Blood Bank Director review and sign-off for antibody investigation, including antibody panels

A colleague in Canada comments that their Blood Bank Director reviews and signs each antibody investigation including antibody panels, conclusion, letter and card as applicable. Since the Director's time is always at a premium, the inquiring institution would like to reduce the time needed for Directors' reviews and wonder what level of review is appropriate according to the laboratory/clinical findings. They would be very interested to learn about the process of review and sign off of antibody investigations at other centers.

Questions:

• Does the Medical Director review all or some investigations? If some, how is this determined?
• How in depth do other directors routinely review the minute details of each panel?
• Is the verification for ruling out delegated to a charge technologist?
• How many charge technologists check the panel before submitting it to the Director for review?

The following comments have been received in response.

ADDENDA Dec. 12, 2009

1. A transfusion medicine physician in the Los Angeles area reports that at her hospital, all antibody work ups are reviewed by a physician and a consultation is provided. The laboratory work ups are reviewed by a supervisory level technologist before the physician's review.
   
   
2. Dr. Sunny Dzik at Massachusetts General Hospital (attribution used with permission) writes:
   
   "It is important to note that we feel that the purpose of the review is to verify findings but also to interpret and communicate these findings to clinicians. Thus, in our program, review of serology also includes the completion of an electronic report that is posted to the patient's medical record. This report indicates the clinical importance of the findings and also the impact of the findings on finding compatible blood for future transfusions. Anesthesiologists find this latter detail very important. Finally, the report is considered very helpful by the OB physicians who have patients with prenatal antibodies.
   • Does the Medical Director review all or some investigations? If some, how is this determined?
     We review all NEW clinically-significant antibodies. We do not review re-confirmations of previously identified antibodies nor workups that reveal clinically unimportant specificities.
     
   • How in depth do other directors routinely review the minute details of each panel?
     We review the original panel sheets in detail. This is done in conjunction with resident trainees as a pratical method for teaching blood group serology.
     
   • Is the verification for ruling out delegated to a charge technologist?
     Yes.. but the medical director doing the review may request additional testing.
     
   • How many charge technologists check the panel before submitting it to the Director for review?
     One. Our senior technologist responsible for antibody identification is the best in the world ! "
     
     
3. A transfusion medicine physician at a teaching hospital in Chicago reports that in his experience, for patient care, the relative contributions of the lab staff and the blood bank director would probably depend on the relative expertise of each, and the complexity of the case. The director is ultimately responsible for the lab diagnosis, but many antibody studies are very straightforward, especially with single antibodies and/or repeat workups with stable findings, and with procedures and competency in place, the serological details could be delegated to technical staff. In the US, blood bank physicians can bill patients for laboratory consultations in antibody investigations, but this requires review of the problem and entry of an interpretation in the patient's record. He adds that in a teaching institution like his, they also train pathology residents. So in his setting, a charge technologist reviews each workup and passes it along to the pathologist and the residents, who go over the panels for teaching purposes as well as patient care. After review and sometimes after additional testing, the pathologist signs out each new workup in the patient's chart. For repeat workups, their lab's custom is to not repeat the chart signout during the next one month if the findings are unchanged.
   
   
4. Dr. Jim AuBuchon (attribution used with permission) comments that the need and purpose of involving a physician in reviewing and signing out antibody identification workups undoubtedly varies by institution and situation. In Jim's opinion, while review of any immunohematology work by a generally knowledgeable transfusion medicine physician might identify an error, most reference laboratorians or even experienced technologists in a general transfusion service lab have skills and knowledge in this field that far surpass those of most transfusion medicine physicians! (Although he reports having initially been attracted to “blood banking” through immunohematology and learned much from dedicated SBBs, he readily admits that they can run rings around him!) Many labs routinely have a second technologist review complicated workups to ensure that all points of view have been considered, leaving little for a physician to add. Thus, physician review is not likely to add much in terms of “correction”.
   
