Managing a patient with a positive antibody screening test result following an order for type and screen

A community hospital in Southern California employs a Type and Screen (T&S) pre-operative order for patients who have a small risk of requiring peri-operative blood transfusions. If the screen for unexpected antibodies is negative, they do not take any further action unless there is a specific order to dispense crossmatched blood, at which time they perform STAT immediate spin crossmatches before issuing the ordered RBCs. On the other hand, if the screen for unexpected antibodies is positive, they identify the antibody and 'set up' 2 units of RBC in advance of actual need, even though no RBCs are ordered to be crossmatched or transfused. These RBC units are crossmatched using a LISS-AHG tube method. The inquiring colleague adds that she has worked at other facilities that do not crossmatch without an order, even if the screening test of a T&S is positive. She would like to know how other facilities manage patients who have a positive antibody screen when a T&S has been ordered.

The following comments have been received in response:

1. An academic medical center in Los Angeles has a policy that once an antibody screen is positive, a type and screen pre-operative order must be replaced with a type and crossmatch order, according to the likely needs of the patient during the peri-operative period. This requirement means that the surgeon who ordered the type and screen must be consulted about the positive antibody status, and make a clinical decision about being adequately prepared before bleeding occurs and transfusion is necessary.

ADDENDA Nov. 3, 2010

2. The medical director of a busy transfusion service at a large community hospital in Los Angeles reports that they (like the inquiring institution) also set up and crossmatch 2 units of blood when a pre-operative antibody screen is positive. They do not request a new order be submitted. This ensures timely availablility of blood should it be requested at the time of surgery.

ADDENDA Nov. 29, 2010

4. A transfusion medicine fellow who is in training at an academic medical center in California reports that it is the laboratory'spolicy for pre-op type and screen orders with positive antibody screens is to perform an antibody identification and to set aside two RBC units that lack the corresponding antigens. This is done in advance of surgery and the units are kept sequestered for the patient, but not "assigned" in the computer. No crossmatches will be performed until a transfusion order for products is received.
   
   
5. A colleague at a hospital in Wisconsin comments that at his institution, they made a new positive antibody screen a "panic value" that must be phoned to the physician. They also recommend to the physician that 2 units of blood be ordered, letting them know that there could be a delay in getting crossmatch comaptible blood during surgery, unless this testing is performed in advance. In most cases, the physician agrees to the 2 unit crossmatch recommendation, but sometimes they want 4 units. Occasionally, the physician keeps the order at a Type and Screen only, because the risk of blood loss might be minimal.
   
   
6. At a facility in Cleveland, they adhere to essentially the same procedure as the large academic facility in Los Angeles as noted above. Whenever an antibody is identified on a type and screen in a patient scheduled for surgery, the surgeon is notified. The surgeon and blood bank decide on whether crossmatched blood is necessary and if so, how many units. At other facilities that the responding colleague is am familiar with, there was a reflex order system such that any time a type and screen on a surgical patient revealed an antibody 2 units of blood were automatically set-up. Regardless of the procedure followed, what is critical is communication between the blood bank and responsible clinician/surgeon.

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