Bi-ennial Report

Transcription

1 Bi-ennial Report UK NATIONAL EXTERNAL QUALITY ASSESSMENT SCHEME for Blood Transfusion Laboratory Practice UK NEQAS (BTLP) PO Box 133 Watford WD18 0WP UK NEQAS (BTLP) 2014 Issued June 2014

2 INDEX 1 INTRODUCTION and SCOPE 1 2 STAFF 1 Page Number 3 PARTICIPANTS PERFORMANCE SUMMARIES Exercises distributed 3 General information 4 12R1 5 12E E3 6 12R E E6 8 12R E R E R E E R E E R E R E ERROR RATES LEARNING POINTS 22 7 SCHEME DEVELOPMENT AND QUALITY INDICATORS 23-25

3 8 QUESTIONNAIRES AND NON-SCORING ELEMENTS 26 9 TRENDS IN TECHNIQUES USED IN UK NEQAS EXERCISES INFORMATION/EDUCATION/PUBLICATIONS/PRESENTATIONS REFERENCES FINANCIAL STATEMENT APPENDICES Steering Committee 31 2 Summary of UI submissions 32 3 UI Rules 33 4 ABO antibody titration pilot - annual report Pre-transfusion testing questionnaire Pre-transfusion testing questionnaire Emergency issue questionnaire 13R Data from anonymous questionnaire Meeting programme Meeting programme

4 1. INTRODUCTION AND SCOPE UK NEQAS (BTLP) is hosted by West Herts Hospital NHS Trust and is located on the ground floor of the Pathology Block at Watford General Hospital. It shares premises and administrative and logistics staff with UK NEQAS (H). The UK NEQAS Unit is part of pathology within the Clinical Support Directorate, and the legal oversight and working arrangements are described in a Memorandum of Agreement with the Trust. The Scheme is advised by and reports to the BTLP Steering Committee (see Appendix 1 for current membership) and reports unsatisfactory performance to the National Quality Assurance Advisory Panel for Haematology. This report presents data for two calendar years: 2012 and STAFF Chair of the Steering Committee Dr Peter Baker Scheme Director - Dr Megan Rowley Scheme Manager - Mrs Clare Milkins Deputy Scheme Manager - Ms Jenny White Senior BMS Mr Arnold Mavurayi Executive Assistant Ms Isabella De-Rosa Telephone: +44 (0) Fax: +44 (0) btlp@ukneqas.org.uk Website: 3. PARTICIPANTS The number of participants registered at December 2013 is shown in table 1. participation by country is shown in table 2. Overseas Table 1 - Participation December 2013 Type of Participant Number Registered UK clinical (including Republic of Ireland and Channel Islands) 395 Overseas clinical 418 UK and overseas diagnostic companies 8 Page 1 of 69

5 Table 2 - Overseas Participation by Country (including non-clinical) Country No. Participants Country No. Participants Australia 1 Macau 1 Belgium 2 Malawi 1 Chile 2 Malta 3 China 1 Mexico 1 Croatia 2 Netherlands 4 Cyprus 7 New Zealand 1 Denmark 33 Norway 5 Egypt 1 Oman 2 Estonia 2 Poland 1 Faroe Islands 1 Portugal 46 Finland 4 Romania 1 France 2 Saudi Arabia 1 Germany 1 Serbia 2 Gibraltar 1 Singapore 1 Greece 11 Slovenia 1 Greenland 1 Spain 2 Hong Kong 1 Sweden 3 Iceland 1 Switzerland 3 Israel 18 Sri Lanka 1 Italy 68 Tunisia 1 Kenya 1 Turkey 163 Kuwait 13 United Arab Emirates 2 Lebanon 1 USA 1 Page 2 of 69

6 4. PERFORMANCE SUMMARIES 4.1 Table 3 Summary of exercises distributed Ex. Code Distributed Contents Main aim 12R1 16 January ABO/D, AS, ABID, XM, PH Detection of ABO and IgG antibodies in the crossmatch; Fy phenotyping. 12E2 20 February AS, ABID Identification of antibody mixtures. 12E3 19 March AS, ABID 12R4 16 April 12E5 14 May AS, ABID 12E6 18 June AS, ABID 12R7 16 July 12E8 17 September AS, ABID ABO/D, AS, ABID, XM, PH ABO/D, AS, ABID, XM, PH 12R9 15 October ABO/D, AS, ABID, XM, PH Identification of an antibody mixture. Detection of a weak antibody D typing of a rr DAT positive sample. Antibody identification with an enzyme non-specific antibody present. Jk phenotyping. Identification of an antibody mixture that includes an antibody of low clinical significance directed against a low frequency antigen. Identification of an antibody with and without the patient red cell phenotype provided. Identification of an antibody mixture, including a cold-reacting antibody, and detection in the crossmatch. Pilot for DAT testing. Rh phenotyping. Identification of an antibody mixture; anti-d standard. Identification of an antibody mixture; detection of IgG antibodies in the crossmatch. Ss phenotyping. 12E10 19 November AS, ABID Identification of antibody mixtures. 13R1 21 January 13E2 18 February AS, ABID ABO/D, AS, ABID plus XM with in-house donor cells (latter not assessed) Emergency scenario and dual population of D pos/d neg. Detection of a weak antibody and Identification of an antibody mixture. 13E3 18 March AS, ABID Identification of antibody mixtures. 13R4 15 April 13E5 13 May AS, ABID 13E6 17 June AS, ABID 13R7 15 July ABO/D, AS, ABID, XM, PH ABO/D, AS, ABID, XM, PH D typing of a DVI sample. Assessment of intra-lab consistency in crossmatching. Fy phenotyping. Detection of a weak antibody and identification of an antibody mixture. Identification of antibody mixtures with mixed field phenotypes provided, representing recently transfused patients. Assessment of detection of incompatibility due to ABO and anti-s;.jk phenotyping. 13E8 16 September AS, ABID Identification of antibody mixtures. 13R9 14 October ABO/D, AS, XM, 13E10 18 November AS, ABID AS - Antibody Screen ABID - Antibody Identification XM - Crossmatch PH Red Cell Phenotyping Q - Questionnaire Sensitivity of the IAT crossmatch in an urgent scenario, including anti-wr a. Detection of the NEQAS standard anti-d and identification of an antibody mixture. Page 3 of 69

7 4.2 General Information Relating to Exercise Summaries and material ( ) Data relates to UK clinical laboratories (including Republic of Ireland). Detailed results are not shown for non-uk laboratories as this group is so large and disparate; however, the overall error rates for UK and non-uk are shown in section 5. Antibody titres quoted are those obtained in the UK NEQAS laboratory on the closing date, by LISS tube IAT, against red cells bearing heterozygous expression of the relevant antigen, unless otherwise stated. Errors and return rates reported may include late results, and any amendments made following appeals. Each patient whole blood sample comprises a pool of four or five donations, which may be whole blood or red cells to which ABO compatible FFP and Alsever s has been added. Each patient plasma sample comprises a pool of ABO compatible plasma, some of which contain red cell antibodies. Each donor sample comprises a single red cell donation, diluted in modified Alsever s solution to a red cell concentration of 7-10%. Preparation of the plasma pools and donor samples is subcontracted to the NHS Blood and Transplant Reagents Unit, although this material may also be prepared or further manipulated within the UK NEQAS Unit. Page 4 of 69

8 4.3 12R1 Patient 1: B D pos, inert Patient 2: A D pos, anti-c (titre 16) Patient 3: AB D pos, inert Donor W: A D pos, R 2 R 2, Fy(a+b+) Donor Y: A D pos, R 1 R 1, Fy(a+b-) Donor Z: A D pos, R 1 r, Fy(a-b+) Return rate: 98.8%. Errors ABO/D typing One D typing error during transcription to website. Antibody Screening: no errors. Antibody Identification: No ID errors. Four UI submissions all unnecessary as non-exclusion of antibodies to low frequency/low clinical significance antigens. Crossmatching All detected the ABO incompatibilities. Two laboratories missed both incompatibilities due to anti-c: o one used the whole blood samples by mistake o one tested manually and could not identify a cause. Four laboratories transposed donor results during manual testing (n=3) or when transcribing results from an automation printout to a worksheet (n=1), resulting in 4 missed incompatibilities and 4 missed compatibilities. Two laboratories made transcription errors at web entry, resulting in one missed incompatibility and one missed compatibility. One laboratory deselected donor Y for Patient 2. Phenotyping (and interpretation of probable Rh genotype) One laboratory transposed donor results. Five others recorded 5 false positive and 2 false negative results E2 Patient 1: Patient 2: Patient 3: Patient 4: Anti-E+Jk b (titre 16 and 8 respectively) Anti-K+Jk b (titre 4 and 8 respectively) Inert Inert Return rate: 99.2% Transcription errors during web-entry One laboratory transposed results for all samples, reporting Patients 1 and 2 as 3 and 4, and vice versa. One laboratory reported anti-jk a in place of anti-jk b for both samples and another for Patient 1 only. Two laboratories reported anti-c ±E, instead of anti-e. Other errors Antibody Screening: No further errors Page 5 of 69

9 Antibody Identification Two laboratories did not report the presence of anti-e, but said that they could not exclude it. Fourteen did not report the presence of anti-k: o 7 laboratories reported that they were unable to exclude anti-k (but did not make a UI submission) o in 3 cases the anti-k was totally masked and the participants were unaware o in 3 cases a positive reaction with a Jk(b-) K+ screen cell was overlooked o one laboratory reported anti-lu a instead of anti-k where the Lu(a+) cell was also K E3 Patient 1: Inert Patient 2: Anti-c+Fy a (titre 8 and 4) Patient 3: Anti-Fy a (titre 4) Patient 4: Inert Return rate: 99.5%. Errors Antibody screening: One false negative, probably due to data entry error. One false positive, with a weak positive reaction recorded. Antibody identification Patient 2 (no errors for Patient 3) One laboratory reported anti-c±e without recording the potential presence of anti-fy a. Three reported anti-e, presumably due to data entry error. Seventeen UI submissions were agreed. One UI submission was not agreed. Five reported anti-fy a as not being excluded but did not make UI submissions R4 Patient 1: A D neg, DAT pos 1, anti-s+ens 2 (titre 4) Patient 2: O D pos, Inert Patient 3: AB D neg, inert 1 Red cells coated with anti-c 2 Enzyme non-specific Donor W: O rr, Ss, Jk(a-b+) Donor Y: O rr, Ss, Jk(a+b-) Donor Z: O rr, SS, Jk(a+b+) Return rate: 99.8%. Performance monitoring D negative or UI were acceptable results for Patient 1. Anti-S or anti-s+ens were acceptable results for Patient 1. Transposition/transcription errors One laboratory transposed samples during manual testing causing two ABO and D errors. One laboratory transposed samples Y and Z, resulting in two incorrect Jk b types. Four laboratories made data entry errors onto the website, resulting in two false positive D types and two missed incompatibilities. Page 6 of 69

10 Other Errors ABO/D typing One laboratory reported UI for P3, due to strong positive results in the reverse group. This was probably due to the use of the separate plasma sample (provided for antibody screening and crossmatching) instead of the whole blood sample for reverse grouping. D typing of DAT positive sample One laboratory reported Patient 1 as D variant, having recorded a mixed field reaction with the anti-d and the control reagent in BioVue, and negative reactions with tube; the participant stated that D variant would not have been reported had this been a clinical sample. A further 47 (12%) laboratories, representing 46% of BioVue users, recorded a positive reaction with the anti-d reagent, and all but 2 also recorded a positive control. However, all of these correctly made an interpretation of D negative or UI. Antibody identification One laboratory reported a second specificity not actually present (anti-k) One missed the anti-s, reporting anti-e+ens Two reported anti-s+ui: o one made no UI submission o one UI submission was not agreed. Seven UI submissions were agreed. The presence of the ENS antibody was recorded by 42% of laboratories. Crossmatching: One laboratory de-selected all three donors for Patient 3. One reported a false positive reaction by IAT. Phenotyping: Four laboratories made five errors using manual techniques: o one false positive was probably due to the use of an incorrect centrifuge speed o 2 were probable misinterpretations or mis-recording of manual results o one obtained only weakly positive reaction in a manual tube technique and reported the unlikely result of Jk(a-b-). Exercise Comments Although 46% of BioVue users reported a false positive reaction with their anti-d reagent, only one laboratory misinterpreted the D type of the rr DAT positive sample (coated with anti-c). Two laboratories made the same interpretation error with a similar sample in 10R4 and ten made the same error in 09R7.This suggests that the educational efforts of the Scheme and of Ortho Clinical Diagnostics are having a positive effect E5 Patient 1: Inert Patient 2: Anti-D (titre 4) Patient 3: Inert Patient 4: Anti-K+C w (titre 4 for both) Return rate: 98.0%. Page 7 of 69

11 Performance monitoring As there is no requirement to detect anti-c w in the antibody screen or to exclude it when undertaking antibody identification (where all positive reactions have been accounted for), anti-k and anti-k+c w were both acceptable results for Patient 4. Errors Antibody screening: no errors. Antibody identification Patient 2 Six laboratories incorrectly reported anti-d+c w. A further seven UI submissions were received from laboratories unable to exclude anti-c w. Patient 4 Nine laboratories reported anti-k alone, but these were not classed as errors E6 Patient 1: Inert Patient 2: Anti-c (titre 4)* Patient 3: Inert Patient 4: Anti-c (titre 4)* *These were prepared from the same pool a red cell phenotype was provided for Patient 2 but not Patient 4. Return rate: 97.8% Errors Antibody screening: None. Antibody identification There were no errors in identification, however: Six participants reported anti-c+ui for both Patients 2 and 4, being unable to exclude antibodies to low frequency and/or low clinical significance antigens. A further five had problems with Patient 4 (no phenotype provided): o one could not exclude anti-fy a (excluded for Patient 2 based on phenotype provided) o 4 were not prepared to submit an interpretation without a phenotype. Exercise Comments Theoretical red cell phenotypes were only provided for one of the two identical samples containing anti-c, in order to assess the difference in antibody identification interpretation depending on whether or not a phenotype is available to help in excluding additional specificities. The exercise instructions stated that patients 3 and 4 had been recently transfused so phenotypes were unavailable. The effect on interpretation of anti-c was minimal, with only one participant unable to exclude anti-fy a in sample 4. However, a further 4 were not prepared to submit any interpretation, despite the fact that this is a realistic clinical scenario. Discussion at a subsequent Steering Committee meeting regarding future exercises, focussed on the scheme providing a phenotype where many of the reactions are mixed field to reflect a recently transfused patient, rather than not providing any phenotype at all. Page 8 of 69

