Orders for Rh Immune Globulin

[ffriesen]

We are in the processing of building physician order entry for our hospital information system and I'm wondering how facilities handle physicians ordering Rh Immune globulin and making sure that the appropriate testing is performed when indicated. We require that a type & screen be performed during the current pregnancy to make sure that the patient is a candidate and then if the patient is greater than 19 weeks pregnant a quantitative test for fetal red cells by flow cytometry to determine RhIg dosage. For postpartum RhIG the mother/baby unit puts in an order for the fetal maternal hemorrhage screen and then we prepare the RhIG based on the results of it or the quantitative test if applicable.

There currently is no way for the clinician to order RhIG in our HIS and I think it was set up that way so that RhIG couldn't be issued without the proper testing being performed for the various scenarios that can occur.

Any suggestions or advice would be greatly appreciated

[David Saikin]

We only receive the order for RhIg . . . it is up to the blood bank staff to provide all the pertinent testing for the product to be released. I think you will be asking a lot from your docs if you expect them to order all the testing which "the blood bank" requires to achieve product administration.

Edited January 6, 2010 by David Saikin
poor spelling

[L106]

fanihas - So you do flow cytometry to quantitate fetal cells prior to issuing the antenatal Rh-Immune Globulin? And do you issue antenatal RhIG at 19 weeks gestation? Is that the only antenatal dose you routinely issue?

Question for all other posters: Do you do flow cytometry prior to issuing antenatal RhIG?

[Malcolm Needs ☆]

fanihas - So you do flow cytometry to quantitate fetal cells prior to issuing the antenatal Rh-Immune Globulin? And do you issue antenatal RhIG at 19 weeks gestation? Is that the only antenatal dose you routinely issue?

Question for all other posters: Do you do flow cytometry prior to issuing antenatal RhIG?

This is certainly not done routinely in the UK, although it may be done if there is something like a known abdominal trauma (say a car smash or an assault, or something like that).

[David Saikin]

It seems a waste of resources to use flow for antenatal RhIg. Do you give the minidose? If you gave the full dose it would not necessitate any prior testing. The cost of mini and full dose was/is always the same at any place I've worked. We always did the full dose (that way we never had to worry about giving the "wrong" product).

[adiescast]

We use the qualitative fetal screen test, then order a KB Stan if it is positive. We have not used flow cytometry for quantitation of fetal bleeds. It seems it would be a bit expensive to use flow instead of the qualitative screen.

RhIg is issued from pharmacy here. There is an order set for OB that the physicians use to order the correct testing before RhIg administration. Blood bank orders the KB Stain if the fetal screen is positive. The physician does not have to do anything about that. The physician does the calculations (with assistance from charts we provided) to determine how many vials to give (if more than one is required)

[ffriesen]

Just to clarify my post... we only do flow cytometry after 19 weeks if there has been an abdominal trauma or other episode where there may be a fetal maternal bleed. Not routinely. Our OB patients usually receive their routine 28 week antenatal RhIG at their physician's office.

Post partum, we do the fetal screen and if positive send it for flow. I was mainly trying to see how facilities handle the computer physician orders for RhIg when indicated and then cover the orders for the other testing if required.

[adiescast]

Ah, we don't have physician order entry up yet, so I don't have an answer for that. It does seem that the RhIg should be orderable by the physician. Our biggest problem would be that blood Bank does the testing, but Pharmacy issue the RhIg.

[GilTphoto]

We use Sunquest and have 3 different RhIG orders. Each has the necessary testing panels programmed to it.

RhIGOP (OutPatient) - used for all antepartum reasons including bleeding while pregnant. Panel includes ABO/Rh, Antibody Screen, RhIG Interpretation (indicated, not indicated), ability to add Fetal Screen if necessary, Allocating RhIG by lot number, transfusion status (OK to transfuse, Not OK to transfuse, issued), number of vials issued.

RhIGAB (post Abortion or Misscarriage) - I would have named it RhIGFD for Fetal Demise. Set up same as RHIGOP.

RhIG - (Post Partum) - Fields include Mother's ABO/Rh, Baby's ABO/Rh, Fetal Screen (pos, neg, NI), RhIG Interpretation. If the Fetal Screen is positive, a KB is ordered by Blood Bank tech.

