MEDT 25 – CLINICAL INTERNSHIP 1 (EACMC) 1

5th ROTATION: ISBB (SIR ANTHONY B. DIRAIN III, RMT, MLS(ASCPi)

SEROLOGY At risked populations present in the Philippines:

In EACMCC, 2 methods of serological testing are performed – ▪ Female sex workers ▪ Males who have sex with other
Immunochromatography, and ELISA. ▪ Male sex workers males
▪ Injecting drug users ▪ Clients of sex workers
IMMUNOCHROMATOGRAPHY TESTS:
▪ Immunochromatography assay What puts Filipinos at risk for HIV?
▪ Lateral flow assay ▪ Unprotected sex with >1 partner
▪ Used to detect the target analyte – our target analyte is either antigen or antibody. ▪ Injecting drug with USED needles
▪ Spx: Plasma, serum, whole blood ▪ Mother that was HIV+
▪ Rapid diagnosis (average of 15 minutes) ▪ **Transfusion – the percentage for cases like this is not that high because before
▪ Screening Tests: we proceed to blood transfusion, the person has to undergo screening tests for
o HIV, HBsAg, Anti-HCV, Syphilis TTIs (transfusion transmissible infections – e.g., Hepa-B, Hepa-C, Syphilis,
Malaria, and HIV) first.
Interpretation of Result:
▪ Reactive = presence of bands on QUALITY ASSESSMENT PROGRAMS (PROFICIENCY TESTING)
control and patient lines. ▪ Verifies that laboratories are proficient in their testing process (produce accurate
▪ Non-Reactive = presence of results).
control band only. ▪ We have 2 types of Quality Assessment Programs:
▪ Invalid = no band formation o IQAP/ IQAS – performed only within the hospital/ laboratory premises; (daily
– e.g., Quality Control)
NOTE: every time we process immunochromatography kits, we should expect that there is o EQAP/ EQAS – the NRL for Serology and Sexually Transmitted Infections –
always a band formed in the control line. SACCL (STD/ AIDS Cooperative Central Laboratory), will send samples
(annually) to laboratories enrolled in them. Then, whatever the results of the
RAPID PLASMA REAGIN (RPR): samples they sent; it has to be input/ encoded in their portal. After encoding/
NOTE: This was what EACMCC formerly use for the screening test of syphilis, but they switched due date, that is the time when they will assess the results from different
to immunochromatography because there were some patients with reactive results in RPR even laboratories enrolled. Certification will be provided – if passed, Certificate
though they do not really have syphilis; because in RPR, we have this what we called – of Achievement will be given; but if failed, Certificate of Participation.
“biological false-positive” (those that are chronic drinkers, old age). Immunochromatography
assay for syphilis is more accurate. Why is EQA Important?
▪ To evaluate the overall performance of laboratories;
▪ Test Principle: Macroscopic Flocculation ▪ To identify problems;
▪ Test Type: screening test for syphilis (rapid test); but this is NOT SPECIFIC ▪ To collect information; and
▪ Target Analyte: Reagin ▪ To establish information exchange network.
▪ Carrier: Charcoal particles
▪ Spx: plasma & serum EQA Should Lead to Corrective Action:

Interpretation of Result: TAKE

IDENTIFY
▪ Reactive = presence of flocculation EQA CORRECTIVE
PROBLEMS
▪ Non-Reactive = no flocculation (common ACTION
sense diba? eme!)
▪ Corrective Action – this is the action taken to correct a problem or deficiency.

ENZYME-LINKED IMMUNOSORBENT ASSAY (ELISA): NOTE: In EACMCC, they have logbook for corrective actions. For example, there was a problem
▪ ELISA is first called with their EQAS, they will rerun the sample. Once you identified the problem, it has to be fixed/
“Radioimmunoassay” (RIA). resolved. Before encoding, there has to another medtech who will serve as a verifier.
▪ Used to detect either antigen or NOTE: (According to Ma’am Ja) On the arrival of NEQAS, you will receive 3 or 4 batches of
antibody; same with serum – 5 samples for Hepa-B, % samples for Hepa-C, 5 samples for syphilis, and 5 samples
immunochromatography, but ELISA for HIV. Samples sent depend also on the availability of the machines in your hospital.
is much more tedious because it NOTE: (According to Ma’am Ja, again) As mentioned by the National Voluntary Blood Services
requires the use of many reagents Program (NVBSP) of DOH, the target population for blood donation is 1% of the population. We
and other procedures like incubation. have a high number of populations in Cavite, but until now, we haven’t met that 1% yet. One
▪ Conjugate (enzyme) attaches to the factor is improper information dissemination, another is the connotation that they don’t want to
target analyte – antigen or antibody. donate because there are others who can donate so they no longer have to, or others who just
▪ Substrate catalyzes the enzyme to form a color change or fluorescence. go there just to know their STD status.
▪ OD (optical density) is then measured by a machine; cut-off calculation follows.
Q&A
(image in the upper right is the ELISA plate; images below are the EIA Reader, Washer, and Q: Regarding blood transfusions, I know that proper communication is the key to avoid
Incubator, respectively) miscalculations in blood transfusion; I want to know what are the SOPs of blood bank to
avoid miscalculations when giving blood bags/ units?
- In EACMCC, our SOP before we release a blood unit is that there will be a second
medtech who will verify, and nurse as the third verifier. Whatever information is
indicated in the ‘blood releasing’, that should also be indicated in the logbook and
the blood unit. All in all, 3 people (primary medtech, secondary medtech, nurse)
verify it.
Q: What samples are being sent by NEQAS?
- Actually, the samples they send are the same samples they receive from SACCL.
NOTE: Regarding the use of the incubator, since we do not always process HIV and Hepa-B,
Samples from real patients.
we turn the incubator off. We will just turn it on if it is needed for processing and once it reached
Q: Are those samples (from NEQAS) preserved upon receiving, since logistics will take
37 deg. C, that’s when we will proceed to testing.
some time?
- When samples are being sent to enrolled laboratories for EQAS, they are stored in
Interpretation of Result:
ice (not directly, just enough for the optimal storage temperature to be maintained).
▪ Reactive = OD reading is above the cut-off value. Also, the samples come with survey forms (if you received the samples, if samples
▪ Non-Reactive = OD reading is below the cut-off value. are stored in ambient temperature, if samples are still in good condition).
 MEDT 25 – CLINICAL INTERNSHIP 1 (EACMC) 2