12 4.9 12R7 Patient 1: B D neg, DAT neg, inert Patient 2: O D pos, DAT neg, anti-m+fy a (titre 8 and 4) Patient 3: A D pos, inert, DAT 2+ positive* *Cells coated with anti-c by the supplier Donor W: O r r, MN,Fy(a-b+) Donor Y: O R 1 r, NN, Fy(a+b+) Donor Z: O R 2 R 2, NN, Fy(a-b+) Return rate: 99.0% Performance monitoring UI was an acceptable result for ABO and D typing for Patient 3. P1 (D negative) was withdrawn from scoring for crossmatching because 28 laboratories in the UK and many overseas deselected the D positive donors. Transposition/transcription errors One laboratory transposed samples 1 and 2 during labelling resulting in ABO/D errors. One laboratory reported a false positive screen due to transcription error at data entry. Two laboratories transposed donors W and Z during web data entry. Three missed compatibilities due to probable transcription error. Eight laboratories reported incorrect Rh phenotypes, probably due to transcription error. One laboratory appeared to have transposed either samples or results causing phenotyping errors. Other errors ABO/D typing One laboratory reported P1 as group A due to misinterpretation of the reactions in a manual system. 6% reported the ABO and D type as UI for the DAT positive sample and another 1% reported group A but UI for the D type: o all used BioVue and recorded a positive or mixed field reaction with the reagent control. Antibody Screening: none Antibody Identification Four laboratories made ID errors: o one reported anti-m only, being unaware of the anti-fy a, which was masked by the anti-m o one reported anti-s+fy a ; having overlooked the possibility of anti-m, they selected Fy(a-) S+ cells which were also M+, to confirm the presence of anti-s o one reported anti-k+fy a in retrospect, positive reactions were noted with Fy(a-) K- cells o one made a UI submission, which was not agreed o 4 other UI submissions were agreed. Crossmatching One laboratory missed both incompatibilities and one compatibility. This was not repeatable and no cause has been established. A further ten laboratories recorded false positive reactions. Two laboratories deselected all three donors for Patient 3. Phenotyping Twelve laboratories made errors, including 10 false positives for e typing. There were 11 sets of correct serological reactions with incorrect Rh shorthand interpretations. Page 9 of 69

13 Results of DAT testing 62% returned a DAT result for Patient 1 and 63% for Patient 2; all reported these as D negative. 68% reported a result for P3: o 5/276 (2%) recorded an incorrect result of DAT negative. Exercise Comments The results suggest that the positive DAT sample was stable, although there was no further information available from the five laboratories who reported Patient 3 as D negative E8 Patient 1: Anti-E+Fy a (titre 4 for both) Patient 2: Anti-D standard Patient 3: Anti-D (titre 1) Patient 4: Inert Return rate: 99.5% Antibody screening Two laboratories made errors: o one false negative due to transcription error at web entry o one, non-repeatable, false negative for P2 (Standard anti-d) using LISS tube technique, cause unknown. Antibody Identification Five laboratories made either transcription or data entry errors. Three laboratories reported an additional anti-c w in samples 2 and 3. One UI submission (unable to exclude anti-c W ) was agreed R9 Patient 1 - A D negative, inert Patient 2 - A D positive, anti-c+k (titre 16 and 32) Patient 3 - B D positive, inert Donor W O rr, K-, S+s- Donor Y O rr, K+, S+s+ Donor Z O rr, K+, S-s+ Return rate: 98.8%. Transposition/transcription errors One laboratory transposed samples 2 and 3 during labelling, accounting for two incorrect ABO groups. One laboratory reported all three donors as compatible with Patient 2; this was likely to be due to web data entry error as the reaction grades recorded were correct. One laboratory transposed results for donors W and Z, resulting in two false positive and two false negative phenotypes. Other errors ABO/D typing: none Antibody Screening: none Page 10 of 69

14 Antibody Identification Ten laboratories made incorrect or incomplete submissions: o 2 reported anti-c+s due to misinterpretation, with one not taking the screening panel results into account o 7 could not exclude anti-k (or in one case also anti-c) but did not make UI submissions o one made a UI submission that was not agreed. Eleven made UI submissions which were agreed. Crossmatching One laboratory deselected all three donors for Patients 1 and 3. One deselected donor W for Patient 3. Two recorded false positive reactions. Phenotyping Four laboratories recorded two false positive and four false negative reactions. Fifty-three laboratories had no anti-s reagent and 66 no anti-s E10 Patient 1: Patient 2: Patient 3: Patient 4: Anti-C+D (titre 16 for both) Anti-E+Jk b (titre 8 and 16 respectively) Inert Inert Return rate: 98.2% Errors Antibody screening: None Antibody identification One laboratory transposed the results for Patients 1 and 2 whilst recording reactions onto the panel sheets. One laboratory did not record the potential presence of anti-c. Seven laboratories reported anti-jk b as a single specificity: o 4 were aware that anti-e could not be excluded but did not make a UI submission o 3 did not record the potential presence of anti-e. Three laboratories made UI submissions, two of which were agreed R1 Patient 1: A D pos, inert Patient 2: O D MF (50:50 D pos and D neg), inert Patient 3: A D neg, anti-jk b (titre 4) Exercise format This was an emergency exercise, with instructions to select donations from stock. Request forms were provided, indicating that 2 units of red cells were required from stock within 10 minutes for Patients 1 and 2 (young females), and requesting a group and screen for Patient 3, in an out-ofhours scenario. Emergency results were input into SurveyMonkey questionnaires and final results were input through the usual web reporting systems and scored as usual for ABO/D, antibody screening and antibody identification. Full details can be found in Appendix 7. Return rate: 98.5%. Page 11 of 69

15 Errors ABO/D typing One laboratory reported Patient 2 as group A due to transcription error. Another laboratory reported Patient 1 as D variant based on an initial negative reaction with a rapid anti-d reagent by tube; this was followed by a strong positive reaction by routine testing and, due to the discrepancy, was confirmed by using the original rapid reagent in a non-validated tile technique and observing a weak positive reaction. On investigation postclosing it was noted that this reagent was not working properly. Group A UI was reported for Patient 3 by a laboratory that recorded a negative reaction with two routine anti-d reagents but a weak positive with a confirmatory reagent. One laboratory recorded UI for P3 when the automation did not give a group. Antibody Screening: One laboratory reported a false positive screen, due to data entry error. Antibody Identification: Four laboratories reported anti-jk b plus an additional specificity not actually present (C, K, Lea, Kp a ). One reported anti-jk a, presumably due to ticking the wrong box. Five made UI submissions (anti-jk b + UI), four of which were agreed. D typing of patient 2 (mixed field D positive/d negative) The reaction grades and interpretations are summarised in table 4. Table 4 reaction grade with anti-d vs. interpretation of D type Reaction grade Interpretation with anti-d D UI D positive D variant D negative Total Includes a MF (41%) Includes a weak 1 positive (6%) Strong positive only (53%) 1 but does not include a MF It is notable that of the 41% who recorded a MF reaction, 25% of these made an interpretation of D positive or D variant A summary of the interpretations and technology used is shown in table 5 and the photographs in figures 1 and 2 show the in-house results for the mixed field reaction with a DiaMed card and a BioVue cassette, respectively. Table 5 detection of mixed field reaction vs. Technology used Primary technique Number users % recorded MF for first anti-d reagent DiaMed % BioVue 151 9% Tube % Grifols 46 63% LPM (inc Capture) 42 24% Other 29 24% Solid phase (inc SS) 4 0% Page 12 of 69

16 Figure 1 mixed field reaction with DiaMed for 13R1 In house grouping (using recommended methods starting with 12.5 µl and 10 µl packed cells) Figure 2 mixed field reaction with BioVue for 13R1 In house grouping results (using recommended methods starting with 1% and with 0.8% cell suspensions) Page 13 of 69

17 Exercise comments It was of concern that a female patient of child bearing potential with anomalous D typing results and no clinical and/or transfusion history was reported as D positive or D variant by 25% of laboratories who reported the dual population of red cells. The full report for the emergency testing part of the exercise is shown in Appendix E2 Patient 1: Anti-c+K (anti-c titre: 4 vs r r cells, anti-k titre 8) Patient 2: Inert Patient 3: Inert Patient 4: Anti-c (titre 2 vs R 2 R 2 cells not detectable vs. r r cells) Return rate: 98.5%. Transposition and transcription errors: One laboratory transposed the results for Patients 1 and 4 at data entry. Another reported anti-e+k, presumably due to ticking the wrong box. Other errors Antibody Screening: None. Antibody Identification Patient 1 Seven laboratories reported anti-c plus an incorrect specificity: o only one said they could not exclude anti-k. Two reported anti-c only: o one did not mention anti-k o one said anti-k could not be excluded but did not make a UI submission. Fourteen reported anti-c+ui: o one recorded that anti-c could not be excluded but did not make a UI submission. o 13 made UI submissions, 12 of which were agreed, with the majority being unable to differentiate between anti-k and anti-jk a. Patient 4 Four laboratories reported anti-c plus an additional specificity not actually present. One made a UI submission which was agreed. Page 14 of 69

18 E3 Patient 1: Patient 2: Patient 3: Patient 4: Inert Anti-C+D (titre 16 and 8, respectively) Inert Anti-D+K (titre 16 and 4, respectively) Return rate: 98.5%. Errors Antibody screening: None. Antibody identification One laboratory reported anti-d as a single specificity for Patient 2, with no mention of anti-c, having overlooked a positive reaction with an r r cell, positioned immediately after the 3 D+ cells on the identification panel. Two laboratories reported anti-d as a single specificity for Patient 4, with no mention of anti- K. Both had recorded a positive reaction with a D-K+ cell: o one omitted to transcribe this reaction from the automated printout to the panel profile sheet o in the other case, it is likely that the interpretation was made on the basis of the enzyme panel alone R4 Patient 1: O D VI, inert Patient 2: A D pos, anti-jk b (titre 4) Patient 3: B D pos, inert Donor W: O rr, Jk(a+b+). Fy(a-b+) Donor Y: same pool as donor W Donor Z: same pool as donor W Return rate: 98.0%. Performance monitoring Results of D negative, UI and D variant were accepted as correct for Patient 1. D typing of the DVI patient Seven laboratories recorded a positive reaction with an anti-d reagent (five reference laboratories and two non-reference laboratories). Five reported an interpretation of D variant, one UI, and one D negative. Transposition/transcription errors One laboratory transposed results for Patients 1 and 3 whilst transcribing data from an analyser printout to data entry forms this does not reflect their clinical practice. A second laboratory recorded a weak reaction between Patient 2 and all 3 donors, but made an interpretation of compatible for Donor Y, presumably due to data entry error. A third laboratory reported one false positive crossmatch result, again probably due to data entry error. Other errors Antibody screening: None. Antibody identification Two laboratories reported an additional antibody not actually present (anti-k and anti-kpa). Two UI submissions were agreed. Page 15 of 69

19 Crossmatching 332/347 (96%) of those who recorded reaction grades, recorded the same strength of reaction against all three (identical) donors. Phenotyping One laboratory recorded all 3 donors as Fy(a+b-), instead of Fy(a-b+). Exercise Comments It was notable that two non-reference laboratories in the UK used anti-d typing reagents that detect DVI, which is outwith BCSH guidelines for routine patient testing 1. One of these made an interpretation of D variant and the other UI E5 Patient 1: Inert Patient 2: Anti-s (titre 4) Patient 3: Anti-K+Fy a (titre 32 and 2 respectively)* Patient 4: Inert *This plasma contained a contaminating anti-jk a reacting weakly by enzyme IAT only. This was confirmed by the supplier on retrospective testing of the individual donations. It was reported by 2 reference laboratories but did not affect the results submitted. Return rate: 98.7%. Errors Antibody screening: None. Antibody identification Patient 2 All laboratories reported the anti-s. Four reported an additional antibody not actually present (anti-c, -E, -N, -Jkb). Eight made UI submissions of which four were agreed. One reported anti-s+ui but did not make a UI submission. Patient 4 One laboratory reported anti-k+ui, but the UI submission was not agreed as anti-fy a could be identified. Exercise Comments Several users of Immucor Capture reported non-specific reaction in Patient 2. The majority reported anti-s following further testing by a different technique, but two reported anti-s+ui. UK NEQAS inhouse testing, using manual Capture, did not find any non-specific reactions. Page 16 of 69

20 E6 Patient 1: Patient 2: Patient 3: Patient 4: Anti-D+Jk b (titre 32 and 8 respectively) Anti-E+Fy a (titre 4 and 8 respectively) phenotype MF for C, E, M, N, Le b, Jk b Inert phenotype mixed field (MF) for several antigens Inert Return rate 99.5%. Errors Antibody screening: None. Antibody identification Patient 1 One laboratory reported anti-e+jkb due to misinterpretation and no systematic process for exclusion. One laboratory reported anti-d, with anti-jkb + other specificities as not excluded, but did not make a UI submission. One UI submission was not agreed as the anti-jkb could have been identified. Antibody identification Patient 2 (MF E) Three laboratories reported anti-fy a alone: o One was unable to exclude anti-e but did not make a UI submission o 2 missed the anti-e which was masked. Neither used an enzyme panel, although had one available. Outcome of providing patient phenotypes as mixed field Participants had no problems excluding additional specificities, but a few contacted the scheme to say they could not distinguish between allo- and auto-anti-e. Given that the result sheets do not specify allo or autoantibodies, participants were advised to report the specificity regardless. The patient auto result has since been added to the phenotype information provided for E exercises R7 Patient 1: B D pos, inert Patient 2: O D pos, anti-s (titre 4) Patient 3: AB D pos, inert Donor W: O D pos, Ss, Jk(a-b+) Donor Y: A D pos, ss, Jk(a+b-) Donor Z: O D pos, SS Jk(a+b+) Return rate 99.8%. Transposition/transcription errors One laboratory reported Patient 2 as D negative due to transcription error at data entry on website. Three laboratories reported Patient 2 vs. donor Z as compatible, two presumably due to data entry error and the 3 rd due to confirmed transcription error. Other errors ABO/D typing: None. Antibody Screening: None. Antibody identification Two laboratories reported anti-s plus a second specificity not actually present. Three UI submissions were not agreed as they were due to non-specific positive reactions in Capture. Page 17 of 69

