Importance of Patient History

[Brenda K Hutson]

I was just thinking about a work-up from this weekend and it brought to mind something I have found myself struggling to impress upon staff when starting a some new positions in my career.

I received a call from one of my Techs. this past weekend, asking what else she needed to do. A bleeding patient had come into the ER and had taken 2 uncrossmatched O NEG RBCs. Turned out the patient had a Positive Antibody Screen. The Tech called the ER but both units had already been transfused. The patient ended up having an Anti-E and a positive autocontrol. As Murphys' Law would have it, 1 of the 2 O NEG was actually E POS! The Tech had tried to ask the Physician for a history, but they said he was in no shape to answer questions when he first arrived.

I told her to do a DAT (came up positive with IgG). So I told her she needed to keep asking them to try and get a transfusion history; that while we would do an eluate, I was especially concerned about any antibodies that may no longer be demonstrable. She eventually found out that he had been transfused 20+ units at a local Hospital, this past May. So she called that Hospital. The Antibody Screen at that time had been Negative.

There have been a few places I have worked where they never bothered to try and get a history on a patient. In fact, they would usually get frustrated with me when I would initiate some type of coversheet for all work-ups. It would include such things as:

1. Any previous Transfusions and/or Pregnancies?

2. Any transfusions/pregnancies in past 3 months?

3. If Transfused ever, where? When? How many?

4. Is patient aware of any antibodies? This happened to me many years ago; similar scenario; patient in ER taking 2 uncrossmatched; positive screen; called ER MD and asked for history; just as I was entering the Anti-E,c in the computer, the MD called back and said "the patient said something about having an antibody card; would that be helpful to you?" Yes, especially an hour ago!

5. Medications

6. et. al.

The history of the patient is invaluable. It can tell you how to approach the work-up (i.e. are you possibly looking at a naturally occurring antibody). It can tell you whether you have to do an eluate (even if no history of transfusions and/or pregnancies, if it is a first time patient and appears to possibly be a warm auto, I will still do an elution). Also, if not transfused in 3 months and ends up with Warm Auto, I would try to perform a complete phenotype. And a huge risk for the patient is the possibility that previously identified antibodies elsewhere, have now gone below detectable levels; but it is critical nevertheless that you give Antigen Negative blood.

I find that after a few months of seeing the benefits of getting a history (not to mention seeing the negative issues that can occur when you do not get a history and/or are unable to), they start complying. In fact, I would say that obtaining that history is the 2nd thing you should do once your screen comes up positive (the 1st would be to throw in a panel). But if as in this case, you gave uncrossmatched, the first would be to call the MD and let them know.

Anyway, just thought I would share that experience in case some of you also have problems convincing staff to get a history.

Brenda Hutson, CLS(ASCP)SBB

[Mary**]

:bored:I completely agree with you!

[tlorme]

AMEN, Brenda!!! One of the first things I did after taking over as the BB supervisor 14 years go was to implement a coversheet for all antibody workups or testing 'problems' (+ DAT, etc) (we are a large university medical center with a regional trauma center, active OB, Oncology and Open Heart programs to name a few). I find myself constantly reminding my younger techs (and some seasoned ones too!) of the invaluable nature of obtaining an accurate and complete history on a patient. I've modified my form many times over the years to include prompts for the techs so they don't forget to ask more than the basic "has your patient ever been transfused?". I take evey 'learning opportunity' presented to educate all of my BB techs how important this information is, whether we have issued uncrossmatched blood to a trauma or are just starting a workup on a Pre-op patient. It never ceases to amaze me how difficult it is to obtain this information from a direct patient caregiver (MD or RN). Thank you for your comments....I concur!

