ASCLS Today Volume 32 Number 2

Deb Rodahl, MBA, MLS(ASCP)^CM, ASCLS President

If you want to get something done, just ask a busy person! Why is this? Usually it is because they have a proven track record of getting things done (on time) and they practice the secrets of time management. What are the secrets to time management? The truth is that there are no secrets in time management, just a lot of great tips and tricks. 

If you can manage your time more effectively, you will be rewarded in a variety of ways:

• More time for you and your family
• Less overall stress
• Improved self-esteem

Have you thought about where you have time management issues? Work, home, volunteer activities, other commitments, all of the above? Do you have concerns about work/life balance? The truth is that we own the majority of our time management challenges. Things may conspire against us (flat tires/health/needs of the family) – after all life is unpredictable! However, how we react to these challenges is in our control. You must assess this for yourself. What are your time wasters? 

Minor Time Wasters:

• Interruptions we face during the day
• Being a slave on the telephone
• Unexpected/unwanted visitors
• Needless reports/junk mail
• Meetings without agendas

Major Time Wasters:

• Procrastination
• Afraid to delegate
• Not wanting to say “no”
• Problems with objectives/priorities

There are a lot of things that make it difficult for us to manage our time effectively. Let’s consider some of the most common ones, and see if they apply to you:

• Unclear objectives: It’s hard to hit a target with your eyes closed, and it’s just as hard to accomplish something when you aren’t exactly clear about what you want to. The use of SMART goals (specific, measurable, achievable, realistic, and time-limited) helps ensure your objects are clear and measurable.
• Disorganization: It’s easy to see when your desk is too messy, but sometimes you have to step back and ask yourself if you are taking an organized approach in completing all of your tasks. 
• Inability to say “no”: We all want to be as helpful as we can when others need us, but this can mean taking time away from other priorities to do something we may not have planned. 
• Interruptions: Many times, we are in the middle of accomplishing something really important and the telephone rings. These calls can not only take you away from your task, but sometimes they interrupt your train of thought and you can’t return to where you were without retracing your steps. I know someone who will hang a sign on her door to indicate that she is “in” but to not interrupt. Her staff knows they can bring critical items to her but to hold-off on basic questions or updates.
• More interruptions: We all like to visit with others, but conversations at inappropriate times can cost us time. We need to monitor ourselves on this. Find a way to dismiss yourself from the “water-cooler”, Xerox machine, or hallway conversations. Sometimes I just “apologize” by saying I’d like to stop (stay) – but I’m on a deadline!
• Periods of inactivity: As much as we think we are always busy, there are times in our day when we are not really doing anything. Recognizing and making use of these times can have a positive effect on our efforts 
• Too many things at once: Many of our tasks are not routines. They require concentration to detail. When we are attempting to do too many different things at one time, each individual task suffers as a result. Multi-tasking is not “lean” or productive to efficiency or effectiveness.
• Stress and fatigue: Everyone experiences stress from time to time, and sometimes we actually operate a little better when there is some level of stress. Too much stress, on the other hand, causes our work to suffer and wears us down physically and mentally, leading to burn out. Dealing with stress is an important part of time management
• All work and no play: Most successful people know how to balance work and play. When work takes over your life, you not only give your body little time to re-energize, but you may end up sacrificing the really important things in life like family and friends. My boss recently shared with us that he will work on e-mail catch-up at home, but does not take projects home. This is his commitment to his family to help his work/life balance. 

The obstacles that we face are not insurmountable. Sometimes, the hardest thing to do is to identify that these obstacles exist and are affecting your ability to manage your time. Start by making a list of everything you need to complete (daily, weekly, and monthly). Sometimes the feeling of checking off items on your to-do list can be very motivating. It actually can release endorphins! Try creating a multi-leveled to-do list. Group your list into categories. For example, your work list might be organized by projects, meetings, and routine tasks. Keep a separate list for other parts of your life (home, volunteer activities, school, etc.). If your lists are overwhelming you, maybe you have too much on it – so evaluate your to-do list. Use the Five D’s to make a first pass review of your list (tip – this works for e-mail, too):

