Making Sure RhoGAM is Offered

[AMcCord]

We deliver approx 700 babies per year on average. We used to do about 98% of all Prenatals for our deliveries, now we're down to about 80%. Because of that decrease, we are seeing more and more patients for the first time, when they come in to deliver. OB nursing service has a policy that says they are supposed to make sure that there is a blood type on the chart. This usually takes the form of patient notes from the physician's office, not a copy of a lab report from a CLIA licensed laboratory. IF they don't have a type on the chart and can't get the notes from the office, they ask for an order for a blood type (doesn't happen often). They also remind the physician that a cord blood should be collected. Two big sources of errors right there - the notes from the office could have the wrong type and it puts a burden on nursing service to remind the doc to collect the cord blood - they could forget the reminder on a busy day. If we don't receive a cord blood, we have no way of knowing that someone has delivered. Actually, we don't even know who is in labor. We thought we were doing doing a good job with this, but we had a recent incident where a physican declined to collect a cord blood specimen on an Rh neg mom after several reminders from a nurse. We picked up the omission because mom had a Type and Screen order (these are done only when ordered, not as a routine order upon admission) and an alert tech noted that they never received a cord blood post delivery. She inquired about the missing cord blood and was told the Dr did not collect. This was referred to a pathologist, who called the Dr in question. The answer - " Why, yes, of course the patient should get RhoGAM!" Don't know what happened there, it's still under investigation. We are now questioning our system, obviously!!! Has this happened before? Gives me the willies thinking about it.

We need to make sure it doesn't happen again. So...here's the question. What do you do to meet CAP TRM.40780 - is there a system to identify all potential Rh immune globulin candidates? Do you have written policies for physicians at your institution that require a cord blood on all Rh neg mom's? or an order set for physicians that requires a cord blood on all Rh neg mom's? If yes, how do you know who the Rh neg mom's are so you can verify that you have them all covered? Is an office note acceptable on the chart? Is a lab report from a CLIA licensed lab required for mom's chart type? Does lab get a report of who is in labor? or make a report of Rh neg mom's in labor somehow? I know this is a problem many of us struggle with. Has anyone got a really good system?

Thanks for your help!

Edited May 7, 2010 by AMcCord

[bduff]

At our facility we have all mothers get a type and screen when they come in. All babies have a cord blood collected and they are all sent to the blood bank. When the cord comes to the bank we check to see if it needs to be tested and will call labor and delivery for a cord blood order if there wasn't one in the computer. We then put it upon the nurses/doctors on Mother baby to be aware of the mother's type and the need for RhIg. We also try to make sure that the mothers have the fetal screen done too. We do this mentally... there is no real tracking. I think that since the day shift techs do most of the mother and baby testing we really have a handle on who needs to get RhIg. Actually the evening and night shifts don't do any cord blood testing they save the cords for days to put away and at that point we check them. There are a few cords that don't get collected but very rarely since it is so routine for them to be collected on every patient.

We also used to do just a Type on all mothers and add a screen if they went for a c-section. We recently changed this because by the time they are going to surgery it is really too late to start the screen if it is a true emergency situation. I really recommend doing a type and screen on every mother considering we know they will all bleed to some degree.

[Deny Morlino]

Per OB policy the Rh of the patient must be determined upon each admission to the hospital either through testing or via records check if criteria are met. As a result of this we are aware of every OB patient admitted. Similar to bduff a cord blood is collected on all neonates and submitted to blood bank. 99% of the time an ABO/Rh is ordered on the cord blood. OB policy also states that a postpartum Rh be drawn for the patient to assure the patient is not a candidate for RhIg. If the patient is Rh negative then we pursue (mandated by blood bank policy) the baby's Rh and if indicated a fetal screen and reflex Kleihauer-Betke. Our OB/Gyns are the biggest advocate of these policies. Perhaps your pathologist can open a dialog with the OB/Gyns as to the importance of assuring all mothers are screened for RhIg candidacy. I will not go into our procedure on miscarriages, etc. any more than to say it is along the same lines as outlined above.