[Brenda K Hutson]

One other thing I just remembered. Crazy as it may seem, I find that you have to be very specific when asking the patient's Nurse to obtain the pregnancy and transfusion history on patients. You have to emphasize the words ALL and ANYWHERE! Otherwise, you may get a response from the Nurse that there is no documentation of transfusions on the chart; etc. I once called and asked the Nurse to find out the patient's pregnancy and transfusion history, and she replied, "Of course she isn't pregnant; she is 72 years old!" I wanted to say; Thanks for the news flash; now ask her if she has ever been pregnant!" And with that, if it is a patient that is unable to answer any questions (in coma; dementia; non-English speaking; etc), I can at least get the pregnancy issue answered by asking if the patient has any children. Of course that isn't 100% either; could be

1. Adopted children

2. And w/o being able to ask patient directly, you may not know that they have been pregnant, even though they have no children (and sometimes they are hesitant to say yes if they had an abortion at some point; we had that happen just the other day; you have to be very careful in how you ask about that).

And finally, the history is only as good as the knowledge, coherence and honesty of the individual providing the information. But if you get an affirmative, that can definitely be helpful.

Brenda

AMEN, Brenda!!! One of the first things I did after taking over as the BB supervisor 14 years go was to implement a coversheet for all antibody workups or testing 'problems' (+ DAT, etc) (we are a large university medical center with a regional trauma center, active OB, Oncology and Open Heart programs to name a few). I find myself constantly reminding my younger techs (and some seasoned ones too!) of the invaluable nature of obtaining an accurate and complete history on a patient. I've modified my form many times over the years to include prompts for the techs so they don't forget to ask more than the basic "has your patient ever been transfused?". I take evey 'learning opportunity' presented to educate all of my BB techs how important this information is, whether we have issued uncrossmatched blood to a trauma or are just starting a workup on a Pre-op patient. It never ceases to amaze me how difficult it is to obtain this information from a direct patient caregiver (MD or RN). Thank you for your comments....I concur!

[Liz]

I agree Brenda. We have a file and all the AbSc and AbId are in it with a similar cover page added each time on which I write the diagnosis and recommendations. Added on this cover sheet is also a small table for the patient's selective phenotype in case we needed to do it. Also, one needs to know if a patient took RhIg. It doesn't always help though, here common sense must be used as it isn't "common". One patient had anti-D and we were told by the resident ie the 11 yo in a white coat: Rhogam!! I said I don't think so, and spoke to the OB Doctor who said no the patient has formed anti-D and is expecting twins (I know that mom is D negative and they are D positive with DAT and IAT positive). The rest is history with intrauterine transfusions etc, but please dear OB resident don't tell me the patient took RhIG and the sky high anti-D titer and HDNF are due to it.

[John C. Staley]

When I left my previous life were were in the process of inplementing SafeTrace TX corporation wide which consists of 20+ hospitals in UT and 1 in southern ID. Once installed in a facilities you would be able to see patients transfusion history regardless of which facility they had been seen in. Since these facilities did a lot of "patient sharing" this was one of the big benefits.

Of course if the patient was seen outside the corporation then we were back to phone calls for detailed patient history. I have been told that UT is in the process of linking all facilities regardless of affiliation making patient history readily available. This is, of course, a long process that will not be finished anytime soon but is at least moving in the right directions.

[ElinF]

We have a database though our reference lab that we can look at (which doesn't include DOBs- stupid!) but it is a start. What kind of cover sheet are you talking about? Could you email me an example? faire@sjrmc.com

In our computer system we have a place for all those questions...recently transfused, pregnant in last 3 months etc, but I often wonder how accuate that actually is and I usually don't go by that.

I try to send patient's cards, but sometimes that is hard to keep up on.

[Brenda K Hutson]

I think that is a great idea and would definitely improve patient safety. I am just a little surprised in that I would think HIPAA would have issues with that?? You may not recall this now, but at one point I submitted a Thread regarding the fact that we had purchased a local Hospital previously owned by another group. So this other group had all of the patient histories. Now of course, the patients that went to the Hospital under the other group, were now going to go there under our Hospital affiliation. However, they refused to give us any Blood Bank records on those patients! I thought that was incredibly wrong but I believe they used HIPAA as the reason (which doesn't mean that is a correct interpretation of HIPAA requirements; but sometimes there are gray areas that result in differing opinions with relation to that).

