ID-MTS Gel and Automation: A Users Perspective

1. ID-MTS Gel and Automation:A Users Perspective Jody Smalley, MT(ASCP)SBB INOVA Fairfax Hospital Falls Church, Virginia This is the question of the day: Why DID we chose Automation? Hello. I am Jody Smalley. Technical Specialist in charge of education and Training at Inova Fairfax Hospital in Falls Church Virginia. This is the question of the day: Why DID we chose Automation? Hello. I am Jody Smalley. Technical Specialist in charge of education and Training at Inova Fairfax Hospital in Falls Church Virginia.

2. INOVA Fairfax Hospital Hospital Profile 656 bed hospital (150 more to be added) Busy Level 1 trauma center Active cancer center Transplantation services Neonatal facility (2nd Highest # in US) Expanding ER and OR First let me tell you a little about our hospital: Last count we have Beds As we all know, our area ranks 4th the race for the Nation’s top worst traffic areas so we have a lot of motor vehicle accidents.Unfortunately for the drivers, but fortunately for those needing transplants, this gives us an organ donor pool and therefore active transplant service. We do bone marrow and stem cell harvests, liver, lung, kidney, and heart transplants. We have a very active cancer center and a heart surgery group. The blood bank also supports outpatient transfusion programs with dialysis centers and oncology offices. We recently started a cord blood collection program. The cord blood from some of our large number of births is collected and sent to the New York Blood Center for processing and storage. All of these services keep our blood bank very busy.First let me tell you a little about our hospital: Last count we have Beds As we all know, our area ranks 4th the race for the Nation’s top worst traffic areas so we have a lot of motor vehicle accidents.Unfortunately for the drivers, but fortunately for those needing transplants, this gives us an organ donor pool and therefore active transplant service. We do bone marrow and stem cell harvests, liver, lung, kidney, and heart transplants. We have a very active cancer center and a heart surgery group. The blood bank also supports outpatient transfusion programs with dialysis centers and oncology offices. We recently started a cord blood collection program. The cord blood from some of our large number of births is collected and sent to the New York Blood Center for processing and storage. All of these services keep our blood bank very busy.

3. How We Chose ID-MTS Gel Technology Four years ago our technologists compared: Standard serological tube testing Solid phase testing ID-MTS Gel Test We ran a parallel study comparing tube testing, solid phase and the ID-MTS Gel test. Several technologists were involved and the techs recommended Gel. We ran a parallel study comparing tube testing, solid phase and the ID-MTS Gel test. Several technologists were involved and the techs recommended Gel.

4. How We Chose ID-MTS Gel Technology The technologists recommended Gel because it is: Simple to use and easy to read. There is no tube shaking involved so if you have inexperienced techs or students they don’t shake out the reactions. You can read behind someone very easily. At the beginning when we were training, we would pass the cards around and say…”what do you think this is?” We grade our reactions using 0-4+ and there are charts to compare results to. We have 3 other smaller hospitals in the Inova System and the gel test provided consistency across the system. All our sister hospitals are using it. They have generalists rotating through the blood bank and found it was much easier to train chemists and hematologists to work in blood bank using gel.The technologists recommended Gel because it is: Simple to use and easy to read. There is no tube shaking involved so if you have inexperienced techs or students they don’t shake out the reactions. You can read behind someone very easily. At the beginning when we were training, we would pass the cards around and say…”what do you think this is?” We grade our reactions using 0-4+ and there are charts to compare results to. We have 3 other smaller hospitals in the Inova System and the gel test provided consistency across the system. All our sister hospitals are using it. They have generalists rotating through the blood bank and found it was much easier to train chemists and hematologists to work in blood bank using gel.

5. The Gel is a dextran-acrylamide gel and reagent predispensed into a specially designed microtube.The Gel is a dextran-acrylamide gel and reagent predispensed into a specially designed microtube.

6. At first when we were testing the system, we were unsure about the pipette. This was the original pipette. It works well but it took us about a day to get used to it. Even my med tech students are reluctant to use tubes after they use the gel. I always make them start out using tubes because tubes are considered the “gold standard” but it is so much easier to check behind them when they use Gel because I can see their results so clearly on the gel card.At first when we were testing the system, we were unsure about the pipette. This was the original pipette. It works well but it took us about a day to get used to it. Even my med tech students are reluctant to use tubes after they use the gel. I always make them start out using tubes because tubes are considered the “gold standard” but it is so much easier to check behind them when they use Gel because I can see their results so clearly on the gel card.

