Utilization and Inventory Management of Group O RhD Negative Red Blood Cells

The purpose of this statement is to provide recommendations or examples of best practices for the use of group O RhD negative red blood cell (RBC) units in order to ensure their availability for those patients for whom there is no alternative.

While the total number of RBCs issued by Canadian Blood Services has decreased over the past 10 years, the demand for O RhD negative RBCs continues to increase in Canada.

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While only 6 to 7% of the general population in most areas in Canada are O RhD negative, O RhD negative RBC issues have increased to over 12% of all RBCs. Canadian Blood Services has made continuous efforts to recruit, retain, and encourage frequent donations from O RhD negative donors, while acknowledging that frequent donations increase the risk of iron deficiency. Further, as the donor population ages, supporting this level of O RhD negative RBC collections will likely become even more challenging. It is therefore imperative to ensure that O RhD negative RBC use follows clinical guidelines to protect and conserve a vulnerable donor population and to ensure adequacy of supply for recipients for whom there is no alternative.

Group O RhD negative individuals1 of child-bearing potential should receive only RhD negative components to prevent the development of alloantibodies directed at the RhD antigen which could result in hemolytic disease of the fetus and/or newborn in the case of a future RhD positive pregnancy. Individuals alloimmunized against RhD antigen must receive RhD negative RBCs, unless extenuating circumstances exist, to avoid a hemolytic transfusion reaction.

Other group O RhD negative individuals should receive O RhD negative RBCs but consideration should be given to the significant use and/or anticipated use of O RhD positive RBCs.

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4.1 Hospital Policies to Mitigate Unnecessary or Inappropriate Use of O RhD Negative RBCs

• Change to group-specific units immediately once the patient’s ABO group is confirmed.
  • Hospitals should confirm the ABO/Rh type of patients who are bleeding or have severe anemia upon presentation; and implement policies/procedures to switch to group-specific RBCs as soon as possible.
  • Use group-specific phenotypically matched or antigen negative RBCs when available instead of using O RhD negative RBCs.
• Establish policies for the acceptable and unacceptable indications for utilization of O RhD negative RBCs. Examples of such indications are listed in Table 1.
  • Transfuse all bleeding individuals of non-childbearing potential with group O RhD positive RBCs until their blood group is confirmed, unless there is history of allogeneic anti-D.
  • Have a policy and procedure for switching known O RhD negative hemorrhaging patients to O RhD positive RBCs, unless known to have anti-D. This includes defining patients who can be switched, number of units at which point the patient will be switched, and whether medical director approval is required each time.
  • Develop a policy for patients in whom blood grouping may be discrepant or indeterminant including patients undergoing hematopoietic stem cell transplantation, ideally to minimize O RhD negative RBC transfusion.

4.2 Hospital Inventory Management

• Community/rural hospitals and pre-hospital transfusion programs should consider including and/or exclusively using O RhD positive RBCs for emergency transfusion.
  • The benefit of providing emergency transfusion likely outweighs the risk of alloimmunization.
  • Studies have shown that most patients receiving pre-hospital transfusion are not individuals of childbearing potential. Hence, many pre-hospital transfusion programs use either O RhD-positive RBCs or carry a mix of O RhD positive and negative RBCs.
• Always request group specific units for patients with specific requirements (notably for patients with RBC alloantibodies). Group O RhD negative substitutions should only be used if group specific units are not available.
  • This may be facilitated through early communication with your local Canadian Blood Services distribution site for any antigen negative blood requests, notably for difficult and/or frequent requests.
• Reduce crossmatched RBC inventory by using strategies such as just in time (crossmatch on demand), electronic crossmatch, and implementing a maximum surgical blood order schedule (MSBOS).
  • Review and, if appropriate, cancel RBC inventory tagged for specific patients 24 hours after surgery or immediately after imminent need has passed, while making allowances for patients with RBC antibodies.

4.3 Hospital Inventory Monitoring for Quality Improvement

• Collect, monitor, and review usage data to confirm the appropriate use of O RhD negative RBCs. Ensure that the emergency use of O RhD negative RBCs is reviewed by the hospital transfusion services and/or transfusion committee; and benchmarked against comparative centres where data exist.
  • Review transfusion of older O RhD negative RBCs to non-O RhD negative individuals to avoid the unit outdating as well as the overall outdate rates of O RhD negative RBCs. High rates of transfusion to avoid outdating are highly indicative of overstocking O RhD negative RBCs.
  • This review may identify cases where the switch to group-specific RBCs could have been made earlier, where determination of patient blood group took longer than acceptable or was not performed, or patients for whom O RhD negative RBCs were not indicated.
• Review hospital inventory levels of O RhD negative RBCs compared to the total number RBCs.
  • Hospitals and regions should prioritize review after hospital organizational or clinical program changes, especially for those that will reduce RBC demand. Regular review is also recommended. Promptly notify your local Canadian Blood Services distribution centre of any adjustments.
  • Jurisdictional Inventory and/or Shipment Indices as discussed in The National Plan for Management of Shortages of Labile Blood Components should be adhered to, although inventory varies by institution, dependent on the patient population served and distance from the blood centre.
• Consider protocols for redistribution and/or shared inventory of O RhD negative RBCs to avoid expiry.
  • Participating in a redistribution program to larger nearby hospitals may mitigate outdating, although high redistribution rates are highly indicative of overstocking.