21 Crossmatching Two laboratories missed the incompatibility between the anti-s and Donor W (Ss). Both found it positive on repeat: o one, using manual BioVue, suspected that the red cell concentration used was too low (<0.8%) o one, using automated DiaMed, found a stronger reaction on repeat with manual testing. One laboratory deselected Donor Y for Patient 3. Phenotyping Eight laboratories recorded three false positive and ten false negative results: o two of these may have transposed results. Forty laboratories did not have either reagent available, and a further seven had no anti-jk b. Exercise Comments Outcome re Capture non-specific reactions in Patient 2 (anti-s) Two Capture users phoned before the closing date about non-specific reactions in the sample containing anti-s. They were requested to report in the same way as they would for a clinical sample; both reported anti-s alone. It is not known if all Capture users found these non-specific reactions. In-house testing using a manual Capture technique did not detect non-specific reactions. Discussions with representatives from Immucor concluded that there are several differences between the manual and automated techniques, including centrifugation, the order in which the reagents are added, and the washing phase; however, it is unclear whether any of these variations are the cause of the differences in reactions seen between UK NEQAS in-house manual testing and automated testing by participants E8 Patient 1: Patient 2: Patient 3: Patient 4: Anti-C+D (titre 16 and 8 respectively) Anti-c+K (titre 2 and >32 respectively) Inert Inert Return rate: 99.0%. Errors Antibody screening: One laboratory reported a false positive result, presumably due to data entry error. Antibody ID: One laboratory did not record the presence of the anti-c in Patient 1, having overlooked the positive reaction with an r r cell, which was positioned directly following three D positive cells on the identification panel. Two laboratories reported anti-c only in Patient 2: o one reported that anti-k (and anti-fy a ) could not be excluded but did not make a UI submission (retrospective UI submission was not agreed as anti-fy a could be excluded and anti-k identified) o one did not record the presence of anti-k. One of three initial UI submissions was not agreed, as anti-c could have been identified. Page 18 of 69

22 R9 Patient 1 - A D pos, anti-wr a (titre 8) Patient 2 - O D pos, anti-jk b (titre 2) Patient 3 - AB D neg, inert Donor W O D neg, Wr(a-), Jk(a-b+) Donor Y O D pos, Wr(a+), Jk(a+b+) Donor Z A D neg, Wr(a-), Jk(a+b-) Return rate: 99.3%. Aim: this exercise was designed to assess the sensitivity of the IAT crossmatch. In order to achieve this and to prevent de-selection of antigen negative donors, the scenario was given where there is insufficient time to identify antibodies or select antigen negative units, with instructions that a serological crossmatch should be undertaken. Anti-Wr a was selected as it is unlikely to be detected in the antibody screen. Problems with exercise and performance monitoring Several laboratories reported Donor Y as compatible with Patient 1, having ticked to say that a serological crossmatch had been performed, but having not recorded any reaction grade for the IAT. At least one of these had done a DRT crossmatch only, as they would do in clinical practice. It was assumed that at least some of the other laboratories had done the same. The instructions stated that a serological crossmatch should be done, but did not specify an IAT crossmatch. Patient 1 was therefore withdrawn from scoring for crossmatching. Patient 1 was also not scored for screening as detection of anti-wr a is dependent on profile of screening cells. Contrary to the instructions, many laboratories de-selected donor Y for Patient 3 because of the D incompatibility. Patient 3 was therefore withdrawn from scoring. Errors ABO/D typing One laboratory recorded weak anomalous reactions in the reverse groups for Patients 1 and 3 by automated DiaMed and was therefore unable to interpret the ABO groups. The same reactions were seen on repeat and the cause remains unknown. Antibody screening One laboratory tested the whole blood sample (supplied for grouping only) instead of the separate plasma sample, so did not detect the anti-jk b. Crossmatching Twenty-two laboratories missed the incompatibility due to anti-wr a (not scored): o 5 recorded a negative reaction by IAT (two due to donor cell transposition) o one used EI o 15 did not record a reaction for the IAT (it has been assumed they did not include an IAT). Three laboratories missed the anti-jk b against both donors W and Y: o one was due to data entry error o one had problems preparing the cell suspension for use on the Gelstation, but obtained a positive reaction on repeat even with original cell suspension. o one used a reduced incubation time in a manual DiaMed technique, but obtained a positive reaction on repeat even with the non-standard 10 minute incubation time. Nine laboratories missed the anti-jk b vs donor Y only: o 7 used a BLISS addition technique (64% vs 27% of BioVue users overall) o 2 used manual DiaMed with no cause established. Exercise comments Ortho Clinical Diagnostics (OCD) provide validated procedures for crossmatching by both suspension and addition methods for manual and automated testing. However, OCD advised the Page 19 of 69

23 Scheme that the suspension method using 0.8% red cell diluents has a higher sensitivity than the addition method using 3-5% cells and BLISS E10 Patient 1: Anti-D UK NEQAS standard Patient 2: Anti-K+Fy a (titre both 4) Patient 3: Inert Patient 4: Inert Return rate: 98.7%. Errors Antibody screening: No errors (100% detection of the standard anti-d). Antibody identification: Five laboratories reported the presence of an additional specificity in Patient 1 that was not actually present (four anti-cw; one anti-k). One laboratory misidentified Patient 2 as anti-c+fya and did not record the potential presence of anti-k. One laboratory reported anti-fya only, with anti-k as not excluded, but they did not make a UI submission. Exercise comments Analysis of the reaction grade by technique for the standard anti-d revealed that 51/364 (14%) of laboratories appeared to have undertaken antibody screening more than once, i.e. they ticked two different techniques, or the same technique but by both manual and automated methods. EQA samples should be tested to the same level as equivalent clinical samples before results are submitted, to ensure that EQA results reflect clinical practice. 5. SUMMARY OF ERROR RATES The error rate is based on the number of opportunities for error by all participants returning results. Figures shown in brackets following the error rate for UK laboratories are the percentages known to be due to transcription or transposition errors (Tx). This information is not available for non-uk laboratories, as these participants are not contacted regarding errors made. Tables 6 and 7 compare error rates over the last four years for UK and non-uk participants respectively, where n = the number of tests distributed in each category, that were suitable for scoring; e.g. there were 12 samples (suitable for scoring) distributed for ABO grouping during 2012, but only 11 during The data for 2010 was for the financial year covering exercises 09R4 to 10E3; subsequently, data for each calendar year is displayed. Page 20 of 69

24 Table 6 Error Rates by Test Test 2013 (13R1 13E10) 2012 (12R1 12E10) 2011 (11R1 11E10) 2010 (09R4 10E3) n error rate (%Tx) n error rate (%Tx) n error rate (%Tx) n error rate (%Tx) ABO (40%) (88%) (92%) (78%) D (50%) (88%) (91%) (23%) 1 False Neg Ab Screen False Pos Ab Screen (100%) (80%) (89%) (21%) (100%) (75%) (67%) (83%) ABID (single) (34%) (27%) (36%) (44%) ABID (dual) 9 0.9% (7%) (25%) (29%) (11%) Missed Incompatibility Missed Compatibility False Pos Phenotyping False Neg Phenotyping (24%) (78%) (18%) (62%) (50%) (18%) (33%) (50%) (83%) (24%) (11%) (58%) (38%) (44%) (8%) (44%) 1 Includes one or more DAT positive sample. Table 7 - Non-UK error rates Test (13R1 13E10) (12R1 12E10) (11R1 11E10) (09R4 10E3) n error rate n error rate n error rate n error rate ABO D False Neg Ab Screen False Pos Ab Screen ABID (single) ABID (dual) Missed Incompatibility Missed Compatibility False Pos Phenotyping False Neg Phenotyping 1 Includes one or more DAT positive sample Page 21 of 69

25 6. LEARNING POINTS FROM EXERCISE RESULTS Table 8 Learning points Issue Exercise(s) Learning point ABO/D Grouping Making ABO/D interpretations based on mixed field reactions Manual testing systems Interpretation of D type based on a weak reaction with an anti-d reagent Interpretation of D type in the presence of a positive reaction with a reagent control Adequate controls for rapid grouping reagents Antibody Identification Recognition that an additional specificity may be masked in an antibody mixture Use of screening panel results and phenotype when interpreting ID results Positive reactions not accounted for by the specificity already identified. Inclusion of an enzyme panel Positively identifying antibodies not actually present Antibodies of low clinical significance and to low frequency antigens Procedure for recording and interpreting ID results 12R4 13R1 12R7 13R1 12R4 13R1 12E2; 12E3 12R7; 12E10 13E2; 13E6 13E8 12R9 A mixed field D typing reaction might be due to a D negative patient being transfused D positive blood, and no interpretation should be made until the cause of the anomaly can be confirmed. SHOT reports show that ABO grouping errors all occur in manual test systems or during manual intervention in automated systems. Full automation should be used where possible and where this is not possible, systems should be in place to minimise the risk of error. An interpretation of D positive should not be made on the basis of a weak positive result with a single anti-d reagent where no patient details are provided. BCSH guidelines recommend further investigation, with an interim interpretation of D negative, for female patients of child bearing potential or any patient likely to require regular transfusion. Where a reagent control gives a positive reaction the test is invalidated regardless of the strength of reaction relative to anti-d reagent(s), and no interpretation should be made until the D status has been confirmed using saline reacting monoclonal anti-d reagents. Rapid grouping is particularly high risk as the testing and reporting is manual, and the reagents may be infrequently used. The use of adequate controls is essential. When interpreting antibody identification results it is vital that the presence of additional clinically significant antibodies is systematically excluded, and that all positive reactions are accounted for before a final interpretation is made. When interpreting antibody identification results all available information should be taken into account, including patient phenotype, differential reaction by technique, and results of all cells tested (including the screening panel). 12E2; 13E3 Where reactions in the screen and/or panel cannot be attributed to the antibody(ies) already positively identified, it is essential to investigate the potential presence of other antibodies (regardless of clinical significance), in order to safely complete the antibody identification process. Accounting for all reactions will cover the possibility of error in the initial identification, ensure that all clinically significant antibodies are identified, and prevent unexpected problems in crossmatching should the patient require transfusion. 13E6 An enzyme technique can be an invaluable part of the antibody identification process, particularly where there is a mixture of antibodies or where weak Rh or 12E5; 12R7; 13R1; 13E2; 13R4; 13E5; 13R7; 13E10 12R1; 12E5 12E8; 13E2 13R4 Phenotyping, crossmatching and general areas Kidd antibodies require confirmation or need to be excluded. The specificity of an antibody should only be assigned when it is reactive with at least two examples of reagent red cells carrying the antigen and non-reactive with at least two examples of reagent red cells lacking the antigen. This rule applies independently to each antibody specificity potentially present in an antibody mixture, including those considered of unlikely clinical significance. Once all reactions in the identification and screening panel have been accounted for by the presence of antibodies already identified, there is no need to exclude antibodies of low clinical significance or those directed against low frequency antigens. 12E10; 13E3 Interpretation and documentation of antibody identification results is an errorprone manual process, and this should be considered when establishing procedures for reporting antibody identification for both clinical and EQA samples. Equipment maintenance 12R4 Laboratory equipment should be regularly calibrated and maintained, to avoid suboptimal testing (in this case incorrect centrifugation speed). Rare phenotypes 12R4 Where particularly rare phenotypes are found, tests should be repeated and Preparation of EQA samples for use 13R7 controls checks for validity. EQA samples should be appropriately prepared for use in the required test system. In this example, red cells in Alsever s (7-10%) were used directly in an automated system for crossmatching but were much too weak, and consequently the antibody was not detected. Page 22 of 69

26 7. SCHEME DEVELOPMENT AND QUALITY INDICATORS 7.1 Accreditation Unconditional CPA accreditation of the Scheme has been maintained with the most recent being in July The Scheme will be inspected by UKAS to ISO17043 standards from IT and communications By December 2013, 99% of UK and 95% of non-uk laboratories had taken advantage of web-based entry of results and receipt of reports. There were only four UK laboratories who were still returning results on paper (compared with 13 in 2012). Following 2013/14 re-registration, we wrote to all UK laboratories who were still receiving paper reports for either BTLP and/or FMH and encouraged them to register for the web. The scheme no longer offers a paper-based service to new participants and has decided to give notice in the 2014/15 re-registration newsletter that this option will no longer be available to existing participants from April Significant progress has been made with development of a new information website during 2013 and this will be launched in UI Submissions A total 134 UI submissions were received during this two year review period, 129 from the UK (including Ireland) and five from outside of the UK. On review of the panel sheets and explanations, the Scheme agreed with 112 submissions (84%) and disagreed with 22 (16%). Appendix 2 lists all the UI submissions, and provides further details on the 22 where there was no agreement; the current version of the Rules are in appendix 3. This data will be continue to be reviewed. 7.4 ABO titration Pilot The ABO titration pilot continued during 2012 and Participation increased by 10% during 2013, from 68 to 75 participants. All plasma samples were sent undiluted and covered a range of titration values, including duplicates, and a replicate sample distributed in sequential exericses. The results show a wide variation in practice, and a wide range of results within all techniques, including the standard. The annual report for 2012/13 can be found in Appendix 4. The scheme has been working with NIBSC to develop reference preparations for anti-a and anti-b to support the programme, and the first part of the validation has been undertaken. WHO has agreed the project, which allows for the reference preparations to be developed as international standards. 7.5 Point of care D typing In early 2012, the Scheme started a collaboration with one of the organisations providing a service for termination of pregnancy, where women are given prophylactic anti-d based on results from a commercial tile-based D typing kit at the client s side in the clinic. Testing and recording of results is all manual, and venous samples are taken following equivocal results and referred to a hospital laboratory for confirmatory testing. 49 clinics registered in the scheme in April 2012, and there was a 15% increase in participation in During 2013, the scheme distributed two anomalous D types: a 50:50 Dpos/Dneg mixed field and partial DVI. 7.6 Simulated whole blood samples Simulated whole blood samples are currently under development. The aim is to reduce haemolysis and allow the addition of the alloantibody to the whole blood sample for grouping and screening. Following a review of previous experiments and observations, the first phase of the trial took place in 2013, where testing was undertaken using anti-d. The next phase of the trial will take place in early 2014, using different antibody specificities, and will include testing using automated technologies, with the help of steering committee members. Page 23 of 69

27 7.7 Direct Antiglobulin Test (DAT) Plans to pilot EQA for the DAT have been postponed because the supplier of the material was unable to meet our requirements. We are now working with a different supplier and hope to undertake the pilot in On-line competency assessment scheme During the last two years, the Scheme has been developing a an on-line competency assessment scheme, called TACT (Training, Assessment and Competency Tool). An IT company (Certus Technology Associates Ltd) has been engaged to help deliver the core interactive web-based scheme during TACT will generate transfusion scenarios that can be accessed 24/7/365. The scenarios will challenge staff in a number of critical areas, e.g. sample and request acceptance, ABO and RhD interpretation, antibody screen and identification, component selection and compatibility processes. Selected, yet controlled random elements within the scenario generation process, will help to enhance the participation experience by eliminating predictability. Laboratory managers will have a constant link to the activities of their staff members within TACT and be able to use the system to complement their own internal training and competency schemes. TACT will incorporate automatic assessment based on BCSH guidance and the opportunity for managers to review scenarios with staff against local practices. Staff will be able to build a portfolio of activity which will allocate them a current competency rating based on their performance in the different categories being assessed. Activities attempted / completed within TACT may be used as CPD evidence and be transferred across employing organisations when moving jobs. Currently, a repository of scenarios is being created and the logistics of the automated assessment mechanism is being configured for pilot testing in Spring Once launched, and in order to keep TACT at the forefront of laboratory training and competency assessment activities, we intend to continually develop and enhance TACT with subscriber uptake dictating the rate of that development. 7.9 Pilot Scheme for red cell genotyping A pilot scheme for red cell genotyping is in the early stages of development and we are collaborating with the International Blood Group Reference Laboratory and the Chair of the International Society for Blood Transfusion Working Group on red cell genotyping. There were two meetings in 2013, to discuss implementation and development of this pilot scheme. A pre-pilot exercise, in collaboration with ISBT, is planned for April 2014, with a view to present the results at the ISBT Congress in June scheme re-design There are plans for further changes to scheme design which will follow the completion of the simulated whole blood sample project and be based on the outcomes of the Scheme Design Task Force meeting which took place in June Recommendations from the Task Force, included the following: o Assess serology and process separately. o Distribute more samples which will give anomalous ABO/D results. o o o o o Include age and gender with instructions at least some of the time. Change IT to default the interpretation to compatible for a reaction grade of negative and incompatible for a reaction grade of weak or strong positive, for crossmatching and screening. Investigate ways to increase the volume of red cells distributed for crossmatching. Collect a wider range of reaction grades for screening and crossmatching rather than weak/strong. Consider moving from 4 R (full programme) + 6 E (antibody screening and ID only) exercises a year to 6 R + additional theoretical exercises for antibody identification and process. Page 24 of 69