• Do: Determine from the list the things you think are most important to accomplish and are things you should do yourself.
• Diminish: Consider perfectionist vs the magic of “good enough.” Resist the temptation to do small, insignificant tasks too well.
• Delegate: Effective leaders do not try to accomplish everything themselves and they recognize that some things are better handled by others. Delegating not only frees up your time for other things, it ensures that resources are used wisely and that others who want to help are motivated and involved.
• Delay until another time: Some things can wait. The danger is delaying too many things until deadlines are near. The best policy here is to consider when things are due, how long it will take to accomplish them, and what your current workload will allow. It makes sense to delay things that are not due when you’re overburdened and to accomplish them ahead of time when you can.
• Delete: You may recognize that some of the items on your list are not achievable or realistic, or that they are just not important. A good leader knows when to concentrate on the important and eliminate the rest. 

These are just a few helpful tips for time management and organization. Not all tips work for everyone, you just have to try and see what works for you. However, remember that it takes at least 30 days for a new activity to become habit, so practice, practice, practice!

D. Wayne Wilson, B.S., MT(AMT)

Medical laboratory scientists use their acquired scientific knowledge to correlate a patient’s medical history and laboratory results to validate the patient’s diagnosis. The new information presented is influential in interpreting results, as should be the goal when new ideas are encountered. Diverse ideas are synthesized into new innovative ideas in the same fashion as organic chemical molecules. 
The initial idea is the primary molecule with a set pH, in the presence of solvents and catalysts. The presentation of the idea is as vital as the stereochemistry of the molecule to initiate a reaction. The forum must be the correct venue with the correct language for the appropriate targeted audience. This is as essential as the pH is to avoid an inert reaction. Different paradigms are floating in the environment like the solvents. In the optimal environment, solvents spontaneously react with the initial molecule in a concerted manner to produce a new, stable, diverse product. 

The initial idea, like the initial organic molecule can undergo a variety of reactions, such as, substitution, elimination, or an addition reaction to produce the final product, the new idea. A single reaction or series of reactions can take place depending on us, the catalyst. The catalyst is how quickly we can open our mind toward alternative ideas. The faster we are open to listening and investigating the truth, the faster we expedite the reaction process. People in the same setting from different cultures and backgrounds with different experiences learning from each other is a culture of diversity. This creates a habitat that is efficacious in avoiding stagnation and recognizing innovation. 

On the surface, advocating for diversity appears to be a simple concept. However, to fully embrace diversity requires a conscious effort. People in the same setting from different cultures and backgrounds with different experiences is the starting point for cultivating a culture of diversity. 

The difficulty in embracing diversity is allowing ourselves to be open and influenced by new ideas from someone who is different from us. The dilemma lies in the potential destruction of our ideas and convictions we have nicely wrapped in our mind, forcing us to return to the drawing board in search of truth and rationality. The most basic questions can challenge the status quo of doctrine that has been accepted as the unmitigated truth. 

As field experts, the notion of an outsider or perhaps an amateur questioning scientific dogmas may elicit the disposition of being attacked from someone with inferior knowledge. Ideas and questions examined in a diverse environment without biases lends itself to the true pursuit of knowledge. Einstein’s resolve to gain clarity from a contradicting idea remained intact for ten years of contemplation before he developed the Theory of Relativity. Curiosity was the key driver of Einstein’s skepticism, as he maintained an open mind opposed to accepting the status quo. 

A truly embraced diverse environment creates a focal point that is modeled to recognize innovation. The fruits of diversity are a highly-demanded commodity that requires maturation in emotional intelligence. Receptivity to diverse ideas in opposition to our own, is the antithesis of human behavior. Social psychologist, Dr. Leon Festinger, developed the Cognitive Dissonance Theory which describes the need for consistency and the influence it has on human behavior. The beliefs we hold are often consistent with our actions, and if we recognize our actions are not congruous with our beliefs the result is dissonance. To mitigate the discomfort of dissonance we change our beliefs, actions, or perception of the action. The feeling of being right can be intoxicating, in contrary to the inevitable dreadful feeling associated with being wrong. 