[tbostock]

AMcCord: There is probably some liability issue with accepting results from another lab with regards to blood types, even if it's CLIA licensed. If you are using the blood type result in order to qualify the mom to have RhIg, or the baby to have cord blood testing done at your hospital, you're better off getting "your own" type and screen.

[rravkin@aol.com]

AmcCord,

Your story is somewhat familiar. We would draw two specimens at different times and, preferably by different phlebotomists, on patients without any tangible history. The first specimen is for the type and screen; the second is for a confirmation of the ABO.Rh type only. In addition, we have a second tech retype the initial specimen. The key word here is "tangible history." The historical info on patients is unfortunately precarious at times and so if there is any question about viability we simply treat the patient as if they do not have a history at all. Also, determining the candidacy of a patient for RhoGam comes in the form of a questionare insert that accompanies the RhoGam and also in our policy. Usually, the mother Rh type has to be confirmed negative and the babies type does not necessarily have to be know at the same time. The date and time of the Rh negative confirmation is also required. If you want to be confused even more try checking out the thread about Du testing and it's implication in the issuence of RhoGam. Here, this thread suggests that the dicission to order RhoGam can be influenced by the result of the Du test; for example it was stated that RhoGam would be withhelded if the result was positive. I have to say that because the Du test does not have the capability of determining the orgin of a positive result making a decission to withhold RhoGam is a questionable practice; is the postive do to altered concentration or construction??

I hope this helps but there doesn't seem to be any easy answers at present do to restrictions in information exchange and associated liabilities.

[L106]

What do you do to meet CAP TRM.40780 - is there a system to identify all potential Rh immune globulin candidates? Do you have written policies for physicians at your institution that require a cord blood on all Rh neg mom's? or an order set for physicians that requires a cord blood on all Rh neg mom's? If yes, how do you know who the Rh neg mom's are so you can verify that you have them all covered? Is an office note acceptable on the chart? Is a lab report from a CLIA licensed lab required for mom's chart type? Does lab get a report of who is in labor? or make a report of Rh neg mom's in labor somehow? I know this is a problem many of us struggle with. Has anyone got a really good system?

Thanks for your help!

My answer to your last question: We sure don't! Only a small fraction of our OB patients have their prenatal testing sent to our hospital lab; most are sent to a commercial reference lab. Our obstetricians don't even bother to inform us if the reference lab identifies an antibody in the plasma of a pregnant woman who will be coming to our facility to deliver. Fortunately (in our experience), the babies never seem to have any signficant problems. (But we're going to get burned one of these days!)

Back to the main topic: Our OB nursing unit is responsible for checking the patients' prenatal records, verifying their Rh types, and identifying potential Rh immune globulin candidates. Blood Bank staff has no idea of who is in labor (or their blood type.) OB claims they enter ABO/Rh and Rhogam information for every mother and newborn in a ledger. So, do I feel confident about the set-up? "No!"

[tgarrison]

Our labor and delivery doctors order a type and screen on every patient. In our computer system, we have it built that when we have a female between the ages of 11-55 a question of Rhogam candidacy is triggered. If the patient is not being seen for obstetric reasons, we result as not indicated. If the patient is pregnant and not currently here for delivery (such as miscarriage, bleeding, etc), we attach a message that depending on the patient's clinical condition RHIG may be indicated. Then if we have a mother that is here for delivery, we leave the question blank until we get a cord blood workup. This remains on our pending test list until completed. After the cord blood testing is performed, the tech answers the question with yes or no and the baby's type/Rh. If the tech answers yes, the computer automatically orders a Rhogam Workup which gets a new specimen.

[kate murphy]

We do the same as bduff - type and screen upon admission for all L/D patients. Cords collected on all babies and sent to BB. We determine based on mom's Rh if the cord needs testing. We also prompt for FMH screening and RHIG dosing.

AMcCord - I would be worried about the liability issue as well as meeting CAP TRM.40780.

I think your hospital Risk Management or Quality Assurance staff should look at the process. All you need is one bad outcome....