28 7.11 Key Performance Indicators Targets and achievement rates for key performance indicators are shown in table 9. Table 9 Combined Key Performance Indicators for 2012 and 2013 Category No. of Events Target Target Achievement Rate Actual Achievement Rate Exercise Distributions 20 On schedule 100% 100% Report Distributions 20 Complaints 23 New Unsatisfactory Performers 31 Borderline Performers 77 Reported Sample Quality Plasma Reported Sample Quality Whole Blood Samples Reported Sample Quality Red cells in Alsever s Integrity of Samples 47,950 Within 6&8 days of C/D 1 (E&R exercises respectively) Acknowledged within one week; dealt with in 4 weeks 90% 100% 70% 100% Make telephone contact 90% 84% 4 Within 5 days of C/D 1,2 80% 100% Telephone or written contact 50% 58% Within 10 days of C/D 1,2 80% 100% 69 2% unsatisfactory 24 2% unsatisfactory 21 2% unsatisfactory <0.5% unsuitable for testing (UFT) per exercise 90% of samples 90% of samples 90% of samples 90% (i.e. 9/10 exercises) 100% (mean = 0.2% USQ) 3 0% (mean = 8.1% USQ) 3,5 100% (mean = 0.8% USQ) 3 100% (mean = 0.04% UFT) 1 - C/D = Closing Date 2 - Of those contacted 3 - USQ = reported as Unsatisfactory Sample Quality 4 - KPI not met 5 UPs were not phoned as it would not have been helpful 5 - KPI not met within the UK and ROI, a target of 4% USQ would have been achieved in 100% of samples. The current target is unrealistic and will be changed following further discussion. Work is being undertaken to develop a simulated whole sample to address this issue. The whole blood samples are only used for ABO/D typing in-house testing demonstrates that haemolysis does not affect the blood grouping results. Page 25 of 69

29 8. QUESTIONNAIRES AND NON-SCORING ELEMENTS 8.1 Standard Practice questionnaire Annual standard practice questionnaires were distributed in 2012 and See Appendices 5 and 6 for reports. 8.2 Emergency Exercise 13R1 was an emergency scenario, where three patient samples and request forms were distributed for either crossmatch within minutes (against donor units from the bank) or for group and save. ABO/D grouping, antibody screening and antibody identification were assessed in the usual way, but additional information was collected through SurveyMonkey and reported at a later date. The report can be found in Appendix Anonymous questionnaire An anonymous questionnaire was distributed to all participants at the annual meeting, with the request that one person from each organisation complete and return the survey by the end of the meeting. The questionnaire asked how the EQA exercises are undertaken, with respect to the level of testing undertaken compared to clinical samples. It also asked about collaboration within and outside networks, and how the reports are used. This followed a similar questionnaire several years ago and was undertaken in light of the recent Pathology Quality Review. The results showed that 45% of respondents at least sometimes have more than one member of staff undertaking the exercise prior to submission of results, and 35% use more than one technique. 13% admitted that their submitted results are sometimes influenced by other laboratories, either within or outside of the network. The data was reported to participants in the annual newsletter in February 2014 and the relevant section is appended as Appendix 8. Page 26 of 69

30 9. TRENDS IN USE OF TECHNIQUES IN UK NEQAS EXERCISES Data prior to 2008 are taken from one exercise in each year and therefore only include laboratories returning results. Subsequent data are derived from questionnaires. Historically, questionnaire data have shown that some participants use different or additional techniques for UK NEQAS samples than for clinical samples. Abbreviations used in figures 1 LPM Liquid phase microplate CAT Column agglutination technology Figure 1 ABO/D typing technology Figure 2 IAT antibody screening technology Page 27 of 69

31 Figure 3 - Use of enzyme techniques in antibody screening Figure 4 - IAT crossmatching technology Figure 5 Means of establishing final compatibility Page 28 of 69

32 10. INFORMATION, EDUCATION AND PUBLICATIONS/PRESENTATIONS Education Annual meeting November 2012: See appendix 9 for programme details. Annual meeting November 2013: See appendix 10 for programme details. MRCPath teaching Publications Scheme Publications Abstract (Oral): Titration of IgG antibodies in pregnancy a snapshot of performance and policy in the UK. Vox Sang 2012, 103, Suppl 1. White J, Milkins C, Mavurayi A, Rowley M. Abstract (Oral): Requirement for a Knowledge-based Competency Assessment Scheme provided by UK NEQAS (BTLP). Transfusion Medicine 2012, 22, Suppl 1. White J, Chaffe B, Milkins C, Rowley M. Transfusion Medicine 2011, 21, Suppl 1. White J, Milkins C, Rowley M. Abstract (Poster): Requirement for a blood transfusion laboratory knowledge based competency assessment scheme in the UK. Vox Sang 2013, 105, Suppl 1. White J, Chafffe W, Milkins C, Rowley M. Abstract (Poster): Labelling of transfusion samples from unknown patients in emergency situations Transfusion Medicine 2013, 23, Suppl 2. White J, Milkins C, Rowley M. Grifols article: Pre-transfusion testing and transfusion guidelines in the UK published in English and Chinese (and now more recently in Japanese) Letter to the Editor: No Progress in ABO Titre Measurement: Time to Aim for a Reference? Transplantation - in press. Bentall A, Regan F, White J, Milkins C, Rowley M, Ball S, Briggs D. Scheme Representations UK NEQAS (BTLP) has been represented on, or associated with, the following committees and organisations during the two year period: BCSH Transfusion Task Force BBTS Special Interest Group for Blood Bank Technology Serious Hazards of Transfusion (SHOT) Working Expert Group and Steering Group UK Transfusion Laboratory Collaborative (as a collaborator) BGS Reading organising committee RCPath - FRCPath examinations BCSH guideline writing group for: o Specification and use of IT systems in blood transfusion practice o Pre-transfusion compatibility testing o Use of anti-d Ig for the prevention of HDFN o Blood grouping and antibody testing in pregnancy Related Publications SHOT annual report 2012, published 2013 BCSH Guidelines for pre-transfusion compatibility procedures in blood transfusion laboratories (2012). Transfusion Medicine volume 23, issue 1, pages 3-35 February 2013, and at Page 29 of 69

33 Presentations/teaching In addition to those already included in the publications section, Scheme staff made several contributions through oral presentations and teaching to many different organizations. 11. REFERENCES 1 - BCSH Guidelines for pre-transfusion compatibility procedures in blood transfusion laboratories (2012). Transfusion Medicine volume 23, issue 1, pages 3-35 February 2013, and at FINANCIAL STATEMENT Income and Expenditure Summaries for the two-year period, April 2011 to March 2013 (to the nearest 500) Income: Participant Type UK Clinical Laboratories: 611,500 Non-UK Clinical Laboratories: 383,500 Non-Clinical Laboratories: 6,000 Grand Total 1,001,000 Expenditure: Category Capital Expenditure 0 Salaries: 588,500 Revenue: 242,000 Overheads: Education/R&D (inc. books meetings etc.) Grand Total 1,001,000 Page 30 of 69

34 Appendix 1 Composition of Steering Committee at December 2013 Dr Peter Baker (Chair), Royal Liverpool University Hospital Mr Martin Maley, RCI, NHSBT, Newcastle Mrs Anna Capps-Jenner, Ealing Hospital and TDL Mr Ray Melanaphy, Northern Ireland BTS Ms Catherine Almond, Kent & Canterbury Hospital Dr Rekha Anand, NHSBT, Birmingham Dr Mallika Sekhar, Royal Free NHS Foundation Trust Vacancy Mr Malcolm James (co-opted), NHSBT Reagents, Birmingham Mrs Debbie Asher (Observer - NQAAP representative), Norfolk and Norwich University Hospital Mrs Clare Milkins (Secretary), Scheme Manager, UK NEQAS Dr Megan Rowley, Scheme Director, UK NEQAS Ms Jenny White, Deputy Scheme Manager, UK NEQAS Page 31 of 69

35 Appendix 2 Summary of Data for UI submissions January 12 to December 13 (UK and non-uk) Table 1 Details by exercise Exercise No. UI No. Antibodies No. agreed Code returns disagreed 12R1 c E2 K+Jk b E3 Fy a +c R4 S + ENS E5 D; K+C w E6 c R7 M+Fy a E8 D R9 K+c E10 E+Jk b R1 Jk b E2 K+c; c R4 Jk b E5 K+Fy a ; s E6 D+Jk b R7 S E8 K+c E10 K+Fy a Total Table 2 Reasons for disagreeing with the UI submissions Category No. submissions Could have identified the antibody with the IAT panel results submitted 11 False positive or false negative reactions recorded 6 Could have excluded additional antibody (ies) based on IAT results submitted 3 Did not consider the presence of an antibody (actually present) 2 Total 22 Page 32 of 69

36 Appendix 3 Acceptance of a result of UI for antibody identification This process should only be used where antibodies of likely clinical significance cannot be fully elucidated or excluded. N.B. UK NEQAS (BTLP) samples do not contain more than two specificities, so if you have positively identified two specificities please do not make an UI submission. The following rules apply: a. the following will incur penalties Misinterpretations contributed to by false negative or false positive reactions. If a specificity (actually present) is not entered as positively identified and we feel that it can be identified based on two positive and two negative reactions (as stated in BCSH guidelines) by whatever method is appropriate (e.g. IAT, OR enzymes in the case of Rh). This will be based on a maximum of 2 antibodies being present. (N.B: Serological reactions obtained with the antibody screening cells should be included in the interpretation). If a specificity not actually present is entered as positively identified. If a specificity is entered as cannot be excluded, but we feel that it can be excluded, either because of one or more negative reactions with an appropriate antigen positive cell, or because of one or more negative reactions by a particular method. For example, stating that an Rh antibody cannot be excluded from an antibody mixture in the presence of a negative result with an enzyme treated cell carrying the corresponding antigen would incur a penalty. If a specificity is entered as cannot be excluded, but the patient phenotype provided shows that the patient is positive for the corresponding antigen. If a clinically significant antibody is not identified in the presence of an enzyme non-specific antibody. b. the following will not incur penalties Being unable to exclude a specificity in line with BCSH guidelines. E.g. having no homozygous cell available to exclude anti-jka. Including a specificity (if actually present) even if the inclusion does not comply with BCSH guidelines (e.g. only one r r cell). If an antibody (actually present) is reacting with homozygous but not with heterozygous cells, and is recorded as cannot be excluded rather than as positively identified. However, this would only apply if our in-house testing also found non-reactivity with heterozygous cells by the same technique; otherwise, this would be classed as a false negative result. c. the following documentation is required for a UI submission to be considered The UI box should be marked in addition to any boxes for antibodies that you can confidently identify. The UI submission must include details of antibodies that cannot be positively identified, but cannot be excluded, and your explanation of why identification cannot be confirmed. Copies of all panel sheets showing the reactions recorded, (including those used for antibody screening) must be returned with your exercise result sheet and marked with your PRN. If supporting paperwork is not submitted, antibodies recorded as positively identified will be considered as your result for performance monitoring purposes. Copies of all panel sheets showing the reactions recorded, (including those used for antibody screening) must be returned with your exercise result sheet and marked with your PRN. If supporting paperwork is not submitted, antibodies recorded as positively identified will be considered as your result for performance monitoring purposes. Page 33 of 69

37 Appendix 4 UK NEQAS (BTLP) ABO titration pilot annual summary Introduction The UK NEQAS (BTLP) ABO titration pilot has been running since an exploratory pilot exercise in 2009 revealed a wide variation of methodology in use, the titration results obtained and their use in the ABO incompatible (ABOi) transplant context. The main focus of the pilot is to look at ABO titration in laboratories supporting ABOi transplant, and the pilot included 38 such laboratories with a further 31 laboratories performing ABO titration for other clinical reasons. Since 2010, results obtained with standard indirect antiglobulin (IAT) and direct room temperature (DRT) techniques based on DiaMed (as the most commonly used column agglutination technology) have been requested alongside those using in-house techniques, in an attempt to allow a more direct comparison of results. In-house validation and examination of participants results showed that using the Diluent 2 or CellStab as the red cell diluent did not affect results, and the standard technique provided in allowed the use of either of these diluents, in theory allowing more laboratories to submit results using the standard technique. The reports issued for each pilot exercise summarised the medians by method, and included individual results for each laboratory. This report provides a more detailed analysis of the results. Exercise Summary Table 1 shows a summary of the exercises distributed in the cycle. Table 1 summary of ABO titration exercise material, participation and results Data 12/13 ABOT1 12/13 ABOT2 12/13 ABOT3 12/13 ABOT4 June 2012 September 2012 December 2012 March 2013 Number of participants 69 (36 UK) 69 (37 UK) 68 (36 UK) 67 (37 UK) Return rate 92.8% 91.3% 89.9% 89.6% Number Std. results 49 DRT 44 DRT 48 DRT 46 DRT 48 IAT 49 IAT 50 IAT 48 IAT Number in-house results 42 DRT 45 DRT 38 DRT 35 DRT 31 IAT and 5 DTT 2 28 IAT and 6 DTT 2 21 IAT and 7 DTT 2 22 IAT and 7 DTT 2 Plasma sample 1 Group and titre 1 Group O 32 DRT, 256 IAT Group O 64 DRT, 128 IAT Group B 32 DRT, 16 IAT Group O 256 DRT, 2048 IAT Plasma sample 2 Group and titre 1 Group O 32 DRT, 256 IAT Group O 64 DRT, 256 IAT Group O 64 DRT, 256 IAT Group O 64 DRT, 256 IAT Group O Group B Group O Group O Plasma sample 3 Group and titre 1 32 DRT 32 DRT 16 DRT 128 DRT 128 IAT 32 IAT 16 IAT 256 IAT Cells provided for titration A 1 rr A 1 rr A 1 rr A 1 rr Replicate samples P1 and P2 one pool P2 same pool as P2 same pool as P2 same pool as 12/13 ABOT3/T4 12/13 ABOT2/T4 12/13 ABOT2/T3 Additional information collected Other reasons for performing ABOT Clinical use of results Clinical use of results Screen for red cell antibodies 1 Titres shown are median results obtained with the standard technique; 2 DTT or equivalent A subtyping Clinical use of results Survey renal Tp units Page 34 of 69

