Background:

For many years the nurses and physicians at the UCSF newborn nursery (Parnassus Campus) have routinely been ordering a cord blood bank panel on ANY infant of a mother who was Rh-negative or O-positive.  This testing is due to concerns about jaundice due to ABO or Rh Incompatibility. 

The battery of tests (and charges at UCSF as of November 2013) are ABO group ($112), Rh type ($77) and Direct Antiglobulin test (DAT= Direct Coombs Test, $100).  These tests can provide information about the risk of the infant developing significant hemolysis and jaundice can affect treatment decisions for those who are possible candidates for phototherapy. 

Most tests are not needed.

However, with the exception of the Rh type on infants of Rh-negative mothers (which is required to make decisions about post-partum RhoGam for the mother, and need not be discussed further) most of these tests are unnecessary most of the time.  For example, if mother and baby have the same blood type, the yield of the DAT is very low. Similarly, if the mother is A-, the baby needs an Rh type, but there is no particular reason to do the baby’s ABO group and if mother is O+, there is no need to do the baby’s Rh type.  Finally, if the DAT is negative, even if there is an ABO incompatibility, the infant should not be counted as having hemolysis for treatment purposes.  Therefore knowing about DAT-negative ABO incompatibility should not affect management, and only the DAT is needed

The proposed solution:

To make things simpler, we propose to label order sets based on common clinical scenarios.  This would cut down on the variation of care due to the number of nurses, trainees and physicians that work in the newborn nursery. Based on our discussion with Dr. Moayeri, Associate Medical Director of the UCSF Blood Bank, we thought it would be better if the blood bank introduced two new panels, which would be called:

‘Newborn cord/peripheral blood test (Rh negative mother)’

• This panel will include just the Rh type and DAT

‘Newborn cord/peripheral blood test (O-positivemother)’

• This will include just a DAT 

In both cases, blood will be held in the blood bank for additional tests if requested. 

Overall, for hundreds of newborn infants each year at UCSF, instead of ordering the complete panel of ABO type, Rh type and and a Direct Antiglobulin test, less tests will be ordered. 

One of the keys to this approach will be developing a standard order set and approach.  This will cut down on variation of care and also improve efficiency.  

In summary, with this proposal, we believe we can order less tests without compromising patient safety or clinical care.   

 [This idea was developed during a discussion at our newborn nursery staff meetings that includes attending physicians and our nurse practitioner staff, as well as Morvarid  Moayeri, MD, PhD, the Associate Medical Director of the UCSF Blood Bank]