7. The blood bank in our old original lab had all the crossmatch techs in one large area. When we moved to the new lab , it was thought that the crossmatch techs would have less distractions if they worked in booths. Each booth has an MTS centrifuge and incubator. The blood bank in our old original lab had all the crossmatch techs in one large area. When we moved to the new lab , it was thought that the crossmatch techs would have less distractions if they worked in booths. Each booth has an MTS centrifuge and incubator.

8. We found that using the gel system did increase our productivity.We found that using the gel system did increase our productivity.

9. We quickly became accustomed to the Gel System. It incorporated well into our work flow.We quickly became accustomed to the Gel System. It incorporated well into our work flow.

10. Our laboratory computer system is Cerner. You can see the computer there in the corner. The hospital has PHAMIS LAST WORD interfaced with Cerner . Unfortunately the nurses on the floor cannot look in their computers to see if the blood is ready so they have to call the blood bank and ask. This means we have a lot of phone calls!Our laboratory computer system is Cerner. You can see the computer there in the corner. The hospital has PHAMIS LAST WORD interfaced with Cerner . Unfortunately the nurses on the floor cannot look in their computers to see if the blood is ready so they have to call the blood bank and ask. This means we have a lot of phone calls!

11. What We Gained From The New Technology: The ability to handle a steadily increasing workload with steadily decreasing manpower Smaller hospitals cross-trained chemists, hematologists or generalists to help in blood bank Easier to training students, evaluate student progress and assess competency We did gain a lot from the new Gel technology. It did ease the impact of the increasing work load. Gel made cross training much easier. Chemists are used to pipetting things and took to the Gel system like ducks in water. It is easier to see if the students have accurately identified antibodies because we can read the Gel cards behind them.We did gain a lot from the new Gel technology. It did ease the impact of the increasing work load. Gel made cross training much easier. Chemists are used to pipetting things and took to the Gel system like ducks in water. It is easier to see if the students have accurately identified antibodies because we can read the Gel cards behind them.

12. Student Working On Project This is one of last year’s students using Gel while working on her student project.This is one of last year’s students using Gel while working on her student project.

13. ID-MTS Gel Technology is  Proven! We felt a measure of success when we switched from tubes to the Gel system. For a while it took some of the pressure off. We felt a measure of success when we switched from tubes to the Gel system. For a while it took some of the pressure off.

14. Issues Plaguing The INOVA Transfusion Service: 1. Errors- Patient safety issue 2. Staffing Shortages-Unable to hire experienced techs causing: Long hours and swing shifts Increased stress and illness for existing staff 3. Work Process Redesign Analysis- Consultant recommended automation as a strong candidate to solve problems Unfortunately, we had some serious errors a while ago. Of course like good blood bankers should, we looked at the system to see why these errors occurred.  When I was asked to speak here in Ocean City, I was asked to tell the reasons we got automation. Our blood bank supervisor said the number one reason was “errors”. Our lab manager said “you can’t go and tell them THAT!” But it is true. A number of factors were involved but if we had not made the errors…the blood bank issues would not have come to administrative attention…. Now I am not telling you to go out there and make errors….but that is the number one reason we got automated. We also had serious staff shortages which increased pressure on the existing staff. When we had a Work Process Redesign Analysis and automation was recommended Unfortunately, we had some serious errors a while ago. Of course like good blood bankers should, we looked at the system to see why these errors occurred.

15. Errors Hospital wide initiative to decrease errors Blood bank had several serious non-fatal errors Root cause of errors demanded better process control TECAN MEGAFlex-ID and the MTS Reader M automation was a way to achieve the required process control Apparently some other errors were occurring throughout the hospital too. There was a hospital initiative to decrease errors. We are one of the top 100 hospitals in the USA and errors simply are not acceptable. Among other errors that happened, one error occurred when a tech mixed up 2 patient samples. One patient was typed as B+ but was actually an AB+ and the B+ patient received AB+ RBCs. The other patient was typed as B+ but was actually AB+ and got B+ plasma. Fortunately for us the patient reactions were not fatal. The patient who got mismatched blood got a positive DAT and the other had no effects that we could detect. We were lucky the patient transfused with RBCs was not group O! Automation with positive specimen ID incorporated in the Tecan, was one way to address this process control problemApparently some other errors were occurring throughout the hospital too. There was a hospital initiative to decrease errors. We are one of the top 100 hospitals in the USA and errors simply are not acceptable. Among other errors that happened, one error occurred when a tech mixed up 2 patient samples. One patient was typed as B+ but was actually an AB+ and the B+ patient received AB+ RBCs. The other patient was typed as B+ but was actually AB+ and got B+ plasma. Fortunately for us the patient reactions were not fatal. The patient who got mismatched blood got a positive DAT and the other had no effects that we could detect. We were lucky the patient transfused with RBCs was not group O! Automation with positive specimen ID incorporated in the Tecan, was one way to address this process control problem