38 Appendix 4 Examples of results by technology (including standard ) Figure 1 shows results of a low titre sample ABOT3 P3 to demonstrate the distribution of results using inhouse technologies by DRT, IAT and IAT using DTT-treated plasma, and the standard technique. Figure 2 shows results of a high titre sample ABOT4 P1 to show the distribution of results using in-house technologies by DRT, IAT and IAT using DTT-treated plasma, and the standard technique. The number in each group is shown in brackets after the technology. Figure 1: ABOT3 Patient 3 Technique Anti-A titre median (range) DRT Standard 16 (8-64) DRT In-house Overall 8 (4-64) DRT In-house DiaMed 8 (8-32) DRT In-house BioVue 8 (4-16) DRT In-house tube 16 (4-64) DRT In-house Immucor 4 (4-8) IAT Standard 16 (8-32) IAT In-house Overall 16 (4-128) IAT In-house DiaMed untreated 8 (8-32) IAT In-house BioVue untreated 32 (16-128) IAT In-house tube untreated 24 (8-32) IAT In-house Immucor untreated 4 (4-8) IAT DTT (or equivalent) overall 4 (0-8) Page 35 of 69

39 Appendix 4 Figure 2: ABOT4 Patient 1 Technique Anti-A titre median (range) DRT Standard 256 (64-512) DRT In-house Overall 128 ( ) DRT In-house DiaMed 128 (64-256) DRT In-house BioVue 384 ( ) DRT In-house tube 64 (32-512) DRT In-house Immucor 32 (32-32) IAT Standard 2048 ( ) IAT In-house Overall 3048 ( ) IAT In-house DiaMed untreated 4048 ( ) IAT In-house BioVue untreated ( ) IAT In-house tube untreated 1536 ( ) IAT In-house Immucor untreated 2096 ( ) IAT DTT (or equivalent) overall 512 ( ) Difference between standard and media 2012/13 The IAT medians obtained for the 12 samples distributed in 2012/13 using in-house techniques (All in-house, BioVue, DiaMed, Tube, DTT) were examined for distance from the corresponding IAT median for the standard technique. Each was assigned a score of 1 for each dilution above the standard median and of -1 for each dilution below the standard median. The cumulative scores are Cumulative difference between standard medians and medians using in-house (IH) techniques Figure 3: Cumulative difference IH IAT medians vs. standard IAT median In figure 3, 0 represents the standard median. As expected, the DDT median was lower than the median using the standard technique which uses untreated plasma. The IAT BioVue median was higher than that for the IAT standard technique (DiaMed) in 11/12 (92%) samples (data on each samples was provided in individual exercise reports during 2012/13). Replicate samples Exercises 12ABOT2, 12ABOT3 and 12/13ABOT4 contained a replicate sample from a pool of plasma that was frozen in aliquots, with one thawed for each exercise. Results from laboratories who completed all three exercises using the same technology for each are included in Table 2, which shows the number (%) of results obtained with each method that were the same for all three replicates, and the number (%) where one or more result differed by one, two or more than two doubling dilutions. Page 36 of 69

40 Appendix 4 Table 2 reproducibility of titration result for the three replicate samples, by method Method (number) Same each time Within 1 dilution Within 2 dilutions >2 dilutions apart Std DRT (33) 5 (15%) 12 (36%) 13 (39%) 3 (9%) IH DRT (28) 4 (14%) 15 (54%) 7 (25%) 2 (7%) IH DiaMed DRT (11) 2 (18%) 8 (73%) 1 (18%) 0 (0%) IH Tube DRT (12) 0 (0%) 6 (50%) 4 (33%) 2 (17%) Std IAT (38) 16 (42%) 19 (50%) 3 (8%) 0 (0%) IH IAT (12) 1 (8%) 7 (58%) 2 (17%) 2 (17%) IH IAT DTT (3) 1 0 (0%) 1 (33%) 1 (33%) 1 (33%) 1 2 DiaMed and 1 tube Figure 4 shows the overall percentage of replicate results that did not differ by more than one dilution over the three exercises 12/13 ABO T2, T3 and T4, by technology. Figure 4: Replicate results within 1 doubling dilution, by technology Exercise 12/13ABOT1 included two samples from the same pool (P1 and P2). Figures 5 and 6 show the reproducibility of the DRT and IAT titration results by technology. In figure 5, in-house results of P1 are plotted vs. those for P2 (N.B. where multiple results occur at one point in the chart, these will be overlaid). Figure 6 shows the difference between results for P1 vs. P2 in individual laboratories, displayed by technology for DRT and IAT. Technologies with <5 results have not been included in figures 5 and 6. Page 37 of 69

41 Appendix 4 Figure 5: 12/13ABOT1 DRT and IAT in-house individual results P1 vs. P2 identified by technology Page 38 of 69

42 Appendix 4 Figure 6: 12/13 ABOT1 DRT and IAT - difference P1 vs. P2 in individual laboratories by technology Difference of results from method median (cumulative data for 1012/13) All of the IAT results obtained for the 12 samples distributed in 2012/13 using in house techniques (BioVue, DiaMed and Tube technology) and the standard technique were examined for distance from the method median. Each result was assigned a score of 1 for each dilution above the median and of - 1 for each dilution below the median. Where the median fell between two doubling dilutions the results either side of were assigned a value of 0.5. The cumulative results by technology are displayed in Figure 7 below, and Figure 8 shows all results together. The numbers for other in-house methods were too small for anaylsis. Page 39 of 69

43 Appendix 4 Figure 7: % IAT results at intervals from the IAT method median for each technology Page 40 of 69

44 Appendix 4 Figure 8: % IAT results at intervals from the IAT method median all technologies A subtyping In 12/13 ABOT4, 49/60 laboratories undertook A 1 /A 2 typing, including 30 that use these results to support an ABOi solid organ transplant program. Three reported a result for Patient Z only, and one of these stated that they did not report on A subtypes other than A 1, as their reagent identifies A 1 but a negative results does not confirm A 2 (as opposed to any other A subgroup). Two laboratories, both supporting ABOi solid organ transplant programmes, reported all three patient samples as A 1. Red cell antibodies In exercise 12/13 ABOT3, 21/32 laboratories that support ABOi solid organ transplant, stated that they screen patients for red cell antibodies other than ABO: 8 at the time of each ABO titration 10 at admission to the transplant programme only 3 at the time each routine group and screen sample is taken One of these stated that the result of this screen would not be taken into account when selecting red cells for ABO titration, and four said that they did not know. A further five laboratories stated that they do not screen for red cell antibodies other than ABO, three did not know whether a red cell antibody screen is performed, and three did not answer this question. Clinical use of ABO titration results to support ABOi transplant With exercise 12/13 ABOT4, a project was undertaken in collaboration with Dr Andrew Bentall (University Hospitals Birmingham) to investigate how titration results are used in clinical practice. The UK renal transplant centres routinely provided with titration results by participating laboratories were contacted to find out whether the three patients in exercise12/13 ABOT4 would be admitted to the ABOi program and whether an ABOi transplant would take place, based on the titration results obtained in this exercise. Page 41 of 69

45 Appendix 4 14 UK centres (undertaking 359 transplants) participated. The median IAT titre at which clinicians would accept patients onto the ABOi programme for treatment was 512 (range ). The median target for acceptable titre at day of transplantation was 8 (range 2-16). The laboratories providing results for these centres have a titre range differing by up to 5 dilutions based on UK NEQAS data; using a reference technique across all the respective laboratories reduced variability to a maximum of 1 dilution from the median. Variation in local in-house titre results did not correlate with the titres considered acceptable for inclusion in ABOi programmes 1 Discussion Titration techniques are likely to include manual steps in dilution and / or reading and therefore some variation in replicate results is to be expected. However, it would be reasonable to expect results of replicate samples to be within one doubling dilution. IAT results appear to be more reproducible than DRT results. Overall, 62% of intra laboratory results obtained by DRT and 86% by IAT (untreated plasma) were within one doubling dilution for the three replicate samples distributed in 12/13 ABOT2, T3 and T4. Although it is not clear how technology affects reproducibility, apart perhaps from the method for reading the titration endpoint, when this was examined by technique, 92% of IAT results obtained using the standard technique were within one doubling dilution cf. 66% in-house IAT results. The opposite was observed for the DRT, with 51% standard DRT results being within one doubling dilution cf. 68% in-house DRT results. Two replicate samples were distributed in exercise 12/13 ABOT1, and 95.5% results overall by DRT and 98.8% by IAT were within one dilution, with 61% of IAT results and 72% DRT results being identical for both samples. The proportion of results within one doubling dilution was higher than that seen for the replicate samples sent over three exercises (12/13 ABOT2, T3 and T4). This might be because fewer replicates (2 cf. 3) were compared, or because fewer variables impacted on results of tests performed on the same day, e.g. they were less likely to have been undertaken by different individuals. Although the number of laboratories returning results of techniques using BioVue technology (and other in-house techniques) was small, the BioVue IAT median was generally higher than that for other techniques, and was higher than the IAT standard technique median for 11/12 (92%) samples issued in 2012/13. This effect was also apparent when comparing the cumulative differences between the standard and in-house method medians (see Figure 3). When comparing the cumulative difference of each result from the median result for the individual technology, a tighter range of results was obtained using the IAT standard technique than with a tube technique (see Figures 7 and 8). Conclusions There is still considerable variation in results obtained between techniques, and the introduction of a standard technique would facilitate the transfer of results and transplant protocols (i.e. acceptable titration values for admission to ABOi renal transplant programs and suitability for transplant) across centres. Use of the standard technique appears to reduce the inter laboratory range of results, compared to tube techniques. Where any single technology is used, reproducibility on the day is good within one doubling dilution, but becomes more variable in a significant proportion of laboratories when replicate samples are tested on separate occasions. References 1 No progress in ABO titre measurement; time to aim for a reference? Bentall, A. et al, Transplantation, Volume 97, Number 3, February 15, Page 42 of 69

46 Appendix 4 Appendix Standard technique in use Prepare dilutions of plasma in saline (PBS or NaCl) using a doubling dilution method. Make the dilutions with a minimum volume of 200µl, using an automatic pipette. Use a new tip to dispense each dilution. Prepare a 0.8-1% red cell suspension in CellStab (use ID-diluent 2 if CellStab is not available). LISS indirect antiglobulin test (IAT) using IgG cards a) Add 50ul of cells suspended in CellStab to each microtube b) Add 25ul of each plasma dilution to the corresponding microtube c) Incubate at 37 o C for 15 d) Centrifuge 10 in DiaMed centrifuge Direct agglutination at room temperature (DRT) using NaCl cards a) Add 50ul of cells suspended in CellStab to each microtube b) Add 50ul of each plasma dilution to the corresponding microtube c) Incubate at RT for 15 d) Centrifuge 10 in DiaMed centrifuge Page 43 of 69

47 NQAAP Report for 2012 Appendix 5: Introduction Pre-Transfusion Testing Questionnaire - UK and Republic of Ireland Distributed with exercise 12R4 April 2012 The purpose of this questionnaire was to update basic information on routine pre-transfusion grouping and antibody screening procedures, last gathered in January We will continue to update this information on an annual basis. Return rate Responses were received from 305/409 (75%) laboratories, compared with 77% in 2011, 75% in 2009 and 86% in Seventeen respondents stated that their laboratory does not undertake routine pretransfusion testing, and five returned blank questionnaires. Data from 283 hospital transfusion laboratories has been analysed; however, three of these did not complete any details in the testing section. Summary and trend data Table 1 shows a summary of current data compared to historical data where available Table 1 Trends in routine pre-transfusion testing n=283 n=307 n= n= n=446 Automation for group and screen Used during core hours 1 81% 74% 73% 68% 41% Proportion of full automation used 24/7 2 90% 84% 79% 82% NDA Proportion of full automation interfaced to LIMS 98% 98% 96% 89% NDA Routine ABO/D Grouping Liquid phase microplates 10% 13% 13% 14% 41% Column Agglutination Technology (CAT) 86% 82% 80% 77% 33% Omit reverse group on patients with historical groups 23% 24% 26% 25% 13% Omit reverse group on patients without historical group <1% <1% <1% <1% 1% D typing reagents Single anti-d used once for patients with a historical group 52% 52% 44% 45% 15% Single anti-d once for patients with no historical group 28% 31% 22% 25% 5% Routinely include IAT for D typing on apparent D 5% 6% 8% 6% negatives 3% Include and anti-cde reagent 3% 3% 5% 1% 10% Routine method of establishing compatibility Electronic issue 54% 46% 46% 37% 10% Immediate spin 8% 8% 7% 8% 15% IAT ( other technique(s)) 38% 46% 47% 55% 75% IAT technology antibody screening CAT 92% 90% 89% 90% 85% Solid Phase Microplate (SPMP) 8% 10% 8% 9% 4% IAT technology crossmatching CAT 98% 96% 81% 96% 77% 3 Tube 2% 2% 7% 3% 17% 3 1 Full automation from 2008 onwards cf. full or semi automation in /11/12 data includes only those always used out of hours whilst 2008 includes used out of hours exercise data. NDA = no data available Page 44 of 69

48 NQAAP Report for 2012 Appendix 5: Analysis of 2012 data General information /automation Workload (n=283) Figure 1 shows the percentage of laboratories within workload categories based on the approximate number of group and screens performed per year for 2012 (with previous years for comparison). Figure 1 IT and automation 281/283 (99%) have an IT system for recording and reporting results of blood grouping tests. The two laboratories with no IT system process <1000 groups and screens per annum. Table 2 shows the LIMS used by the 276 laboratories answering this question. 75% use isoft or Clinisys. There were 23 other commercial IT suppliers reported, with none of these having more than ten users. Table 2 LIMS used by number (%) of laboratories (where stated) IT system Number (%) of laboratories isoft 108 (39%) Clinisys 99 (36%) Other* 69 (25%) Total 276 (100%) * including two using in-house systems and two not stating an IT supplier Page 45 of 69

