Kleihauer Betke

[BBK710]

Who performs this test? Hematology or Blood Bank?

Is it done on all shifts as a STAT test? If so how do you maintain tech competency if your 2nd & 3rd shift techs are generalists?

What is your turnaround time?

The majority of the KBs that we do are ordered by physicians on antepartum patients who have fallen or have been in a car accident. Our current policy is that this test is done on day shift only since that is the only shift that does evaluations on Rh neg moms post partum. We have a physician who wants us to change our policy to to the test stat on all shifts. Obviously our generalists are having a fit.

Any information that you can offer would be appreciated.

[bbville]

We do KB's on all shifts and they are done in Blood Bank. (I had 2 today myself) Last year there was a questionaire with a CAP Survey that I had all techs answer along with the counting the 2 survey specimens (after the survey had been resulted). I was surprised to find how many techs needed education regarding this procedure.

I find that many techs do not make and stain quality slides and I emphasize thin smears and following the procedure precisely. Changing reagents as needed is very important also.

Probably making the positive control is the part that many techs dislike most. We have experimented with making slides and freezing them so they would be ready to stain with patients, but really have not had good luck with that.

Our ER and OB physicians have always insisted that this procedure be offered round the clock.

One other thing we have is the RhIg Dose calculator available on all computers at work in case of positive slides on Rh negative Moms. If a slide is positive it must be counted by 2 techs.

[Mary**]

:bonk:We do them in Blood Bank on all shifts. I would prefer to only do them on days, but........(my opinion doesn't always count!). Many techs mistake WBCs for fetal cells. An inexperienced tech recntly reported a 120 ml bleed on second shift on an antenatal patient which obviously prompted the physican to complain! We do save the slides for a few days in case there is a question.

A few years ago we had problems with the CAP KB survey. I changed the brand of reagents and started ordering commerical controls (Fetaltrol). They are quantative and must be counted. They are expensive, but they are worth it.

Good luck.

[swede]

We have gone round and round with our docs, but have finally come to an agreement. The staining is done on all shifts. Days is the only shift that will do a count. PM and Night shifts will stain and look at the slides. If they think the slide is positive, they report a preliminary report of "positive, count to follow". If it is negative, they report negative.

For competency, we stain slides and have each tech interpret if they are positive or negative. Days will do the counts.

For proficiency, Days stains one CAP challenge, PM/nghts stains the other. PM/Nights will look at the slides to determine pos or neg, Days will do the counts.

[BenchTech]

I don’t know a single tech that enjoys doing a Kleihauer Betke in fact I can’t think of a test that I hate more. Unfortunately if the majority of your orders are on patients who have fallen or have been in accidents having the results can be extremely important to have turned around as quickly as possible. Where the test is done can really depend on the facility. If you work a large specialized medical center where all techs are only blood bankers or hematologists I have found that the test is generally performed in hematology as it is more similar to what they generally do than what the blood bankers do. If the majority of your techs are generalists as in most hospitals, then it is not asking too much to have the blood bankers do the test. Any where I have ever been we have always done it as a STAT test, 1-2 hr turn around on all shifts. In order to keep competency we would routinely make up “test” cases for people to review. One of the cases would generally be a patient with a really high WBC count spiked with some cord blood so people could get used to seeing the cells side by side. As for generalists having a fit, they always have fits when stuff changes especially if you are adding work when they already feel overwork. Most of the time they are just nervous that they will be expected to do more with out receiving the additional training and support that they need. As long as you make the transition with out pushing someone who is uncomfortable with the test into it to fast you should be okay.

Edited April 10, 2009 by BenchTech
Looked Funny

[illinoisbloodbanker]

We have found that washing the specimen and removing any buffy coat layer helps to diminish the complication of white cells in the final smear. As a final assurance, we always place the pippette at the bottom of the tube of washed cells to obtain our specimen for the stain. We have noticed a huge improvement. By the way, they are performed on all shifts by generalists.

[bbbirder]

We do these on all shiftsl. We have a 2nd tech review all slides (results report is not delayed for this review.)

Linda Frederick

[Likewine99]

KB's are done on all shifts, STAT eligible, performed in Hematology. Techs are generalists and competency is monitored by having the techs all count the same slide and the CV between the results is HUGE.

Our stated TAT is 2 hours from time of receipt in the dept, hard to do on nights esp. We do the tes regardless of the patient's ABO/Rh and as stated by the other posts, our pts are OB and usually have been in an MVA or fallen.

Yes we hate this test too but have been "requested" to keep performing it 24/7.

[GilTphoto]

We only do them post-partum. If a pregnant woman falls or is bleeding, we give 1 RhIG, but don't do a KB.

Does anyone have a reference for the need for doing them ante-partum?

[KarenJ]

We send ours to a larger facility. We were doing way more CAP surveys than patients and average 1 patient every 6-8 months, so keeping everybody proficient was not working very well. The hospital we reference to performs flow, except fot the middle of the night when they do a KLB, but confirm with flow the next day. Surprisingly, even with getting a courier etc, the TAT isn't much worse than when we were doing them in house.