   Jim adds that in his experience, where a physician’s input is most helpful is in placing the findings in a clinically useful context. Most clinicians have absolutely no idea about the clinical significance of a particular specificity, the potential difficulty and timeline for acquiring compatible units, nor the type and length of testing that would be required to provide a predictably compatible transfusion. Much of such information could be inserted into a report as a “canned comment” based on the specificity(ies) detected, but the transfusion medicine physician might still be able to offer some individualized commentary that could be useful based on the patient’s age, gender, medical history or current status. This information might go into the report being sent to a hospital or to a patient’s chart, although placing it directly in the progress notes (facilitated through electronic medical records) ensures that it will be read by the clinician. (It is this kind of interpretive comments that are necessary (in the US) for a transfusion medicine physician to bill for services related to a technical procedure.)
   
   Finally, he concludes saying that review of immunohematology workups is an excellent way to teach important points in red cell serology and their application in transfusion medicine. Daily review of such work with residents, fellows or med tech students affords marvelous and broad-reaching teaching opportunities and demonstrates the connectivity between bench and bedside. (And, besides, the techs can usually teach him something, and they enjoy knowing that their work is appreciated by the “boss” and has clinical relevance.)

ADDENDA Dec. 29, 2009

5. A Medical Director of a University Health System Transfusion Service in Virginia has provided the following feedback to this discussion:
   • Does the Medical Director review all or some investigations? If some, how is this determined?
     At his medical center, a physician reviews all antibody investigations. They have pathology residents and a transfusion medicine fellow who are assigned responsibility for this task. A transfusion service medical director reviews all new antibodies, but not investigations that find only previously identified antibodies. For those institutions that do not have residents and/or a fellow in the blood bank or transfusion service, the responding physician believes that the medical director should review all antibody investigations. The medical directors at his center are charged with deciding when to order molecular typing.
     The issue of antibody investigation review is an interesting one, and the process will largely be determined by the nature of the institution. However, regardless of the individual characteristics of the blood bank or transfusion service, a procedure should be established that assures very careful review of these studies. As technologists gain experience, this process contributes to their own professional development, as well as providing a high level of patient care.
   • How in depth do other directors routinely review the minute details of each panel?
     The physician review is performed in depth; at the same level of analysis as a technologist's review. This provides an educational opportunity for the physicians, as well as an extra check of the work of the technologists.
   • Is the verification for ruling out delegated to a charge technologist?
     Both the charge technologist and the physicians assume responsibility for verification of ruling out.
   • How many charge technologists check the panel before submitting it to the Director for review?
     One.

ADDENDA Jan. 20, 2010

6. The medical director of an transfusion service at an academic medical center in Ohio provides the following answers to the set of questions under discussion:
   • Q: Does the Medical Director review all or some investigations?
     A: All of the transfusion medicine attending physicians (which includes the Medical Director) review all antibody identification panels which are generated from a positive antibody screen. The antibody panels are first previewed by a resident who enters his/her interpretation into the Laboratory Information System (LIS) which is interfaced to the Hospital Information System (HIS) as part of graded responsibility education. The attending then reviews the panel and the resident interpretation and then enters his/her interpretation. This is set up as a different test in the computer system.
   • Q: How in depth do other directors routinely review the minute details of each panel?
     A: The attendings review the minute details of each panel with extensive detail ('crossout level').
   • Q: Is the verification for ruling out delegated to a charge technologist?
     A: They have an SOP that designates rules for antibody identification and ruling in or ruling out different antibodies. All reference technologists are trained in working up and interpreting the panels. There is a second review by technical coordinator or individual trained in review. However, as mentioned above, all antibody identification panels which are generated from a positive antibody screen are reviewed by a physician
   • Q: How many charge technologists check the panel before submitting it to the Director for review?
     A: There is at least 1 technologist reviewing the panel before a physician sees it.

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