49 NQAAP Report for 2012 Appendix 5: Table 3 shows the use of automation for routine group and screens within core hours. Table 3 Number (%) laboratories using automation for group and screens during core hours Testing Number (%) of laboratories Full automated 228 (81%) Semi-automated (i.e. not walkaway) 8 (3%) No automation 47 (17%) Total 283 (100%) During core hours, approximately 93% of group and screens are tested with full automation (taking the number of group and screens performed by each laboratory to be the midpoint where the category is a range, using 500 for the <1000 category and for the >25000 category). This does not take account of urgent testing which may be undertaken manually in a laboratory with automation even during core hours. Table 4 shows the number (%) of laboratories with an interface between the automation and laboratory information management system (LIMS). Table 4 Number (%) laboratories with automation LIMS interface Interface between automation Number (%) with full and LIMS automation Number (%) with semiautomated testing Bi-directional 147 (66%) 0 (0%) Uni-directional 72 (32%) 8 (100%) Not interfaced 5 (2%) 0 (0%) Total 224* (100%) 8 (100%) *four laboratories using full automation did not answer this question Testing outside core hours 268/282 (95%) stated that they undertake pre-transfusion testing outside core hours o 221/268 (83%) have full automation and 220 stated how this is used for routine testing out of hours: 198/220 (90%) always use the automation 17/220 (8%) sometimes use the automation 5/220 (2%) never use the automation, but it is possible that these only undertake urgent testing out of hours. Details of testing ABO/D typing technology Table 5 shows the number (%) of laboratories using each technology as their primary ABO/D typing technique for patients with a previous group, and table 6 the percentage of each using full automation, semi-automated systems and manual testing. Table 5 ABO/D typing techniques Technology All laboratories DiaMed 148 (53%) BioVue 89 (32%) Liquid phase microplate 29 (10%) Solid phase 1 (<1%) Grifols 2 (1%) Tube 11 (4%) All techniques 280 (100%) Page 46 of 69

50 NQAAP Report for 2012 Appendix 5: Table 6 Use of automation by technology Full Technology automation Semiautomation Manual testing DiaMed (n=148) 119 (81%) 2 (1%) 27 (8%) BioVue (n=89) 82 (92%) 0 (0%) 7 (8%) Liquid phase microplate (n=29) 22 (76%) 1 5 (17%) 2 (7%) Solid phase (n=1) 1 (100%) 0 (0%) 0 (0%) Grifols (n=2) 2 (100%) 0 (0%) 0 (0%) Tube (n=11) N/A N/A 11 (100%) 1 all using Immucor automated systems Use of automation for other tests Table 7 shows the number (%) of the 236 laboratories with automation that use it for tests other than group and screen. Table 7 Use of automation by test Test Number (%) Antibody ID 129 (55%) Crossmatching 67 (28%) Phenotyping 60 (25%) Inclusion of a reverse group 64/277 (23%) omit the reverse group for patients with historical groups, however 5 of these include a reverse group if there is only one historical group record. 1/277 (<1%), using a manual DiaMed technique, also omits the reverse group for new patients. D typing Table 8 shows the number (%) using one anti-d reagent once, or testing for D in duplicate, either with different reagents or with one reagent twice, for patients with and without a historical group. Table 8 D typing protocol for patients with and without a previous group D typing reagents Patients with a historical group Patients with no historical group Use a single anti-d reagent once 147 (52%) 77 (28%) Test in duplicate 132 (48%) 199 (72%) Total Three of those using a single anti-d once for patients with no previous group, undertake manual testing. 9/280 (3%) laboratories incorporate an anti-cde reagent into routine testing: o 7 for all patients o 2 only for patients with no previous group 14/277 (5%) routinely confirm D negatives using an IAT anti-d reagent: o 10 for all patients o 4 only for patients with no previous group IAT technology used for routine antibody screening and crossmatching Table 9 shows the number (%) using each IAT technology for antibody screening and crossmatching. Page 47 of 69

51 NQAAP Report for 2012 Appendix 5: Table 9 - IAT technology used for antibody screening and crossmatching IAT technology Technique Capture Solid BioVue DiaMed RRS Screen Grifols Tube Antibody screening (n=279) 91 (33%) 163 (59%) 22 (8%) 1 (<1%) 2 (<1%) 0 (0%) Crossmatching (n=278) 80 (29%) 191 (69%) 1 (<1%) 0 (0%) 2 (<1%) 4 (1%) Method for establishing final compatibility 151 (54%) use electronic issue (one during core hours only) 107 (38%) use an IAT crossmatch (with or without an immediate spin) 22 (8%) use an immediate spin crossmatch. Electronic issue details 91/151 (60%) require two samples taken at separate times before a patient is eligible for electronic issue o Seven of these only require one sample if the patient groups as O. Of those using EI as their primary method for establishing compatibility: o 4/151 (3%) are using manual systems o 3/151 (2%) are using semi-automated systems. Use of an enzyme technique 12/280 (4%) routinely perform an antibody screen with enzyme treated cells. 251/280 (90%) have access to an enzyme panel for antibody identification. Conclusions The report issued in 2011 (11R1) included a full discussion. Most of the discussion points are still pertinent and will not be repeated on an annual basis unless significant changes are apparent. However, it is noted that: Workload figures and decreasing EQA registrations viewed together suggest a trend towards testing in fewer but larger laboratories. Use of full automation for group and screen has increased (81% cf. 74% in 2011), and use of automation 24/7 in laboratories that test out of hours has also risen (90% cf. 84% in 2011). For the first time there are no laboratories performing routine antibody screening in tubes. More than half (54%) of laboratories now use electronic issue as the routine method of establishing compatibility. The questionnaire data will continue to be collected and analysed on an annual basis. Page 48 of 69

52 Appendix 6: Pre-Transfusion Testing Questionnaire - UK and Republic of Ireland Data collected February June 2013 Introduction The purpose of this questionnaire was to update basic information on routine pre-transfusion grouping and antibody screening procedures, last gathered in April We will continue to update this information on an annual basis. Return rate Responses were received from 289/400 (72%) laboratories, cf. 75% in 2012, 77% in 2011, 75% in 2009 and 86% in Eleven respondents stated that their laboratory does not undertake routine pretransfusion testing. Duplicate entries have been removed, with the most recent entry kept for inclusion in the analysis. Data from 278 hospital transfusion laboratories has been analysed; however, two of these did not complete any details in the testing section. Summary and trend data Table 1 shows a summary of current data compared to historical data where available Trends in routine pre-transfusion testing n=278 n=283 n= n= n= n=446 Automation for group and screen Used during core hours 1 84% 81% 74% 73% 68% 41% Proportion of full automation used 24/7 2 93% 90% 84% 79% 82% NDA Proportion of full automation interfaced to LIMS 98% 98% 98% 96% 89% NDA Routine ABO/D Grouping Liquid phase microplates 10% 10% 13% 13% 14% 41% Column Agglutination Technology (CAT) 86% 86% 82% 80% 77% 33% Omit reverse group on patients with historical groups Omit reverse group on patients without historical group D typing reagents Single anti-d used once for patients with a historical group 22% 23% 24% 26% 25% 13% 0% <1% <1% <1% <1% 1% 53% 52% 52% 44% 45% 15% Single anti-d once for patients with no historical group 31% 28% 31% 22% 25% 5% Routinely include IAT for D typing on apparent D negatives 6% 5% 6% 8% 6% 3% Include and anti-cde reagent 3% 3% 3% 5% 1% 10% Routine method of establishing compatibility Electronic issue 55% 54% 46% 46% 37% 10% Immediate spin 7% 8% 8% 7% 8% 15% IAT ( other technique(s)) 39% 38% 46% 47% 55% 75% IAT technology antibody screening CAT 91% 92% 90% 89% 90% 85% Solid Phase Microplate (SPMP) 8% 8% 10% 8% 9% 4% IAT technology crossmatching CAT 98% 98% 96% 81% 96% 77% 3 Tube 1% 2% 2% 7% 3% 17% 3 1 Full automation from 2008 onwards cf. full or semi automation in /11/12 data includes only those always used out of hours whilst 2008 includes used out of hours exercise data. NDA = no data available Page 49 of 69

53 Appendix 6: Analysis of 2013 data General information /automation Workload (n=278) Figure 1 shows the percentage of laboratories within workload categories based on the approximate number of group and screens performed per year for 2013 (with previous years for comparison). Figure 1 27/47 (57%) of ROI laboratories test <5000 samples per year cf. 48/231 (21%) in the UK. IT and automation 273/277 (98.6%) record and report results of blood grouping tests through a laboratory information management system (LIMS). Four laboratories stated that they do not report through a LIMS; two process <1000 groups and screens per annum, and two process However, in the last pre-transfusion questionnaire in 2012, two of these four stated that they did report through a LIMS. Table 2 shows the LIMS used by the 270 laboratories answering this question. 75% use isoft or Clinisys. There were 24 other commercial IT suppliers reported, with none of these having more than ten users. Table 2 Details of LIMS used (where stated) IT system Number of laboratories isoft 110 (41%) Clinisys 92 (34%) Other* 68 (25%) Total 270 (100%) * including two using in-house systems Page 50 of 69

54 Appendix 6: Booking EQA samples into the LIMS 196/271 (72%) book EQA samples into the LIMS. The most common reasons cited for not doing so are: The format of the samples (not whole blood) Problems with cumulative data for NEQAS patient IDs (changing blood groups) Interference with workload statistics and cluttering database Problems booking into shared databases within Trusts Custom and practice Table 3 shows the use of automation for routine group and screens within core hours. Table 3 Use of automation for group and screens during core hours Testing Number of laboratories Full automated 231 (84%) Semi-automated (i.e. not walkaway) 4 (1%) No automation 41 (15%) Total 276 (100%) During core hours, approximately 96% of group and screens are tested with full automation (taking the number of group and screens performed by each laboratory to be the midpoint where the category is a range, using 500 for the <1000 category and for the >25000 category). This does not take account of urgent testing which may be undertaken manually in a laboratory with automation even during core hours. Table 4 shows the number and % of laboratories with an interface between the automation and laboratory information management system (LIMS). Table 4 Automation LIMS interface Interface between automation and LIMS Number with full automation Bi-directional 160 (69%) 0 (0%) Uni-directional 67 (29%) 4 (100%) Not interfaced 4 (2%) 0 (0%) Total 231 (100%) 4 (100%) Number with semiautomated testing Testing outside core hours 270/277 (97%) stated that they undertake pre-transfusion testing outside core hours o 226/270 (84%) have full automation and stated whether it is used for testing out of hours: 210/226 (93%) always use the automation 13/226 (6%) sometimes use the automation 3/226 (1%) never use the automation Page 51 of 69

55 Appendix 6: Details of testing (n=276) ABO/D typing technology Table 5 shows the number and percentage of laboratories using each technology as their primary ABO/D typing technique for patients with a previous group, and table 6 the percentage of each using full automation, semi-automated systems or manual testing. Table 5 ABO/D typing techniques Technology Number of laboratories DiaMed 144 (52%) BioVue 84 (30%) Liquid phase microplate 27 (10%) Grifols 8 (3%) Tube 13 (5%) All techniques 276 (100%) Table 6 Use of automation by technology Technology Full Semiautomation: Manual testing: automation: Number Number Number DiaMed (n=144) 121 (84%) 2 (1%) 21 (15%) BioVue (n=84) 77 (92%) 0 (0%) 7 (8%) Liquid phase microplate (n=27) 25 (93%) 1 2 (8%) 0 (0%) Grifols (n=8) 8 (100%) 0 (0%) 0 (0%) Tube (n=13) N/A N/A 13 (100%) 1 23 using solid phase automated systems Use of automation for other tests Table 7 shows the number and % of the 235 laboratories with automation that use it for tests other than group and screen. Table 7 Use of automation by test Test Number of laboratories Antibody ID 145 (62%) Crossmatching 76 (32%) Phenotyping 86 (37%) Inclusion of a reverse group 61/272 (22%) omit the reverse group for patients with more than one historical group (all using automation), however 7 of these include a reverse group if there is only one historical group record. All respondents perform a reverse group on patients with no historical group; however, 24 laboratories did not answer this question. D typing Table 8 shows the number and percentage using one anti-d reagent once, or testing for D in duplicate, either with different reagents or with one reagent twice, for patients with and without a historical group. Table 8 D typing protocol for patients with and without a previous group D typing protocol Patients with a historical group: Patients with no historical group: Number Number Use a single anti-d reagent once 145 (53%) 83 (31%) Test in duplicate 128 (47%) 185 (69%) Total Four of those using a single anti-d once for patients with no previous group, undertake manual testing. 8/272 (3%) laboratories incorporate an anti-cde reagent into routine testing: o 7 for all patients o 1 only for patients with no previous group Page 52 of 69

56 Appendix 6: 17/269 (6%) routinely confirm D negatives using an IAT anti-d reagent: o 12 for all patients o 5 only for patients with no previous group IAT technology used for routine antibody screening and crossmatching Table 9 shows the number and percentage using each IAT technology for antibody screening and crossmatching. Table 9 - IAT technology used for antibody screening and crossmatching IAT technology Technique Solid BioVue DiaMed Capture Screen Grifols Tube Other Antibody screening (n=275) 84 (30%) 158 (58%) 22 (8%) 1 (<1%) 8 (3%) 1 (<1%) 1(<1%) 1 Crossmatching (n=273) 79 (29%) 179 (66%) 2 (1%) 0 (0%) 9 (3%) 4 (1%) 0 (0%) 1 This laboratory uses DiaMed for crossmatching Method for establishing final compatibility 151/275 (55%) use electronic issue (EI), including one using EI during core hours only. 106/275 (39%) use an IAT crossmatch (with or without an immediate spin) 18/275 (7%) use an immediate spin crossmatch. Requirement for a second sample Table 10 shows the number and % of laboratories requiring a group on two samples taken at separate times (one group could be historical), before group specific blood is issued in a routine situation. This is shown, both overall and depending on whether compatibility is established by EI or a serological crossmatch. Table 10 Requirement for two samples by method of establishing compatibility Require second sample? Electronic issue: Number Serological crossmatch: Number All laboratories: Number Yes, always 52 (35%) 18 (14%) 70 (25%) Yes, unless first sample is group O 2 (1%) 1 (1%) 3 1 (1%) No, but in process of implementing two sample policy 47 (31%) 52 (42%) 99 (36%) No 50 (33%) 53 (43%) 103 (37%) Total 151 (100)% 124 (100%) 275 (100%) 1 Two Scotland and one Northern Ireland Testing of second sample All of the 73 laboratories requesting a second sample perform an ABO forward group (with or without a reverse group), 64 (88%) perform a D type and 65 (89%) an antibody screen. The combinations of tests performed are detailed in Table 11. Page 53 of 69