[John C. Staley]

I've always wondered why we were being held responsible for something so far out of our control. We don't admit these patients to the facility. We don't escort them to their rooms. We don't/can't even know they are in the facility unless someone else does their job and orders something. I spent many long hours working with nursing and the OB docs and finally came up with a system that seemed to work. It was the admitting nurse's responsibility to make sure there were prenatal RH results in the chart from the patient's current pregnancy. They could get them from the doctors office or they could come from in-house testing. The bottom line was that the responsibility was placed squarely on the shoulders of nursing where it belonged.

[heathervaught]

I think that most of the discussion has focused on the L&D area of the facility...but not all RhoGAM candidates present into L&D. You must also consider your Emergency unit as well!

[KKidd]

At our facility a type and screen is collected on women presenting in L&D and cord samples are collected on all unless the mother delivered in a car on her way over. THe mother's blood type is placed on the cord sample. All cords from Rh neg moms are held and the BB techs expect to get an order on the cord. If they don't within a reasonable amount of time, the nursery is reminded. Our OBs have standing orders that include a cord blood workup if the mom is Rh negative. We also make sure that RhIG is ordered is the baby is Rh pos.

I did have a nurse that noticed RhIG had not been given when discharging a mom. I only wish that they were all that sharp!

:juggle::juggle::juggle::juggle:

[L106]

I've always wondered why we were being held responsible for something so far out of our control. We don't admit these patients to the facility. We don't escort them to their rooms. We don't/can't even know they are in the facility unless someone else does their job and orders something. I spent many long hours working with nursing and the OB docs and finally came up with a system that seemed to work. It was the admitting nurse's responsibility to make sure there were prenatal RH results in the chart from the patient's current pregnancy. They could get them from the doctors office or they could come from in-house testing. The bottom line was that the responsibility was placed squarely on the shoulders of nursing where it belonged.

I share your sentiments, John, and I am not held responsible for overseeing the Rh-immune globulin issue at our institution. However, my bottom line is that I feel badly about the whole situation because I don't have confidence that many of the OB nursing personnel exhibit the necessary attention to detail and knowledge/understanding of the concepts to make the proper decisions and handle the Rh immune globulin responsibilities.

(But maybe I'm selling the OB personnel short, because we're not seeing problems with women developing Anti-D.)

[John C. Staley]

It took a couple of occasions where an OB nurse had to go to a patient's house to give them the RhIG and explain why they were there before they really began to understand their level of responsibility.

Another point was made above that L&D is not the only place RhIG is required. Again, those who truly are responsible and in control need to accept that responsibility and that is the doctors and nurses. The lab can not be held responsible for patients they do not even know are in the facility!!!

:chainsaw:

[heathervaught]

The lab can not be held responsible for patients they do not even know are in the facility!!!

Absolutely! Last time I checked, there were no classes offered at my "Med Tech" school for ESP. But it would still be a good idea to have the lab MD talk to the head of the Emergency department to make sure that they are aware that it will take the cooperation of the two areas in order to meet this requirement (i.e. we will gladly perform the testing and issue the product, but you need to educate your staff on when to order the testing).

[L106]

It took a couple of occasions where an OB nurse had to go to a patient's house to give them the RhIG and explain why they were there before they really began to understand their level of responsibility.

:chainsaw:

Cool!!

(I hope I never have to use that tactic, but I'm going to keep it in mind if the situation ever arises.)

[AMcCord]

Here's a quick update. Our medical director took a suggestion to the OB/Peds committee that they went for, no major discussion, no quibbles (amazing actually!). Having a close call case we could point to certainly didn't hurt our cause. The standard order sets for all physician groups delivering OBs here requires collection of either a CBC or H&H postpartum. An Rh type will be added to the postpartum draw orders, possibly as part of a lab order set with the CBC/H&H. There is no decision process involved for Dr or nurse - it applies to all patients. If a mom is Rh neg, we will check and make sure that baby has been typed. Why postpartum? We knew the physicians would object to 'any extra sticks' . We don't have to worry about knowing who is in to deliver. We don't have to worry about somebody getting the wrong type documented on the chart from the office. And we don't have to worry about somebody forgetting to collect a cord blood sample. Yes, it's a little more work for the lab, but I hope it makes a tighter safety net for our patients. It doesn't address patients seen in ER - that's another project.

Thanks everyone, for contributing your policies and experiences.