16. Staffing Shortages A Series of unfortunate events created hardship on night shift: One tech had a baby One tech returned to her country (Visa ran out) One tech had surgery One tech took another job We also had staffing problems. We lost most our night shift. One had a baby, one was on a student visa and had to return to her country after working for one year, one had surgery, another got a better offer. We still have an open night shift position…anyone interested?We also had staffing problems. We lost most our night shift. One had a baby, one was on a student visa and had to return to her country after working for one year, one had surgery, another got a better offer. We still have an open night shift position…anyone interested?

17. How Staffing Shortages Affected Our Staff: Existing night shift techs worked 12 hour shifts Day techs worked rotating swing shifts from 3am- noon Variable shifts caused excess illness in techs Experienced techs left for better opportunities New, inexperienced techs could not come up to speed on all of the complex blood bank activities We have had to rotate working night shift among our staff. Swing shifts are difficult and they caused an increase in illness among the staff. We did train 2 night shift techs. One decided the job was too stressful and quit. She got a better offer somewhere else. The other was just not able to keep up with the necessary pace and we had to let her go. We also changed our staffing mix -previously we had one Technologist and one very experienced lab assistant on night shift. The experienced lab assistant got a better job and left so now we have 2 experienced technologists working night shift. That gave us some flexibility we did not have before. We have had to rotate working night shift among our staff. Swing shifts are difficult and they caused an increase in illness among the staff. We did train 2 night shift techs. One decided the job was too stressful and quit. She got a better offer somewhere else. The other was just not able to keep up with the necessary pace and we had to let her go. We also changed our staffing mix -previously we had one Technologist and one very experienced lab assistant on night shift. The experienced lab assistant got a better job and left so now we have 2 experienced technologists working night shift. That gave us some flexibility we did not have before.

18. It seems we in the blood bank never have enough time to get the work done as fast as they need it! Approximately 75% of our work load is STAT so getting a stat driven automated process was mandatory for us. It seems we in the blood bank never have enough time to get the work done as fast as they need it! Approximately 75% of our work load is STAT so getting a stat driven automated process was mandatory for us.

19. Work Process Redesign? Ortho-Clinical Diagnostics provided a consultant to evaluate processes in the hospital transfusion service A consultant came in to evaluate every aspect of our work load and facilities. She spent several days observing. She talked to the techs and watched our processes and work flow.A consultant came in to evaluate every aspect of our work load and facilities. She spent several days observing. She talked to the techs and watched our processes and work flow.

20. Work Process Redesign? The consultant provided a wealth of information on how to effectively change our processes and procedures to accommodate increased workload and decreasing staff The consultant made many suggestions that helped us streamline our processes and become more efficient. The consultant made many suggestions that helped us streamline our processes and become more efficient.

21. Work Process Redesign? One of the primary recommendations was to consider automation of the more routine testing to allow technologists to concentrate on the more complex tasks Automation was a way to compensate for staffing shortage and allow us to keep up with the ever increasing work load.Automation was a way to compensate for staffing shortage and allow us to keep up with the ever increasing work load.

22. How We Selected Our Automation Looked at possibilities available Wanted system that was flexible and robust Needed to interface with Cerner LIS Sent a team to site visit at Duke University Medical Center Duke University Hospital had Cerner and the TECAN. They had the TECAN integrated into their work process and on a site visit, we saw that it could work the same way for us. Duke University Hospital had Cerner and the TECAN. They had the TECAN integrated into their work process and on a site visit, we saw that it could work the same way for us.