57 Appendix 6: Table 11 Details of testing on the second sample Combination of tests on the second sample Number of laboratories Full ABO group, D type and antibody screen 43 (59%) ABO forward group, D type and antibody screen 18 (24%) Full ABO group and antibody screen 4 (6%) Full ABO group only 4 (6%) Full ABO group and D type 3 (4%) ABO forward group only 1 (1%) Total 73 (100%) Table 12 shows the number of laboratories by country that use EI and automation, and the number that either currently test a second sample before issuing group specific blood, or are in the process of implementing a policy to do so. Table 12 Use of automation, EI and requirement for a second sample by country Country Use of automation: Electronic issue: Second sample: Number Number Number England (n=181) 170 (94%) 126 (70%) 125 (69%) Scotland (n=28) 22 (79%) 9 (32%) 15 (54%) Wales (n=12) 10 (83%) 10 (83%) 9 (75%) Northern Ireland (n=8) 7 (88%) 3 (38%) 5 (63%) Republic of Ireland (n=47) 26 (55%) 3 (6%) 18 (38%) Total 236 (100%) 152 (100)% 173 (100%) Use of an enzyme technique 13/274 (5%) routinely perform an antibody screen with enzyme treated cells 249/273 (91%) have access to an enzyme panel for antibody identification Discussion The report issued in 2011 (11R1) included a full discussion. Most of the discussion points are still pertinent and will not be repeated on an annual basis unless significant changes are apparent. However, it is noted that: Workload figures and decreasing EQA registrations viewed together suggest a trend towards testing in fewer but larger laboratories, at least in the UK. Use of full automation for group and screen continues to rise (84% cf. 81% in 2012), as does the use of automation 24/7 in laboratories that test out of hours (93% cf. 90% in 2012). 26% of laboratories request two samples taken at separate times for a group check (one group could be historical), before group specific blood is issued in a routine situation, and a further 36% are in the process of implementing this policy. More than half (55%) of laboratories now use electronic issue as the routine method of establishing compatibility. A higher proportion of those using EI request a second sample than those crossmatching serologically (35% cf. 14%); however, the difference is less pronounced when those in the process of implementing this policy are included. The numbers using automation and EI, and requiring a second sample, varies by country within the UK, and is considerably lower in the Republic of Ireland (where there is a higher proportion of small laboratories) than in the UK. EQA requests are booked into the LIMS in 72% laboratories. This is desirable wherever possible, as it allows the EQA samples to follow the same process as clinical samples and consequently makes the EQA results more relevant to clinical practice. The format of the samples (i.e. they are not whole blood) Page 54 of 69

58 Appendix 6: was cited as a reason for not booking EQA samples to the LIMS, and whilst it is appreciated that the sample format is not ideal, it does not appear to be a barrier to LIMS entry in the majority of laboratories. In some cases there are additional obstacles to overcome, e.g. where there is a shared database and / or there are problems with building up historical records for EQA patients. These situations may require additional planning as to how the samples are allocated names and numbers for entry to the LIMS. The questionnaire data will continue to be collected and analysed on an annual basis Page 55 of 69

59 Appendix 7 Emergency Issue Questionnaire Distributed with exercise 13R1 January 2013 UK and Republic of Ireland Main aims The aims of this emergency exercise were to determine: Testing undertaken where blood is required within minutes The type of blood issued to a young female in minutes Detection of a MF reaction in D typing Effect of finding a MF reaction on type of red cells issued for transfusion Testing undertaken on a sample for group and screen outside of core hours The level of retrospective testing undertaken both before and during the next session of core hours Specifications for emergency group O negative units Labelling of samples for unknown patients Material A whole blood sample and a request form were provided for each of the patients listed below, with instructions for completing the exercise in the emergency format. Blood was required within minutes for patients 1 and 2, and a group and save was requested for Patient 3. Patient 1 Amy Stake, female, age 39, Clinical details In theatre post ENT surgery, unexpected bleeding ++ Expected results Group A D positive, inert Patient 2 Anna Mergenci, female, age 33 Clinical details Ectopic pregnancy, bleeding PV, for immediate surgery Expected results Group O dual population D positive / D negative, inert Patient 3 Jim Slyp, male, age 63 Clinical details Fractured femur following fall, for surgery in minutes Expected results Group A D negative, anti-jk b Two SurveyMonkey questionnaires were issued, one for Patients 1 and 2 and another for Patient 3. Return rate The questionnaire was issued to 400 laboratories in the UK and ROI. Incomplete submissions missing key information within a set of data for a patient have been excluded, as have duplicate submissions. 365 (91%) returns were analysed for Patient 1, 362 (91%) for Patient 2, and 340 (85%) for Patient 3. The numbers undertaking the exercise in an emergency scenario are shown in Table 1. As not all respondents answered all questions, the totals in the analysis do not always equal the number of returns. Table 1: Testing by Patient Questionnaire Tested in emergency scenario Number (% of returns) Not tested in emergency scenario Number (% of returns) Patient (91%) 32 (9%) Patient (91%) 32 (9%) Patient (94%) 21 (6%) Page 56 of 69

60 Appendix 7 Table 2 shows the reasons given for not undertaking emergency testing. Table 2: Reasons for not undertaking emergency testing Reason for not testing in Patients 1 and 2 emergency format Number Patient 3 Number Reference laboratory No emergency testing 12 2 Manufacturer / diagnostics company 3 2 Other Total Issuing O D negative blood, but not completing the exercise 2 Five would not perform G+S until next day and one would not perform a G+S at all given the clinical details for Patient 3. These have been included in the analysis for Patient 3. Data analysis Decisions surrounding duplicate submissions: Complete rather than incomplete submissions have been selected. Submissions relating to out of hours scenarios have been selected rather than those for a lone worker scenario. If there was more than one complete set of data (either both lone worker or both out of hours) then most the most recently submitted has been selected. Edits to data: Responses of Yes / No to whether testing was undertaken have been edited according to whether corresponding result sections were completed. Information in comment fields has been used to edit responses where relevant. Results Both Patient 1 and Patient 2 required blood within minutes and not all questions on testing were repeated for both patients. Therefore, some of the detail in the following section is provided for Patient 1 only. Data from Patient 3 has been reported separately, as the clinical scenario was different. Of those testing Patients 1 and 2 in an emergency, 231 (70%) tested as out of hours, and 101 (30%) as lone worker within core hours, and one did not specify the scenario for testing. There was no apparent difference between these two groups either in the testing undertaken within minutes, or the specification of red cells selected, so they have been analysed together. Patients 1 and 2 requiring blood within minutes ABO grouping undertaken within minutes 296 and 293 (89%) participants recorded an ABO/D group within the minutes, for Patients 1 and 2 respectively. Further details of the extent of this testing are summarised in Table 3. Table 3: Testing undertaken within 15 minutes Procedure Patient 1 Patient 2 Number Number Performed 2 or >2 ABO forward groups (+/-reverse group) 162/296 (55%) 158/293 (54%) Performed 2 or more D types 1 148/274 2 (54%) 136/261 3 (52%) 1 excludes 8 participants who only performed one ABO group presumably these 8 used two anti-d reagents as part of a single group 2 22 did not answer this part of the question 3 32 did not answer this part of the question Page 57 of 69

61 Appendix 7 Patient 1 (Female aged 39, group A D positive, inert) Details of ABO/D grouping within minutes group 255/296 (86%) considered one (or more) of the group(s) performed to be a rapid 135/162 (83%) performing two or >2 forward groups used a new aliquot for subsequent group(s) 183/295 (62%) included a reagent control with their forward group(s) 248/296 (84%) performed a reverse group before issuing blood: 213/248 (86%) tested as part of a full group 35/248 (14%) tested by re-sampling at a different time to the forward group Table 4 shows the technologies used for ABO/D grouping within minutes. The total numbers include 80/294 (27%) laboratories which used more than one technology. Two respondents did not state which technology was used. Table 4: Technology used for ABO/D typing within minutes (Patient 1) Technology Total number As a single technology Tube 206 (70%) 137 (46%) DiaMed 63 (21%) 25 (8%) BioVue 61 (21%) 31 (10%) Slide / Tile 24 (8%) 9 (3%) Microplate 17 (6%) 8 (3%) Grifols 2 (1%) 2 (1%) Other 2 (1%) 2 (1%) ABO/D grouping results 294/296 (99.3%) laboratories reported group A D positive. One reported O D positive, based on a single group by BioVue, and another reported A D variant based on two or more D types by BioVue and tube (including a reagent control), using the same aliquot of red cells. Red cells selected for transfusion Table 5 shows the group of red cells selected for transfusion to Patient 1 within minutes vs. the ABO/D results reported. Table 5: ABO/D reported vs. red cells selected for Patient 1 (A D Pos) within minutes ABO/D result Red cells selected for transfusion A D positive A D negative O D positive O D negative AB D positive A D positive (294) A D variant (1) O D positive (1) None (37) Presumably data entry error as selected units were reported as compatible 88/333 (26%) selected O D negative blood o 66/88 (75%) designated these as flying squad 327/333 (98%) specified that the units were K negative Other specifications noted were: 17 Rh phenotyped blood (8 R 1 R 1, 4 c negative, 4 E negative, 1 Rh matched) 13 high titre negative 10 CMV negative (as part of the specification for flying squad blood) 1 Fy(a-) Page 58 of 69

62 Appendix 7 Additional testing within minutes Table 6 shows the additional testing undertaken on Patient 1 within minutes, by those recording a group vs. those not recording a group within minutes. Table 6: Additional work undertaken by on Patient 1 within 15 minutes Additional test / procedure Group within 15 minutes Number (n=296) No group within 15 minutes Number (n=37) Immediate spin crossmatch 91 (31%) 1 (3%) Check group of the donor units 1 24 (8%) 4 (11%) 1 20/28 in Republic of Ireland Level of testing undertaken before issue of blood Table 7 shows the level of ABO testing undertaken within minutes (excluding those who did not perform an ABO group) and the ABO group of red cells issued. Table 7: Testing undertaken before issue of O group or group A blood Patient 1 (A D pos) - Number Level of testing on primary sample prior to blood issue in 15 minutes Selecting group O (n=65) Selecting group A (n=231) 2 forward groups performed on separate aliquots +/- other tests (n=135) 18 (28%) 117 (51%) 1 forward group 1 + ISXM and / or separate reverse group (n=64) 15 (23%) 49 (21%) 1 forward group 1, no separate reverse group or ISXM 4 (n=96) 31 (48%) 65 2,3 (28%) No reverse group or reagent control 10 (15%) 15 (6%) 1 Includes those performing two or more forward groups on the same aliquot of cells 2 Includes one selecting group AB presumably due to data entry error 3 13 stated that would have requested a 2 nd sample before issue of red cells but it is not known whether the results of testing this sample have been taken into account when testing the primary sample or selecting red cells. 4 ISXM = Immediate Spin crossmatch Patient 2 (Female aged 33, group O dual population D positive / D negative (50:50), inert Red cells selected for transfusion All 37 laboratories not performing an ABO/D group within minutes issued group O D negative blood. Table 8 shows the D grouping results of the 293 laboratories performing and recording an ABO/D group for Patient 2 within minutes vs. red cells selected for transfusion. 291 correctly recorded the ABO group as O, two did not record the result of their ABO group and another recorded as result of group A. Table 8: D groups recorded and blood selected for Patients 2 (O MF D) within 15 minutes Selected O D positive units Selected O D negative units Group reported (number) Number Number D positive (n=219) (74%) 56 (26%) D UI (n=60) 6 (10%) 54 (90%) D variant (n=11) 3 (28%) 8 (73%) D negative (n=3) 1 (33%) 2 (67%) Total (n=293) 173 (59%) 120 (41%) 1 this includes one laboratory which reported group A Page 59 of 69

63 Appendix 7 56/60 of those reporting Patient 2 as UI D gave a reason: 49 dual population / mixed field reactions with anti-d reagent(s) (five issued D positive blood) 6 weak or variable reactions (one issued D positive blood) 1 unspecified D typing anomaly (issued D negative blood). Two laboratories reporting Patient 2 as D positive also commented on reactions with anti-d reagent(s), with one noting a mixed field reaction (and going on to issue D positive blood), and the other noting a weak reaction and issuing D negative blood. The technology used by those noting a mixed field reaction with anti-d / dual population in Patient 2 during testing within minutes, is shown in Table 9. Table 10 shows the same information, but based on the final results submitted for exercise 13R1 after all testing was completed. Table 9: Recording of a MF reaction vs. technology (testing in minutes) Technology 1 Number using MF noted (n=50) technology (n=293) Number (% of labs using technology) Tube 136 (46%) 13 (10%) BioVue 30 (10%) 3 (10%) DiaMed 24 (8%) 14 (58%) Slide/tile 11 (4%) 1 (9%) LPMP 8 (3%) 2 (25%) Grifols 2 (1%) 1 (50%) Other 2 (1%) 0 (0%) Multiple 80 (27%) 16 (20%) 1 Used as single technology apart from multiple Table 10: Recording of a MF reaction vs. technology (final result of all testing for exercise 13R1) Technology 1 Number using MF recorded 2 (n=164) technology (n=395) Number (% of those using the technology) Tube 53 (13%) 12 (23%) BioVue 71 (18%) 9 (13%) DiaMed 116 (29%) 77 (66%) LPMP 11 (3%) 1 (9%) Grifols 9 (2%) 5 (56%) Multiple 135 (34%) 60 (44%) 1 Used as single technology apart from other / multiple 2 with one or more anti-d reagent Patients 1 and 2 Retrospective testing and actions Table 11 shows details of testing undertaken and Table 12 actions that would be undertaken if this were a real clinical situation, after the issue of blood (10-15 minutes), but before the next session of core hours. Table 13 details any retrospective testing undertaken during the next session of core hours. Table 11: Details of testing undertaken after issue at 15 minutes, but before next session of core hours Patient 1 (n=333) Patient 2 (n=330) Further testing Number Number Additional ABO group on 1 st sample 244 (73%) 244 (74%) Additional D type on 1 st sample 229 (69%) 241 (73%) Antibody screen 321 (96%) 314 (95%) Retrospective XM of units issued 227 (68%) 231 (70%) Other testing 7 1 (2%) 10 1 (3%) 1 including patient phenotyping, a DAT on incompatible units, and testing for partial / weak D (patient 2 only) Page 60 of 69

64 Appendix 7 Table 12: Details of actions that would be taken after issue at 15 minutes, but before next session of core hours Further actions Patient 1 (n=333) Patient 2 (n=330) Number (%) Number (%) Seek advice from other staff 12 (4%) 25 (8%) Seek transfusion history 86 (26%) 155 (47%) Serological testing on 2 nd sample 58 (17%) 78 (24%) Table 13: Details of further testing during next session of core hours Patient 1 (n=333) Further testing Number (%) Patient 2 (n=330) Number (%) No further testing 255 (77%) 204 (62%) Group and antibody screen 33 (10%) 55 (17%) Blood group (no screen) 21 (6%) 91 (27%) Crossmatch on units issued 16 (5%) 1 22 (7%) 2 Other 3 13 (4%) 40 (12%) 1 two reported one or more of the units as incompatible one reported both units as incompatible 3 including checking of samples and /or interpretations and authorising of results (both patients); referring for D typing, or resolving in-house, and 6 seeking transfusion history (patient 2 only) Had additional units been requested two hours after the initial sample arrived, assuming that a second (theoretical) sample gave the same results as the first sample, and with no further information available, 99 laboratories would have issued a different group at minutes and 2 hours, with details shown in table 14: Table 14: Change in selection D group between 15 minutes and 2 hours Results of initial D group Changed from issuing D pos to D Neg Changed from issuing D neg to D pos D positive (n=219) 29 (13%) 45 (21%) D UI (n=60) 2 (3%) 3 (5%) D variant (n=11) 0 (0%) 1 (9%) D negative (n=3) 0 (0%) 2 (67%) No group performed (n=37) 0 (0%) 17 (46%) Total (n=330) 31 (9%) 68 (21%) Patient 3 Group and save (male aged 63) Table 15 shows how the group and save sample was processed, and Table 16 the group and screen results recorded within minutes. One laboratory stated that they performed a group and screen, but did not answer any further questions and this has been excluded from the analysis. Table 15: Processing of group and save sample within minutes Action within minutes (n=325) Number Group and screen (+/- other tests) 315 (97%) Rapid group and store sample for testing next day 2 (1%) No testing until next session of core hours 8 (2%) 1 1 two booked in sample and checked labelling Table 16: Group and screen results within minutes Group and screen result minutes (n=315) Number A D negative, antibody present 313 (99%) A D positive, antibody present 1 (<1%) No group recorded, antibody screen positive 1 (<1%) Page 61 of 69