Anyway, that experience is what makes it surprising to me that something of that magnitude could ever be pulled off!

Brenda Hutson

When I left my previous life were were in the process of inplementing SafeTrace TX corporation wide which consists of 20+ hospitals in UT and 1 in southern ID. Once installed in a facilities you would be able to see patients transfusion history regardless of which facility they had been seen in. Since these facilities did a lot of "patient sharing" this was one of the big benefits.

Of course if the patient was seen outside the corporation then we were back to phone calls for detailed patient history. I have been told that UT is in the process of linking all facilities regardless of affiliation making patient history readily available. This is, of course, a long process that will not be finished anytime soon but is at least moving in the right directions.

[Brenda K Hutson]

So patient cards are a great idea; IF the patients understand and use them! Case in point.

Working the MN shift once in a large Institution. ER took 2 uncrossmatched units. When

Antibody Screen completed, it was positive. I immediately called ER and notified the MD. She said they were already transfusing the 2nd unit and the patient needed it. I asked her to try and get a history on the patient (she was a GI Bleed; but was coherent). Just as I finished the work-up (Anti-E and Anti-c) the MD called back. She said, "the patient said something about having an antibody card; would that help?!" Oh well, at least I matched the card!

But I also recall at one Institution I worked at that sent cards (with letters attached, explaining what the cards meant and how they should be used), receiving many calls from concerned patients. All they had to do was see the word Antibody in relation to transfusion, and they started wondering if they had Aids! Sometimes it is difficult to help them understand in layman's terms, what the significance of the antibodies are and why we suggest carrying the card with them (which also freaks some of them out in that they think they will die when they are transfused unless they show that card; which could be true, but that would certainly be the exception).

Brenda Hutson

We have a database though our reference lab that we can look at (which doesn't include DOBs- stupid!) but it is a start. What kind of cover sheet are you talking about? Could you email me an example? faire@sjrmc.com

In our computer system we have a place for all those questions...recently transfused, pregnant in last 3 months etc, but I often wonder how accuate that actually is and I usually don't go by that.

I try to send patient's cards, but sometimes that is hard to keep up on.

[ElinF]

So patient cards are a great idea; IF the patients understand and use them! Case in point.

Working the MN shift once in a large Institution. ER took 2 uncrossmatched units. When

Antibody Screen completed, it was positive. I immediately called ER and notified the MD. She said they were already transfusing the 2nd unit and the patient needed it. I asked her to try and get a history on the patient (she was a GI Bleed; but was coherent). Just as I finished the work-up (Anti-E and Anti-c) the MD called back. She said, "the patient said something about having an antibody card; would that help?!" Oh well, at least I matched the card!

But I also recall at one Institution I worked at that sent cards (with letters attached, explaining what the cards meant and how they should be used), receiving many calls from concerned patients. All they had to do was see the word Antibody in relation to transfusion, and they started wondering if they had Aids! Sometimes it is difficult to help them understand in layman's terms, what the significance of the antibodies are and why we suggest carrying the card with them (which also freaks some of them out in that they think they will die when they are transfused unless they show that card; which could be true, but that would certainly be the exception).

Brenda Hutson

I have had good responses so far. I pretty much just say they have a very special blood type and that seems to work. People like it when they are noted as special - I am not saying they aren't, but if you say the word special it sticks! Even if the patient doesn't remember their card, they might possibily say something to the nurse regarding their "special blood type" which scares them and then that could tip us off to start searching for some history. Anything that helps right? haha

[Brenda K Hutson]

You are correct; I think everyone likes to feel they are special!

Thanks,

Brenda

I have had good responses so far. I pretty much just say they have a very special blood type and that seems to work. People like it when they are noted as special - I am not saying they aren't, but if you say the word special it sticks! Even if the patient doesn't remember their card, they might possibily say something to the nurse regarding their "special blood type" which scares them and then that could tip us off to start searching for some history. Anything that helps right? haha

[rravkin@aol.com]

Brenda,

Amen again as the patient history is very important. However, you mention phenotyping in the presence of a known or suspected Warm Auto; I would think that unless the Warm Auto was first adsorbed the results of the phenotyping would be questionable, especially the negative reaction, given the fact that this immuneglobulin would have a great potential to coat the red cells and potentially interfere with the phenotype reactions.