I have been meaning to set up a 4th, RhIGBP, for RhIG given to Rh negative patient receiving Rh positive blood products, but so far have never actually given for this reason. We give many Rh positive platelets to older Rh negative patient's, and have not seen an anti-D develop yet! Have never given Rh negative women of child bearing age, Rh positive products.

Our Phamacy supplies us with the RhIG and they get the revenue, but we stock it and issue it.

We also issue Patient Information literature on RhIG supplied free from Manufacturer. Our RhIG Consent form has an English and Spanish section. Depending upon which section the patient signs, determines whether we issue an English or Spanish version of Patient Information.

Edited January 17, 2010 by GilTphoto

[ANORRIS]

How many Blood Bank departments vs Hematology departments perfrom the KB? I have worked at hospitals where each one had jurisdiction.

[adiescast]

KB is run by hematology here.

[L106]

KB is performed in our Hematology Dept in our Lab.

[Malcolm Needs ☆]

When I worked in the hospital environment, the KB was also performed in the Blood Transfusion Laboratory.

This was some years ago, but I always wondered about this. The reason being that, it was quite rare to see a positive KB that required a count for quantity (as opposed to the positive control). This meant that, when a count was required, the Biomedical Scientist/Technician (who only worked in BT, and not routinely in Haem) was not well-practiced in accurately counting a very minor cell population (this was in the days before flow cytometry for FMH estimation). However, those in the Haematology Department were well-practiced in doing so, as they regularly performed reticulocyte counts manually.

I would have thought, in those days anyway, it would have been better for the KB to have been performed in the Haematology Department. I'm sure things have changed now.

:confused::confused:

[AMcCord]

Until we discontinued the test, KB was done in Blood Bank.

[AMcCord]

Our order is for RhoGAM. Blood Bank is responsible for determining what tests are required/appropriate for each patient.

[rcollins]

We do the same as AMcCord, order is put in for RhIG and it's up to BB to order appropriate testing. We don't do KBs here--the positives are sent out to local hospital for flow. But where I worked before, the BB techs did the KBs--but we all also worked in heme so we were usually comfortable with doing it.

[bxcall1]

When products(including RhIg) are ordered they 'reflex' the appropriate test orders as well. This is transparent to the person ordering the product. When RhIg is ordered an ABO/Rh and fetalscreen are reflexed. When RBC are ordered the ABO/Rh, ABSC and ISXM are ordered. This is how we set it up in Meditech.

[jcdayaz]

fanihas - So you do flow cytometry to quantitate fetal cells prior to issuing the antenatal Rh-Immune Globulin? And do you issue antenatal RhIG at 19 weeks gestation? Is that the only antenatal dose you routinely issue?

Question for all other posters: Do you do flow cytometry prior to issuing antenatal RhIG?

NO WAY!!!!!!!

It is standard practice here in the US to issue Rhig at @ the 28 week gestation period. Of course, if there has been some trauma type incident that standard goes out the door!! We still would never do flow!!

[bbbirder]

We have reflex orders for Bld type, antibody screen, and fetal screen as BXCALL1 does. In addition, we have a query asking the reason for the RHIG injection. Depending on the answer (less than 20 weeks bleeding, 28 week routine) the Fetal screen gets 'canceled' and we don't run it.

Linda Frederick

[ffriesen]

For the RhIG (Post Partum) order you have in Sunquest, how do you credit for the fetal screen if you end up not doing it because the baby is Rh negative? We also have Sunquest and are looking at building a new battery. Thanks.

[GilTphoto]

For the RhIG (Post Partum) order you have in Sunquest, how do you credit for the fetal screen if you end up not doing it because the baby is Rh negative? We also have Sunquest and are looking at building a new battery. Thanks.

We charge manually

[jwilb]

All labs in my experience do KB stain in hematology or send it out.

[webersl]

When the physician orders a "Rhogam Workup" we get a type and screen. We are thinking of adding a result line to those tests that is "Suggested Rhogam Dose". We would fill this out after going through all the necessary testing. Rhogam is stocked and dispensed through the blood bank. KB is done in hematology.

[tbostock]

We issue the RhIg in the Blood Bank, so we are responsible for making sure the patient is a candidate. On the physician order entry side, they would just order the RhIg, we take care of the rest.

We only do the fetal screen here, if positive, we send out the KB to our reference lab.

[GilTphoto]

The charge is turned off, so we have to bill manually in the hospital computer system