65 Appendix 7 255/315 (81%) laboratories performed an automated group and screen within minutes and 59 (19%) a manual group and screen. The laboratory reporting an antibody screen without an ABO group does not have automation. Of the 60 not performing an automated group and screen: 41 do not have automation 6 do not use automation for urgent work 8 only use automation within core hours 1 only allows core transfusion staff to use automation 4 did not use automation for EQA related reasons: o 3 to assess manual testing o 1 because the sample was haemolysed. Patient 3 - Additional testing / actions Tables 17 and 18 show additional testing and actions undertaken, either before 90 minutes or after 90 minutes but before the next session of core hours. An entry of no data indicates that this information was not requested in the questionnaire. Table 17: Additional testing within minutes and after 90 minutes but before core hours Number undertaking additional testing (n=315) After 90 minutes but Total Further testing Within before the next session minutes of core hours Antibody identification 291(92%) 9 (3%) 300 (95%) 1 Patient phenotype 119 (38%) 60 (19%) 179 (57%) 2 Crossmatch 58 (18%) 6 (3%) 64 (20%) 1 A further 12 stated that they would refer for antibody identification 2 A further 48 stated that they would refer for antibody identification Table 18: Actions that would have been taken within minutes and after 90 minutes but before core hours Number (%) After 90 minutes Total Further actions Within 90 but before core minutes hours Identify antigen negative units in stock 97 (31%) 74 (23%) 171 (54%) Order antigen negative blood from blood (69%) (57%) 37 (12%) service Inform clinical team of potential delay 286 (91%) 6 (2%) 292 (93%) Try to ascertain transfusion history 195 (62%) No data 195 (62%) Try to ascertain antibody history 190 (60%) No data 190 (60%) Seek advice from another member of staff 25 (8%) No data 25 (8%) Other 7 (2%) 25 (8%) 32 (10%) 1 70 of these would also try to identify antigen negative units in stock Other actions included completing testing started in minutes, obtaining a sample to refer, contacting clinicians (to enquire about the patient s potential blood requirement, to try postpone the operation, or to update them on progress of the investigation), checking the patient s haemoglobin result, and checking stock levels. One laboratory performing a group and screen, would not undertake any additional tests / actions within minutes, or before the next session of core hours. Page 62 of 69

66 Appendix 7 General policy questions Second sample requested A second sample would have been requested for Patient 1 (group A D positive, inert) within minutes by 68/333 (20%) laboratories, and for Patient 3 (group A D negative, anti-jk b ) within minutes by 112/315 (36%) participants. Samples from Unknown patients Red cells of a different group would have been selected for Patient 1 (A D positive) by 46/333 (14%), if the sample had been from an unknown patient. Table 19 shows how samples from unknown patients are named, and Table 20 how they are numbered. 32 respondents stated that these questions were not applicable to their case-mix, and a further 31 did not specify whether the emergency numbers used were sequential or not. Table 19: Naming systems for unknown patients (n=301) Response Number (%) Unknown or equivalent 260 (86%) Fictional names using the radio alphabet, eg Tango Delta 10 (3%) Fictional names using a different system 24 (8%) Barcode system to provide additional ID and link patient sample 7 (2%) Table 20: Numbering systems for unknown patients (n=270) Response Number (%) Sequential unique numbers 166 (61%) Non-sequential unique numbers 97 (36%) Barcode system to provide additional ID and link patient / sample 7 (3%) Use of D positive blood for men and for women beyond childbearing age. 158/331 (48%) have a policy for issuing group O D positive red cells for men 148/327 (45%) have a policy for issuing group O D positive red cells for women not of childbearing potential, defined as over: o 45 years by 3 (2%) o 50 years by 31 (21%) o 55 years by 2 (1%) o 60 years by 112 (76%) Policy for selection of emergency O D Negative blood Table 21 shows the specification of group O D negative units selected as emergency flying squad blood. Table 21: Emergency O D negative blood Specification Number D negative cde/cde (rr) 302 (92.1%) K negative 331 (99%) HbS negative 34 (10%) Irradiated 3 (1%) Other 113 (34%) The other category included 83 selecting CMV negative units, 90 selecting units ABO high titre (HT) negative, and 32 selecting both CMV and HT negative, for all or for specific groups of patients. Page 63 of 69

67 Appendix 7 Discussion and conclusions Limitations of the data The questionnaires asked whether or not a second sample would be requested at or before the completion of testing at 15 minutes for Patients 1 and 2, and if yes, the participants were informed that the test results were the same on the second sample. The questionnaire did not ask at what point this second sample would have been tested, and this would presumably have depended at what point it was received. 78 respondents stated that they would have undertaken testing of a second sample after the 15 minutes but before the next session of core hours (including 19 who answered no to the question about whether a second sample would be requested). It is not clear how many of the 68 participants who said that they would have requested a second sample, took these results into account when issuing blood at 15 minutes. Issue of group specific blood within minutes A blood group was reported within minutes by 89% of laboratories, with approximately 55% undertaking a second cell group within the time; however, 16% of these performed the second test on the same aliquot of cells as the first group, which would perpetuate any error in selection of the correct specimen. This 16% includes six laboratories who stated that they would request a second sample within the time-frame. If we assume that these six took the results of the second sample into account, the figure using the same aliquot of red cells reduces to 12% - the same as was reported in a similar exercise in 2010 (10R9). Sixty five (20%) laboratories issued group A blood for Patient 1 (A D positive), having undertaken rapid grouping on a single aliquot of cells and with no immediate spin crossmatch. This figure reduces to 52 (16%), taking into account those who stated they would request a second sample, using the same assumption as above. BCSH guidelines recommend that following an emergency rapid group, a second test to detect ABO incompatibility should be undertaken prior to release of group specific red cells. This can be a repeat group (forward or reverse) or an immediate spin crossmatch, but it is important to go back to the primary sample to avoid perpetuating any errors in sample identification in the laboratory. Group confirmation on a second sample is clearly the safest course of action as it also provides the opportunity to detect wrong blood in tube, but this may not always be possible, especially in emergency situations. Issue of group O D negative blood In this exercise, 102 (31%) participants selected group O units for Patient 1 (88 O D negative and 14 O D positive), and 33 (32%) of these had completed sufficient testing to meet the BCSH recommendations for issue of group specific blood 1. Selection of group O blood in this circumstance, is a local policy decision based on a risk assessment of emergency testing, with factors including the frequency with which emergency testing is undertaken, differences in methodology between routine and emergency testing, level of blood stocks, skill mix and case mix. The National Blood Transfusion Committee recommends use of O D negative in emergency situations, only until the patient s blood group has been determined, with a limit of two units wherever possible 2. Eleven of the 33 stated that they would have requested a second sample, but again it is not clear from the data whether this influenced the selection of red cells. Detection of dual population D positive/ D negative (50:50) The overall detection rate of the mixed field reaction was only 17% and this varied considerably by the technology used, ranging from 9-10% by tube, slide and BioVue users, to 58% by DiaMed users. The overall detection rate was much higher in the final results submitted, reflecting the increased use of DiaMed and multiple techniques undertaken when the results of emergency testing were combined with the routine follow-up testing. Issue of D positive blood to a young female patient with a dual population of D positive and D negative red cells Sixty laboratories reported UI for Patient 2 within minutes, with 56 citing anomalous reactions vs. anti-d. Six of these (10%) were amongst the 173 who selected D positive blood for Patient 2. More participants said they would undertake additional D typing, seek advice from colleagues, refer to a Page 64 of 69

68 Appendix 7 reference centre and seek a transfusion history for patient 2 than for patient 1, after the 15 minute and during the next session of core hours. Where anomalous D typing results are obtained, females of childbearing potential or patients who are likely to require long term transfusion should be treated as D negative until a confirmed group has been assigned. 1 Additional blood required for P2 after 2 hours Had additional units been requested two hours after the initial sample arrived, assuming that a second (theoretical) sample gave the same results as the first sample, and with no further information available, 99 laboratories would have issued a different group at 2 hours from that issues at minutes. Thirty-one switched from O D positive at minutes to O D negative at two hours, and 68 vice versa. Those moving to issue D positive, were presumably doing so in line with policy on using the patient s own blood group once sufficient testing has been undertaken. Of those moving to D negative, 28 (90%) stated that they undertook additional D typing after the 15 minutes, and it may be that they detected the mixed field reaction during this additional testing. Group and screen P3 Fewer participants responded to the questionnaire for patient 3 than for Patients 1 and 2 (340 cf. 365 and 362). Of those who did submit results, the vast majority (97%) performed an automated group and screen. Eight participants did no serological testing, although two booked the sample into the system, and a further two performed a rapid group only. This sample contained anti-jk b and there would have been a delay in providing blood had testing been left until a request for blood had actually been received. Of those who undertook a group and screen, 99% either performed antibody identification during this session of work or referred the sample to a reference centre. 93% would have informed the clinical team about the potential delay in provision of red cells should transfusion have been required, and 60% would have tried to ascertain the patient s antibody history. Communicating with the clinicians about potential delays to transfusion, even when blood has not been requested, is a crucial part of the service. Where feasible, an antibody history should be sought, as there may be a record of additional specificities having been previously detected but no longer present. Utilisation of a regional or national antibody database is desirable in this respect. Of those with automation, 19 (7%) did not use it to test this sample out of hours: 15 of these stated that they revert to manual testing outside core hours or for urgent work, or in one case where non-core transfusion staff are lone working. SHOT reports demonstrate that ABO grouping errors all occur during manual testing or manual intervention during automated testing 3, and the UK Transfusion Collaborative recommends that all laboratories have full walk-away automation in place 24/7 4. Specification for O Negative emergency flying squad blood 99% specified that their emergency O D negative blood is K negative and 92% cde/cde (rr). 83 (25%) participants stated that they use CMV negative if possible, but several stated that this was restricted to obstetric and/or neonatal patients. Since 2012, SaBTO has recommended that CMV negative red cell components are only required for intra-uterine transfusions, neonates, and elective transfusions during pregnancy 5. Page 65 of 69

69 Appendix 7 Use of D positive blood for men and for women beyond child-bearing potential Less than half (48%) have a policy to give emergency O D positive red cells to men, and 45% to women beyond child-bearing potential. The cut-off used to define child-bearing potential varies, with the majority (76%) using 60 years of age. This cut-off also varies between different guidelines, with the recent compatibility testing guidelines recommending 50 years of age 1. Labelling of samples from unknown patient The vast majority of hospitals label these samples as unknown male or unknown female, rather than assigning a fictional name. The majority also use sequential emergency numbers, which are far more likely to be confused or transcribed incorrectly than if the numbers are non-sequential. This causes a potential problem with patient identification when more than one unknown patient arrives in the Emergency Room during the same period of time. The CMO s National Blood Transfusion Committee for England and North Wales and the BCSH Administration guidelines 7 urge caution with the issue of consecutive emergency numbers that, because of their similarity, have the potential to cause ID errors where there is more than one unknown casualty involved. References 1. BCSH (2012) guidelines for pre-transfusion compatibility procedures in blood transfsuion laboratories. (accessed 2 August 2013) 2. NBTC: The appropriate use of group O RhD negative red cells (accessed 6 August 2013) 3. SHOT reports, (accessed 6 August 2013) 4. UK Transfusion Laboratory Collaborative: Recommended minimum standards for hospital transfusion laboratories Transfusion Medicine, 2009, 19, Advisory Committee on the Safety of Blood, Tissues and Organs: Report of the SaBTO CMV Steering Group. March (accessed 30 July 2013) 6. National Blood Transfusion Committee (2006) Recommendations for Organisation of Hospital Transfusion Services following July 2005 London Bombings. (accessed 31 July 2013) 7. BCSH (2009) Guidelines on the administration of blood components. Page 66 of 69

70 Appendix 8 Data from anonymous questionnaire distributed at the 2013 Annual Participants Meeting in Manchester The 2013 meeting was highly successful, with over 250 delegates registered, and the feedback was excellent. We asked delegates to complete an anonymous questionnaire (one from each hospital) designed to collect information on how our EQA exercises and reports are used. The results are shown in the pie charts to the right. How do we treat EQA material? The purpose of EQA is one of inter-laboratory comparison and in order ensure that EQA reflects clinical practice, EQA samples should receive the same level of testing that clinical samples receive. This means that each sample should go through one or other analyser, rather than both, and should not be tested by a second person unless this would happen with a similar clinical sample. Clearly, EQA samples look different, and these days clinical test results rarely require manual transcription onto paper, although clinical results do sometimes require manual input into a computer. EQA results may therefore require some additional checks for transcription errors in critical areas prior to submission. It s good to see that the majority of laboratories do treat their EQA samples in this way. However, the fact that up to 45% at least sometimes undertake additional testing prior to submission of results, suggests that there is a desire to use the samples to competency assess staff and to EQA all analysers, and perhaps manual back-up techniques. Additional analysers and techniques can be subject to EQA by alternating the samples or exercises, or be assessed by IQC. 31% of participants stated that they use leftover EQA material for IQC of other methods or equipment after submission of results, and similarly 83% for competency assessment of staff. This is of course an acceptable use of spare EQA material, although it is advisable to keep sufficient material for re-testing after the closing date, in case of error (additional samples are offered to laboratories who have made errors, but it is useful to retest the original sample as well). We hope that our new TACT competency assessment scheme will address the issue of several members of staff undertaking the EQA to evidence competency. How do we review the results? CPA and ISO standards require that performance in EQA is reviewed and communicated to staff, and 94% stated that they always or sometimes do this. The BTLP web report now includes a PowerPoint presentation which summarises the material, results, discussion and learning points, with additional educational material where appropriate, to aid in in-house discussions or at regional meetings. 47% of respondents stated that they at least sometimes look at or use this, whilst 7% were unaware of its existence. If you have any suggestions for improving this tool, we would love to hear them. Page 67 of 69