[John C. Staley]

We only do them post-partum. If a pregnant woman falls or is bleeding, we give 1 RhIG, but don't do a KB.

Does anyone have a reference for the need for doing them ante-partum?

Interesting. Isn't someone at your facility the least bit concerned that the fetus might be bleeding out when a pregnant woman falls or has other abdominal trauma. For those patients RhIG was not the reason we did KBs.

[KarenJ]

We always have to remind the nurses that it isn't just for RhoGam. The previous hospital I was at had a NICU and we did tons of KLB's 24-7. I do like the accuracy that flow provides. Of the 2 FMHS we have sent for confirmation, both have been negative. I think we have had one post fall since we changed our policy and it was also negative.

[AMcCord]

We also send ours out - same problem, more survey samples than patients and competency was tough to maintain. We get a turnaround time of less than 24 hrs most of the time, though weekends are a trick and holidays are worse (transportation issues). We issue the first vial of RhoGAM before we get the KB results back, with a comment that additional vials may be indicated, making sure that the patient's nurse understands fully. Blood Bank takes the responsibility to make sure that the KB results are back in a timely fashion and that additional RhoGAM is issued if necessary.

It felt a little weird doing it this way at first, but we haven't had any complaints from medical staff regards fetal bleeds and our patients are getting the RhoGAM they need well within 72 hours. At our facility, if a serious fetal bleed is even suspected, the mother is on a chopper headed to a bigger facility very quickly. We do not have a neonatal intensive care unit.

Edited April 16, 2009 by AMcCord
additional thought

[scodina]

Question....

I recently had a physician ask me if there is a way to tell whether a fetal bleed is acute or chronic. Does anyone have an idea of how to differentiate between the two? We initially looked at the babie's retic count, but that was not helpful. Can you think of a better way?

Thanks!

Stephanie

[Cathy]

We do them on all shifts 24/7, mostly generalists. We have pretty good luck freezing our control slides and that saves a great deal of time.

[Barb Thompson]

We offer the test stat on all shifts. I have a problem with most of my techs making poorly stained slides and/or undercounting. Everyone is required to participate in surveys and competencies twice a year. It is expensive, but a necessary evil, as this is the only way to see who needs additional training and practice. Each tech must make, stain and count their own slides. For patient testing, all slides are reviewed within 48 hours. 99% of our KB orders are for OB patients who have fallen, experienced abdominal trauma or been involved in a MVA, and do not involve RhIG.

For those of you sending out FMH by flow cytometry, which reference lab performs this? I could not find it in Quest or LabCorp.

Thanks, Barbara

[Kimster]

The number one reason an Rh negative pregnant woman becomes sensitized is blunt trauma, be it a fall, car accident , domestic abuse, etc. The standard of care is to perform a KB to determine if there is a bleed greater than 15ml. One syringe of RhIg may not be enough to cover the bleed.

[RR1]

Hello everyone,

I have attached the UK BCSH guidelines for FMH - which may help with some of these issues.

FMH_Version_15_230708.pdf

[bbbirder]

We do them on all shifts 24/7, mostly generalists. We have pretty good luck freezing our control slides and that saves a great deal of time.

Cathy, we used to freeze control slides as described in the Sure-Tech product insert. These are fixed before freezing. Then one time we had a proficiency testing failure. Turns out that there was a problem with our current lot of fixative, so our frozen control slides were really not controling our entire system. Lucky for us we had only tested one patient with this lot prior to discovering the problem and we could follow up easily.

Freezing the control slides made it easier, but we no longer do that.

Lidna Frederick

[Cathy]

Thank you Linda. Good information to consider. I have printed the thread and will pass it along.

[GilTphoto]

Does anyone have a reference for the need for doing them ante-partum?

For a significant FMH, needing more than 1 vial of RhIG, the bleed must be greater than 30 mLs.

At what point during pregnancy is the fetus large enough to have a blood volume capable of a FMH. How many weeks gestation?

For those doing KB's for trauma, do you also do a Fetal Screen first to determine who needs a KB, or do you go directly to KB?

[Barb Thompson]

For trauma patients,if a KB is ordered, that's what we do. Most of the patients are Rh pos, so the fetal screen will be positive.

For our RhoGam patients, we do a fetalscreen if > 20 weeks gestation.

Barbara

[scodina]

Question for those of you performing a fetal screen on pregnant moms....are you sure your results are accurate? For the fetal screen to work, the mom must be Rh-negative and the baby Rh-positive. How do you know the baby's type in utero?

[John C. Staley]

I used to give every new tech and a few not so new techs the following lecture.

When doing a K-B you are looking for fetal cells in an adult system.

When doing a screen you are looking for Rh positive cells in an Rh negative system.

Now can you explain to me why you would NOT do a screen in a trauma situation?

This usually resulted in the light bulb of understanding flashing on.

[L106]

John -

I have never heard this topic explained so concisely and so clearly! Those two simple sentences sum it up perfectly! Thanks!

Donna