Musings by Malcolm Needs: Regrets, concerns, challenges
This blog is a follow-up to Malcolm's earlier ones and presents his musings on regrets, concerns. and challenges for the profession going forward.
MALCOLM'S MUSINGS
AUTOMATION
With the advent of more reliable automation, the skill mix of hospital laboratories has changed drastically in the last few years, and fewer and fewer Biomedical Scientists are being employed, whilst many posts are now filled with laboratory assistants who can “feed” the machines, but who are unable to interpret results, especially if these results are atypical. This has resulted in a greater number of “easy” samples being sent to the reference laboratories that would, in days’ bygone, have been resolved at the hospitals. This, I hasten to add, is not the fault of the staff in the laboratories, but is a result of the decisions being made at a much higher level of management. One hesitates to think how some of these hospital laboratories would cope with the number of patients that would be expected after a major incident.
Nonetheless, two huge advantages of automation over manual techniques are
- Ability to have positive sample identification
- Automation 'reads the tests' in the same way whatever the time of day or night (in other words, the 'eyes' of the automation do not get 'tired').
LEAN
As you will be aware, the UK, like many other countries, is going through a recession. As a result, budgets are being cut (some drastically). At the same time, laboratories have been introduced to the concept of LEAN working. Without a doubt, there have been improvements in the way laboratories have been run, with less waste but, also without doubt, there is a time and a place for everything. Let me explain.
Whilst I appreciate that LEAN has its place, and has improved the wastage figures in most laboratories, it cannot be regarded as 'the be all and end all' or 'the panacea for all ills' in all laboratories. Indeed, it is possible to 'over LEAN' a laboratory, in particular a Red Cell Reference Laboratory, where there is a need to have the freedom to select suitable reagents for the investigation to get accurate results. Such a choice, in experienced hands, could actually prove less wasteful than sticking to the LEAN dogma and using the reagents dictated by this dogma.
The blind introduction of LEAN into all aspects of all laboratories may, under certain circumstances, have exactly the opposite effects than those desired.
In a way, what I am trying to get across is the fact that, when I started out, Health and Safety in the laboratory tended to stop at putting on a laboratory coat (certainly smoking was allowed, or, rather, tolerated) and so we needed to 'pull our socks up' in this area, which we did. However, it got to the stage at one point where it became almost impossible to undertake the day's work without breaking some rule instigated by the 'H&S police'.
Similarly, when I started out, there was no such department as Quality (although there was certainly quality in the work performed). Now, we are being 'led by the nose' by both the Quality Department and various accrediting agencies. Most disagree with each other, leading to copious congratulations from one for some technique, and a stern non-conformance from another, again, making some of our work almost impossible.
An improvement in both H&S and Quality was, without doubt, desperately required, but both ended up going 'well over the top'. My comment about LEAN is that there is a danger that the same may happen, and that there is already evidence that precisely this has happened.
STANDARDISATION
Without trying to be either provocative or insulting, and within reason, the Processing, Testing and Issuing of units of blood and blood components is the same for one unit as it is for the other hundreds that are collected day after day, throughout the country. On the other hand, the samples we receive for reference work are patient led in terms of what tests are required, and what advice needs to be included on the reports. Certainly, some samples are very similar to other samples, such as those antenatal reference samples with anti-D in a pregnant woman, all of which would be dealt with in an identical way, resulting in reports that vary only a little.
However, other commonly seen reference samples, such as those from patients with a positive DAT or with multiple antibodies, cannot, and should not, be treated in exactly the same way as one another, and require a report with more detail than available “canned comments” that can be added with the stroke of one or two keys on the keyboard.
Herein lies the problem. In an effort to streamline the way the laboratories work, and to
standardise the work, a “one size fits all” plan of campaign has been forced onto all of the reference laboratories within
NHSBT, with little thought to the differences seen in the kind and number of hospitals served by the laboratories (e.g. the large London Teaching Hospitals that attract patients with rare or, at least, unusual conditions) and the mixture of ethnic concentrations in their various catchment areas. At the same time, the laboratories are expected to work extended hours, with the same number of staff (or with a minimal increase).
It was forecast that this would bring down the morale of the staff, that people, including those with the most experience, would start to leave and mistakes would be made. Sadly, this forecast has proved to be true, but, in addition, because the staff are reluctant to perform extensive testing beyond that which is prescribed by the LEAN process, more and more samples are being sent on to the
IBGRL (in essence, the reference laboratory for the reference laboratories of NHSBT) that they are becoming overwhelmed and their own turnaround times are beginning to become unacceptable.
It is not all doom and gloom, though! Indeed, far from it.
RBC GENOTYPING
NHSBT
Red Cell Immunohaematology Laboratories are (finally) being dragged kicking and screaming into the 20th century (Yes, I do mean the 20th C!) and are now capable of performing genotyping (something our Histopathology and Immunohaematology colleagues have been doing for years with HLA testing). Granted, the genotyping technology being used has been described as “quick and dirty” by some. More specifically,
the molecular technology used in the RCI laboratories is able to detect either the presence or absence of a particular (known) gene at a locus, whereas that used at the IBGRL can be used for complete gene sequencing (e.g. to detect and specify a Partial RHD gene). But, until recently, any molecular techniques looking at predicting red cell antigen expression had to be sent to the IBGRL, and so this is a vast improvement.
In addition, and from the antibody identification side, we are also beginning to use
recombinant blood group proteins (as described to me primarily by
Axel Seltsam in Switzerland (
photo), on a course on which we were both lecturing), and I think these will really come into their own in the next few years.
PAT'S MUSINGS
Based on this blog, Malcolm's third, I wrote most of my comments in a separate personal TM blog, Four Strong Winds (Further Reading). That blog dealt with automation, LEAN, standardization, and blood group genotyping. Of course, my views are not necessarily Malcolm's but it was fun to feed off his musings and offer my takes on his '4 strong winds'.
About Malcolm's mention of
recombinant blood group proteins, I must admit this development had not made it into my brain, maybe because to push its way in, something would need to be jettisoned. Perhaps all that passé blood group serology hogs my neuronal connections and resists being tossed out? To my knowledge no routine transfusion lab is anywhere close to using recombinant blood group proteins. When that becomes a reality, it will be fascinating to see diagnostic companies pivot to dissing reagent red cells as so....20th C.
Regardless, I searched PubMed and found papers on recombinant blood group proteins dating back 10 years. See Seltsam (Further Reading).
Comments are most welcome. No matter where you live and work, I hope you have enjoyed Malcolm's blogs outlining his UK experiences over a long career. Please add to the record of what it was (or is) like to work as a transfusion professional, perhaps contrasting your experiences with Malcolm's. Can you add to the discussion on automation, LEAN, standardization, and blood group genotyping? If uncomfortable with commenting using the web interface, if you write
[email protected], she can add your comments as 'Anonymous' or attribute them, if you prefer.
Further Reading
TM blog: Four strong winds (Musings on trends identified by Malcolm Needs' 3rd CSTM blog)
Seltsam papers: