A transfusion medicine physician in San Diego reports that one of the ER physicians at his hospital has asked the hospital transfusion service to issue RhIg for a patient who had a spontaneous abortion at less than 8 weeks gestation (first trimester). The ER physician wanted to give the RhIg without sending a 'current patient sample' for Rhesus typing, to save the patient the cost of the Rh typing. The ER physician had 'checked' the computer and saw that the patient had previously typed as D Negative. In addition, not only does the record state the patient is Rh negative but the patient herself stated the same. At her THREE prior deliveries (all at the San Diego physician's facility) she had Rh prophylaxis, so that the request to skip yet another Rh typing on this patient is not based on relying on a medical or computer "record" alone, but on what the patient states which is in concert with the record. However, in spite of the aforementioned details, the ER physician's request was in direct conflict with hospital transfusion service policy which required Rh typing of a current patient specimen before the blood bank could issue RhIg. The ER physician thinks that the transfusion service policy is ridiculous since the computer and the patient indicate that the patient is Rh negative. The transfusion service physician is sympathetic to the ER physician and wonders if any regulations exist that a second, third, fourth, etc. Rhesus typing must be done for such a patient who is a candidate for a mini dose of RhIg. (A mini dose was requested becauses she was in her first trimester.) Both the transfusion service and ER physicians wonder if the medical record and the patient's remembrance is sufficient evidence of D typing status, acknowledging that patient identification can never be 100% guaranteed. Would others dispense the RhIg without typing the patient again? If not, what would you say to the ER physician? Of course you could argue (which the San Diego blood banker chose not to do) that a current patient sample should be submitted to see if the patient has become alloimmunized to D, realizing that the ER physician is likely to reply, "it is cheaper to give the mini dose than do the antibody screen and ID."

The following comments have been received.

ADDENDA Nov. 30, 2004

1. A colleague at a hospital in Texas reports that her facility's blood bank will dispense Rh Immune Globulin for immunprophylaxis without performing an Rh typing on a 'current' patient specimen. Rather, they will accept Rh typing results that have been reported by an accredited lab, as long as the actual laboratory report is available for viewing on the patient's chart or in their prenatal records. If the patient's records are not readily available, such as might occur if a patient comes to their ER having a miscarriage, the ER physicians will order an Rh determination. The Texas colleague concludes by saying that her facility has had no problems with acceditation of their laboratory as a result of the aforementioned practice.

ADDENDA Dec. 5, 2004

2. A colleague from an academic medical center in Northern California (the campus of which is often referred to as The Farm) is re-evaluating the need to systematically perform an ABO and/or Rh typing on pregnant patients admitted for Labor and Delivery for whom the prenatal ABO/Rh testing was performed elsewhere. She would like to know from others whether they have a policy to rely on an outside ABO and/or Rh record, and if so, how is that information obtained.

ADDENDA Dec. 18, 2004

3. In the experience of a Professor of Immunohematology in Michigan, there is no requirement that an individual's Rh type be done on a current blood specimen prior to RhIG administration during or after delivery, provided that the treating facility has records of at least two concordant Rh types on file that were determined by testing samples that were collected on separate occasions. He adds that "The typing of a current blood specimen was once required by the product circular, but not any more". The Michigan immunohematologist is of the opinion that a patient's ABO and Rh type should be confirmed at least once during any subsequent pregnancy; if nothing more than for the purpose of detecting insurance fraud. He thinks such testing could be waived in the current scenario, as described by the transfusion medicine physician in San Diego. He concludes with his personal opinion about using another institution's Rh typing results saying "One should never rely on the records of another facility, no matter what the test, no matter what the reported result, if that result will be used to determine patient care."

ADDENDA Dec. 21, 2004

4. A blood bank supervisor at a hospital in Louisiana reports that at her facility their local policy is to obtain a current antibody screening result (to rule out the presence of anti-D) prior to RHIG administration. They will accept another institution's current antibody screen result if an accredited laboratory reported it. However, they do not require that a current Rh typing be done prior to RhIG administration, provided there is a past record that the patient is Rh negative, and the testing was done by an accredited laboratory. They are of the opinion that a current antibody screen is a small price to pay to assure proper utilization of RHIG, and ask the question "Why administer a product to a patient who will not benefit from it?"

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Ira A. Shulman, MD
CBBS e-Network Forum Editor & Moderator