the technology with their more skeptical colleagues."

Submit comments to the e-Network Forum at enetworkforum@cbbsweb.org

Ira A. Shulman, MD
CBBS e-Network Forum Senior Editor & Moderator

W. Tait Stevens, MD
CBBS e-Network Forum Editor & Moderator

Elizabeth M. St. Lezin, MD
CBBS e-Network Forum Associate Editor & Moderator