Human nature has the propensity to unconsciously pursue its own interest, lose sight of the overall good, and rationalize our actions. In the face of adversity directed at the medical laboratory sciences profession, licensure has been at the forefront as a potential solution. A seasoned leader in the medical laboratory sciences professional community may advocate for licensing, while a new professional may be in opposition. The seasoned leader could allow cognitive dissonance to manifest in his/her mind and paint the following picture. 

“If you are correct, then I am wrong and led the profession in the wrong direction. If you are correct, you are intelligent and more knowledgeable than I am. If you are right, you solved the conundrum that I have contemplated for years while you were probably in diapers.” Cognitive dissonance compensation: “I know this is not the case. This individual is new to the field, and does not have a clue to what they are talking about. I am an expert. This new professional needs to be quiet, listen, and learn something. I will put them in their place.”

A great foundation to establishing a substantial dialogue when two counter ideas come into contact is to adopt the ideology, seek to understand before being understood. With this approach, new ideas may permute into “One Voice and One Vision.” To avoid succumbing to counterproductive thinking, a leader must examine his/her thoughts and become self-aware. A leader is often measured by the ability to groom leaders. Respect for each other, respect for years of experiences in the field, and respect toward new ideas are fundamental principles to grow. When an organization has a leader who places the overall good of the profession before themselves it becomes contagious. An intricate component of an efficient laboratory is bi-directional interfacing between the LIS and instruments. Manual entry of patient information and test results is an arduous process and avoided at all costs. Likewise, communication, receptivity to alternative ideas, and learning from each other must also be bi-directional to embrace a culture of diversity, which often naturally elicits innovative ideas.

Judy Moore, B.S.

Part 1 of this article appeared in the February 2018 issue and discussed a ranking system created by the AABB to prioritize emerging infectious diseases (EIDs) based on their risk to the blood supply. Three were ranked in the red category which indicated highest priority. They are human variant Creutzfeldt-Jakob disease (vCJD), Dengue viruses (DENV), and Babesia species. 

vCJD is a transmissible spongiform encephalopathy (TSE) caused by a prion. It has a long incubation phase and is 100% fatal. There are no treatments available to reverse the disease nor are there laboratory tests to screen donor blood or detect infection. Diagnosis is based on symptoms or autopsy. Donor screening is based on whether there is a family history of vCJD or if the donor traveled or resided in the UK and Europe where the majority of cases have been reported. These situations would indefinitely defer the donor. A diagnostic test, however, could be forthcoming. A recent study reports being able to detect asymptomatic carriers of the prion using “plasminogen-bead capture and protein misfolding cyclic amplification (PMCA) technologies” with >99% specificity.¹ 

Dengue viruses (DENV) are flaviviruses transmitted by Aedes mosquitoes. Although typically found outside of the United States, there are some endemic regions in Texas along the border with Mexico and there have been outbreaks in Hawaii, Texas, and Puerto Rico. The virus can cause subclinical symptoms or it can cause a feverish disease with pain and rash and can progress into a hemorrhagic disorder which has a high mortality rate. It was placed in the red category for multiple reasons: the high incidence of asymptomatic infections accompanied by viremia, the detection of viral RNA in blood donors from endemic areas, the ability to cause epidemics, and the presence of the mosquito vector in the US. There are currently no donor questions regarding Dengue risk nor is there a blood screening test. However, there is a travel deferral based on travel to malaria endemic regions which overlap with DENV endemic areas. The deferral would at least capture some of the potentially DENV infected donors.² 