Edited July 31, 2011 by rravkin@aol.com

[Brenda K Hutson]

And that is the beauty of reagents like EGA or Chloroquine. They can pull the antibody off of the cells (unless it is a particularly strong one; then there is nothing you can do), thus allowing Testing with your coombs reactive Antisera.

I used to believe in performing the work-ups on the patients, not just giving phenotypically matched. However, I can see why that will vary depending on your Institution. At the large Institutions I worked at, we had a LOT of work-ups; often complicated; and numerous warm autoantibodies. It was just not feasible to support those patients with phenotypically matched products. But where I am not, we have much fewer such patients and giving phenotypically matched is less expensive (not to mention time-consuming) than performing ongoing adsorptions on these patients.

Brenda

Brenda,

Amen again as the patient history is very important. However, you mention phenotyping in the presence of a known or suspected Warm Auto; I would think that unless the Warm Auto was first adsorbed the results of the phenotyping would be questionable, especially the negative reaction, given the fact that this immuneglobulin would have a great potential to coat the red cells and potentially interfere with the phenotype reactions.

[Liz]

Hello Brenda, what does "coombs reactive antisera" mean: reagent anti-sera for warm reacting IgG antibodies.... sorry for my sudden ignorance......

[Liz]

and EGA? please.

(my excuse?.... just got back from a long meeting at the Ministry of Public Health, serving on the National Transfusion Committee, and so much side talking!!!?) My brain has not recuperated yet.

[Brenda K Hutson]

It is ok with me for you to ask any question (no question is bad except the one not asked out of pride). It means the antisera that you have to take out to the coombs phase of testing (so incubation at 37C; wash; add IgG or Poly AHG; etc). Currently (unless something new has come out that I am not yet aware of), the only "primary" Antigens this would be are Fya, Fyb and s.

Brenda

Hello Brenda, what does "coombs reactive antisera" mean: reagent anti-sera for warm reacting IgG antibodies.... sorry for my sudden ignorance......

[Brenda K Hutson]

Sorry, read and replied to previous question before seeing this. EGA stands for EDTA-Glycine-Acid. It can be used to dissociate the antibody from the RBCs. Cannot use for Kell system though.

Brenda

and EGA? please.

(my excuse?.... just got back from a long meeting at the Ministry of Public Health, serving on the National Transfusion Committee, and so much side talking!!!?) My brain has not recuperated yet.

[OldBloodBanker]

Ah! Brenda! I am deeply grateful for this thread.

I have been preaching this for so many years and I do dearly hope that it has sunk in to those Medical Laboratory Scientist candidates and the pathology residents who have been in my care. It sounds as if you are succeeding in your efforts.

Probably the most difficult history problems arise among sickle cell disease or Thal Major patients in a large urban area. As their rate of isoimmunization is higher than "normal" patients, you are not likely to encounter such a patient without one or more antibodies. The trouble is that they tend to move among hospitals, either because they are searching for better treatment options or because their pain control isn't adequately addressed. And of course they don't tell anyone upon admission what kind of antibodies they may have, should they know, and before long, through no fault of your own, you are staring down the barrel of a DHTR.

A while ago, what was then known as the Chicagoland Blood Bank Society was looking into the possibility of keeping a database of such patients, with their various and sundry antibody problems, (and their phenotypes) and to share them among the area hospitals. While it never came to fruition, and perhaps these days we might have to run into some interference with HIPAA guidelines and regulations, it is certainly a good idea. I envy the network hospitals that share this data.