23. This is a photo of the TECAN with the reader SA. We don’t have the reader SA yet but it centrifuges the specimens and then reads them. We combined 2 crossmatch booths into one large “TECAN” Booth and this system is set up in the shape of a “U”. This is a photo of the TECAN with the reader SA. We don’t have the reader SA yet but it centrifuges the specimens and then reads them. We combined 2 crossmatch booths into one large “TECAN” Booth and this system is set up in the shape of a “U”.

24. TECAN AT WORK Positive ID is an important aspect of automation. Specimens don’t get mixed up by the TECAN. Positive ID is an important aspect of automation. Specimens don’t get mixed up by the TECAN.

25. The TECAN MEGAFlex-ID And Reader M Provides: Efficiency through flexible automation with an extensive testing menu that can handle large batches and STATS The TECAN is now in full use during Day Shift and Evening Shift. The TECAN runs in batches. We keep the routine work in a rack until a STAT arrives-then the STAT “drives the batch” and the run is started. The TECAN does ABO and Rh in Monoclonal cards and the antibody screen in Gel with prediluted cells. We also run batches of Cord bloods -it does ABO Rh and DAT on cord blood samples from Group O,Rh neg mothers or mothers with alloantibody. We still do Weak D testing at the bench. We recently implemented Electronic Crossmatches so the techs in the booths spend their time doing Electronic Crossmatches on patients with negative antibody screens. The patients with positive antibody screens of course need antibody identification and IgG crossmatches. Work processes are smoother and we don’t notice the staffing shortages as much….unless 2 people call in sick…. The TECAN is now in full use during Day Shift and Evening Shift. The TECAN runs in batches. We keep the routine work in a rack until a STAT arrives-then the STAT “drives the batch” and the run is started. The TECAN does ABO and Rh in Monoclonal cards and the antibody screen in Gel with prediluted cells. We also run batches of Cord bloods -it does ABO Rh and DAT on cord blood samples from Group O,Rh neg mothers or mothers with alloantibody. We still do Weak D testing at the bench. We recently implemented Electronic Crossmatches so the techs in the booths spend their time doing Electronic Crossmatches on patients with negative antibody screens. The patients with positive antibody screens of course need antibody identification and IgG crossmatches. Work processes are smoother and we don’t notice the staffing shortages as much….unless 2 people call in sick….

26. TECAN Can Be STAT Driven When a STAT comes in, the TECAN is started. If several STATS come in a once we start them all on the TECAN at once. If anther STAT comes in after the TECAN is already pipetting, we have a tech in a crossmatch booth set it up. When a STAT comes in, the TECAN is started. If several STATS come in a once we start them all on the TECAN at once. If anther STAT comes in after the TECAN is already pipetting, we have a tech in a crossmatch booth set it up.

27. The TECAN MEGAFlex-ID And Reader M provides: Process Control with positive patient ID, automated pipetting, automated reader with ability to export and archive results and images With Positive Patient ID -that part of our process is controlled. The TECAN’s automated pipetting and integration to Cerner has made the TECAN with the reader M the answer to our some of our problems.With Positive Patient ID -that part of our process is controlled. The TECAN’s automated pipetting and integration to Cerner has made the TECAN with the reader M the answer to our some of our problems.

28. The TECAN MEGAFlex-ID And MTS Reader M Provides: Now we have more time to spend identifying antibodies and preparing components for patients.Now we have more time to spend identifying antibodies and preparing components for patients.

29. Tech Locating Blood for Patient With staff shortages, we were happy to be freed up from some of the work by the TECAN. With staff shortages, we were happy to be freed up from some of the work by the TECAN.

30. Tech Thawing Plasma We can always find something to do with our spare time…like thaw plasma, freeze or deglyce RBCs, pool cryo, pool random platelets, prepare aliquots for babies, sign out blood plus a multitude of other tasks…We can always find something to do with our spare time…like thaw plasma, freeze or deglyce RBCs, pool cryo, pool random platelets, prepare aliquots for babies, sign out blood plus a multitude of other tasks…

31. Process Evolving The decision to change technologies linked with the decision to automate with the TECAN and Reader M provides our transfusion service with the ability to increase our workload without negatively impacting our staff. It allows us to continue to provide the excellent care that our patients demand

32. This is the end of my talk and this is a picture of one of me running the TECAN. Thank you for your attention. Any Questions?This is the end of my talk and this is a picture of one of me running the TECAN. Thank you for your attention. Any Questions?