Babesia species are protozoa that infect red blood cells. They are transmitted by the Ixodes tick and are found in the eastern United States. There are over 100 species of Babesia although only a few are considered pathogenic in humans. Babesia microti is responsible for most of the cases of babesiosis in the U.S.³ The disease can be mild or it can be severe and fatal in immunocompromised individuals by causing hemolysis, DIC, and eventually organ failure. The incubation period can be 1-6 weeks after a tick bite and there have been over 70 cases of transfusion-transmitted cases of B. microti in the United States.² (Another study states there have been 159 cases of transfusion-transmitted cases in the U.S.)⁴ There is no blood donor screening test, but like vCJD, that could be changing. In a 2012-2014 study, the American Red Cross screened and removed 335 positive B. microti donor samples from 89,153 screened samples. The screening assay used PCR to detect B. microti DNA and arrayed fluorescence immunoassays (AFIA) to detect antibodies. Positive samples were followed up with quantitative PCR testing and infectivity testing. During the same study period, there were 14 probable cases of transfusion-transmitted babesiosis from 253,031 unscreened donor samples and zero cases from the screened samples. This indicates that the screening assays can successfully reduce the transmission risk of B. microti from blood transfusions.⁴ This would be superior to the current practice of simply deferring a donor based on a questionnaire which is considered ineffective.^4,5 

Prioritizing EID threats among the dozens of EIDs can help policy makers decide where to allocate limited time and resources and how to prepare to meet an increased threat.⁶ Lou Katz, chief medical officer of America’s Blood Centers, suggests a zero-risk model cannot be achieved because it would require unlimited resources which is not reality. Risk-assessment must be used to make decisions in blood banking.⁵ The numerous blood suppliers throughout the country have different degrees of risk and different donor populations. The appropriation of time and money will depend on the unique circumstances of that entity as well as complying with law. For the foreseeable future, blood products will be needed so the risk of transfusion-transmitted infectious diseases is not likely to vanish, but it can be reduced by recognizing potential threats and preparing for them with current knowledge and abilities. 

REFERENCES 
1. Bougard D, Brandel JP, Belondrade M, et al. Detection of prions in the plasma of presymptomatic and symptomatic patients with variant Creutzfeldt-Jakob disease. Sci. Transl. Med. 2016;8:370ra182. 
2. Stramer SL, Hollinger FB, Katz LM, et al. Emerging infectious disease agents and their potential threat to transfusion safety. Transfusion 2009;49:1S-29S. 
3. Centers for disease control and prevention. Parasites-babesiosis. https://www.cdc.gov/parasites/babesiosis/biology.html; March 2, 2017. 
4. Moritz ED, Winton CS, Tonnetti L, et al. Screening for Babesia microti in the U.S. blood supply. N Engl J Med 2016;375:2236-45. 
5. Fusco L. Maintaining the safety of the blood supply against the threat of emerging transfusion-transmitted diseases. AABB News 2017;19:012-7. 
6. Brookes VJ, Del Rio Vilas VJ, Ward MP. Disease prioritization: what is the state of the art? Epidemiol. Infect. 2015;143:2911-22.

Marianne T. Downes, PhD, MLS(ASCP)^CM

The American Red Cross reports that in the United States, platelet transfusions are needed every 30 seconds.ⁱ This translates into a need of over 1 million platelet units annually. Platelets are clinically useful in a wide array of situations including correcting platelet loss due to massive hemorrhage, platelet deficiency secondary to chemotherapy, and supportive therapy for selected congenital platelet defects. Much of this need is met using single donor apheresis platelet concentrates (SDA-PC) which contain ≥3.0 x 1011 platelets suspended in a variable amount of donor plasma. 

While there are studies that have shown increased platelet survival when ABO-compatible platelets are administered, there appears to be no difference in the clinical bleeding outcomes of patients administered ABO-compatible or ABO-incompatible plateletsⁱⁱ which leads to the therapeutic usefulness of major and minor ABO-incompatible platelets. The plasma contained in SDA-PC puts patients at risk of a hemolytic transfusion reaction (HTR) due to minor ABO incompatibility. While rare, HTRs due to the transfusion of Anti-A, Anti-B, and/or Anti-A,B antibodies into recipients with the reciprocal RBC antigens do occur and have been reported as contributing to adverse outcomes, including death, due to HTR in annual Serious Hazards of Transfusions (SHOT) reports and the FDA’s annual report. The risk of an HTR from transfusion of minor ABO-incompatible platelets is estimated at 1/9000.ⁱⁱⁱ 