With respect patient cards that identify their problems: For a number of years, for those patients who suffered from DHTRs caused by the usual evanescent antibody specificities, we used to provide MedicAlert bracelet/necklace applications to the attending physician along with the transfusion reaction report. It was an idea I had hoped would assist other blood bankers in the metropolitan Chicago area. I finally gave up after a pending surgical patient phoned me from our intensive care unit, and told me that she was wearing such a bracelet. She had told several residents that she had a "compatibility problem" but they told her not to worry about it because "the transfusion service at our hospital was so good" that we would figure it out. So she read off "anti-Jka" from her bracelet.

It was our bracelet, and the antibody problem was in our computer system, but her antibody screen was, indeed, negative. If she had been admitted elsewhere would the other physicians have been equally cavalier and dismissed this information?

[Brenda K Hutson]

Wow, all of that work you went to; only to have a Physician sabotage it?! Unbelievable! That makes the picture even more ominous in that we can't exactly go back and educate every Physician in the field.

Your reference to sickle cell patients reminds me of another physician problem; that is when they are presented with patients they do not normally treat; and as such, are not familiar with the standard of practice for their blood products. Add to that, Hospitals that put the diagnosis as the exact symptoms a patient is admitted with (i.e. nausea; dizziness); without mentioning the big problem (bone marrow transplant; leukemia with possible transplant; sickle cell; etc). I have had to tell Physicians what kind of products we needed to provide based on the diagnosis. Then there was the Physician presented with a sickle cell patient (obviously not common for him), who knew "a little;" just enough to mabye mess things up. He insisted on E-C-K- red blood cells (can't recall if he asked for Hemoglobin S NEG). I told him that while that is a common type for those patients, it should not be assumed! That we will type them and give them RBCs lacking the Rh and K antigens they lacked. But that's ok; maybe he will remember that next time around......or not!

Brenda

Ah! Brenda! I am deeply grateful for this thread.

I have been preaching this for so many years and I do dearly hope that it has sunk in to those Medical Laboratory Scientist candidates and the pathology residents who have been in my care. It sounds as if you are succeeding in your efforts.

Probably the most difficult history problems arise among sickle cell disease or Thal Major patients in a large urban area. As their rate of isoimmunization is higher than "normal" patients, you are not likely to encounter such a patient without one or more antibodies. The trouble is that they tend to move among hospitals, either because they are searching for better treatment options or because their pain control isn't adequately addressed. And of course they don't tell anyone upon admission what kind of antibodies they may have, should they know, and before long, through no fault of your own, you are staring down the barrel of a DHTR.

A while ago, what was then known as the Chicagoland Blood Bank Society was looking into the possibility of keeping a database of such patients, with their various and sundry antibody problems, (and their phenotypes) and to share them among the area hospitals. While it never came to fruition, and perhaps these days we might have to run into some interference with HIPAA guidelines and regulations, it is certainly a good idea. I envy the network hospitals that share this data.

With respect patient cards that identify their problems: For a number of years, for those patients who suffered from DHTRs caused by the usual evanescent antibody specificities, we used to provide MedicAlert bracelet/necklace applications to the attending physician along with the transfusion reaction report. It was an idea I had hoped would assist other blood bankers in the metropolitan Chicago area. I finally gave up after a pending surgical patient phoned me from our intensive care unit, and told me that she was wearing such a bracelet. She had told several residents that she had a "compatibility problem" but they told her not to worry about it because "the transfusion service at our hospital was so good" that we would figure it out. So she read off "anti-Jka" from her bracelet.

It was our bracelet, and the antibody problem was in our computer system, but her antibody screen was, indeed, negative. If she had been admitted elsewhere would the other physicians have been equally cavalier and dismissed this information?

[Liz]

thank you Brenda!!

[Malcolm Needs ☆]

I have had good responses so far. I pretty much just say they have a very special blood type and that seems to work. People like it when they are noted as special - I am not saying they aren't, but if you say the word special it sticks! Even if the patient doesn't remember their card, they might possibily say something to the nurse regarding their "special blood type" which scares them and then that could tip us off to start searching for some history. Anything that helps right? haha

Could not agree more about the "special" bit. The layperson often does not understand the "antibody" bit (neither do some professionals, come to that!!!!!!!!!!!!!!!!!), but everyone responds to "special".