- Yes, there are sections in the laboratory (e.g., chemistry section) that requires
reconstitution of the sample for NEQAS, but in serology, no reconstitution is needed
since they are serum already – all you have to do is just follow the instructions
written in the box. The instruction usually is to centrifuge the sample first for 10
minutes, mix, then proceed to testing.
Q: For example, if the blood is for STAT request, what is the SOP if the blood is
disturbed? What if there’s miscommunication?
- We advise the physician or the requesting party that the blood is still disturbed,
cannot be transfused yet, and still needs to stand for at least 4-6 hours for the red
cells to settle. Before they actually request for STAT, they inquire first in the
laboratory.
- If there’s miscommunication, we will assess who committed or caused the problem
with the communication. That is why here in the blood bank, we have tons of log
books because just like what our chief medtech says, “you cannot claim that you
did something if you do not have any proof”.
- (Additional answer from Ma’am Ja: For example, you are relaying information
from a different department (e.g., nurse station), always see to it that you note
whoever staff you talked to because it will be questionable if you will just claim that
you talked to this staff but you did not take note of it. That is the importance of call
logs. But for example, the request for transfusion is STAT and we told the physician
that the blood is disturbed and cannot be packed yet, sometimes, what the
attending physician does is that they change the request from ‘packed RBC’ to
‘whole blood’ so that it can be transfused to the patient right away. With this,
changes happen like deferrals, so on and so forth; we also make review and make
changes with the forms involved, change the crossmatching, and we will tell the
attending physician if the blood is ready for release.)
- Here in EACMCC, for every blood unit (A, B, O) we make stocks of 1 whole blood
and 1 packed RBC, except for AB – bihira lang magrequest nito.
Q: Have you experienced a case where a blood unit has to be returned because it is not
yet the time for transfusion?
- Yes, we experience such case in EACMCC. Before we release the blood unit, we
inform the nurse that if the blood unit cannot be transfused within 30 minutes, it has
to be returned in the blood bank laboratory so that we can put it back on its ambient
temperature. Because if they return the blood unit beyond 30 minutes, we will no
longer accept it, or we will accept it but it will then be subject for disposal already.
That is actually DOH’s order; sometimes, if it is beyond 30 minutes but it is still cold,
we accept it. If it is already warm and poked, we will not reissue it.
- (Additional answer from Ma’am Ja: In our hospital as well, we do make sure that
if the nurse (for example) said that they already have to pick up the blood unit, we
have a policy stating that the nurses should have checked and secured the IV line,
checked the patient’s vital signs if it is within range, already; because if they have
not done it yet and our blood bank already released the blood unit, it will cause
delay in transfusion and will exceed the 30-minute rule. This is actually the primary
rule of AABB and ISBT that was discussed in the 38th convention of PBCC.)
Q: What do you do in cases where the patient experiences adverse reaction upon
transfusion?
- In EACMCC, the nurses are the ones who transfuse blood to a patient. What they
do in such case is that they stop the transfusion. It also depends on the physician’s
advice since they are also present in the transfusion site.
- (Additional answer from Ma’am Ja: So, for example, an adverse reaction
occurred, it is the physician’s discretion if he/she wants to investigate. In the
investigation, the laboratory will require certain specimens.)
- In EACMCC, the nurse will get transfusion investigation form and while they are
filling the form out, we collect blood from the patient for liver function test. We also
collect the first and fifth urine output of the patient. Whatever the result of that is,
we inform the chief medical technologist and the pathologist.
Q: Is NEQAS participation free or there is a registration fee needed to be included?
- There is a registration fee. They will not release or distribute samples unless
otherwise it is paid. There is also a deadline to when you can only pay for the
registration; if you were not able to pay on or before the deadline, your laboratory
will not be included, or there can be a penalization.
Q: Based on your experiences, what are the current challenges being experienced by the
immunology, serology, and blood bank?
- The only major problem being experienced in our laboratory is typographical error.
It is inevitable that is why in such cases, for example we released a wrong result,
we inform the patient that his/her result has to be changed. In EACMCC, whoever
(medtech) delivered the wrong result, they will be the one to bring the right result
to the patient’s house (in cases of out-patient).