The 29th edition of the Standards for Blood Banks and Transfusion Services published by AABB only recommends that facilities should have a policy in place to minimize the amount of incompatible plasma transfused into patients^iv, but there is no nationwide policy in place. Some facility policies take no consideration of ABO type and use platelets on a first-in/first-out basis due to the short shelf-life of the product and to keep wastage minimal. Other facilities transfuse ABO-identical platelets whenever feasible, and ABO-minor compatible whenever possible among a range of other policy variations. As reported by Joan Cid, Sarah K. Harm and Mark H. Yazer in their aptly named article “Platelet Transfusion-the Art and Science of Compromise,” each transfusion service must employ its own policies based on needs and keeping abreast of the current literature and still unanswered questions in transfusion science.^v 

While certain compromises must be made, given that transfusion of platelet concentrates worldwide contribute to nearly 25% of adverse events, a recent article in Blood Transfusion calls for improving the safety and efficacy of platelet transfusion.vi One suggested method of improving the safety of platelet transfusion includes using platelets with low-titer Anti-A and Anti-B antibodies when minor ABO-incompatible platelets must be used. Theoretically, this would lower the risk of HTR associated with platelet transfusion, but as yet there is an unsatisfying amount of data supporting the efficacy of such a policy.ⁱⁱⁱ There are similar concerns and issues surrounding use of whole blood.

Part of the reason for lack of good data is there are a variety of methods by which titers can be performed (gel verses tube, testing serial dilutions of plasma verses positivity at a “trigger threshold”) and no consensus as to the titer threshold by which to consider low-titer and high-titer platelets. Various studies report cut-offs for designating high-titer anywhere from ≥1:64 to ≥1:250. Testing protocols vary widely. A local clinical affiliate for West Virginia University’s Medical Laboratory Science program aseptically separates a segment from only type O SDA-PC, dilutes the plasma 1:100 and tests against A1 cells for macroscopic agglutination by tube method. Those units whose diluted plasma yields agglutination are labeled “high-titer” and transfused only to type O recipients. There is no testing of Anti-B titers in platelets at this facility as HTR due to Anti-B is rarer than to Anti-A. A different facility reports the use of 1:20 dilution of plasma tested against A₂B cells on microtiter platesⁱⁱⁱ to determine high-titer units. Thusly, it is difficult to compare data across centers. One method suggested to increase safety is for instrument manufacturers to develop and validate automated Anti-A and Anti-B titer screening.ⁱⁱⁱ Another potential step would be if product suppliers were to implement validated titers on all platelet products, there would be consistent and comparable data to evaluate. A more robust reporting system that captures all adverse events, not just fatal events, would yield a more comprehensive body of outcomes from which to draw conclusions. 

In conclusion, while we are not yet ready for implementation of new standards, we do appear to be moving in that direction. With the collection and reporting of more data, especially data that might indicate reduced risk of HTR when low-titer minor ABO-incompatible platelets are transfused verses no titer designation, we can feasibly make platelet transfusion safer and hopefully reduce the risk of HTR due to transfusion of minor ABO-incompatible platelets. 

ⁱ American Red Cross. Platelet Donation. http://www.redcrossblood.org/platelets accessed 10/2/2016.

ⁱⁱ Triulzi DJ, Assmann, SF, Strauss RG et al. The impact of platelet transfusion characteristics on posttransfusion platelet increments and clinical bleeding in patients with hypoproliferative thrombocytopenia. Blood. 2012; 119: 5553-62. 

ⁱⁱⁱ Valsami,S, Dimitroulis,D, Gialeraki,A et al. Current trends in platelet transfusions practice: The role of OBO-RhD and human leukocyte antigen incompatibility. Asian J Transfus Sci. 2015; 9(2): 117-123. 

^iv Standards for Blood Banks and Transfusion Services 29th ed. AABB, Bethesda, MD. 2014. 

^v Cid J, Harm CK, Yazer MH. Patelet transfusion- the art and science of compromise. Transfus Med Hemother 2013; 40 160-171. 

^vi Garraud O, Congnasse F, Tissot, JD, et al. Improving platelet transfusion safety: biomedical and technical considerations. Blood Transfus. 2016; 14; 109-22.