L&D Prenatals

[mjshepherd]

Help!

Currently our L&D department does not get a copy of the actual performing laboratories report on the prenatal testing. The prenatal information comes as a patient HX from the admitting physicians office.

CAP allows us to accept test results performed outside our facility if they are a CLIA-licensed laboratory, however these patient HX have no information on where the testing was even performed. I have tried educating the physicians on why we need a copy of the actual lab report but they are totally non-compliant. My director and I are in complete agreement, If we don't have a copy of the performing labs report we have to perform a Type and screen at admission, however the administration is resisting this due to physicians complaining of the cost to their patient. Every way I try to turn I get blocked, any sugestions?

[Deny Morlino]

A question, assumption, and opinion I am assuming the history L&D receives is a composite of information from the physician's office. Someone there would have to spend time entering the lab results into the history format. Could you try the approach of a time savings for the offices if they just include a copy of the lab report in the history? This hits many birds at once (you may need information not included in the history but available on the report, there is less chance for incorrect data entry into the history, etc.). Just my suggestions

[bduff]

I am in favor of doing type and screens on all L&D patients. That is what we do at our hospital. These ladies can lose lots of blood in a short amount of time and to have to do the type and screen at the last minute when the Dr.s are screaming is not a good thing. Also, they are pregnant, they can develop an antibody at any time. Our Medical Director is very much on board on having T&S on every admission. Also, if you are going by history of another lab, they got the type wrong, the patient should have gotten RhIg and never did whose fault would it be? That is enough reason for me to do a Type and Screen on every L&D that walks through that door.

[L106]

Help!

Currently our L&D department does not get a copy of the actual performing laboratories report on the prenatal testing. The prenatal information comes as a patient HX from the admitting physicians office.

CAP allows us to accept test results performed outside our facility if they are a CLIA-licensed laboratory, however these patient HX have no information on where the testing was even performed./QUOTE]

Is this a CAP requirement that the Lab/Blood Bank ensure that prenatal testing is performed by a CLIA-licensed laboratory?

[adiescast]

Actually, it is probably ultimately a CLIA requirement.

We are also moving to doing a type and screen on admission to L&D. It ensures that we have a second type, checks for newly developed antibodies, and prepares for the chance of transfusion. I think it is worth the cost.

[Linb132]

I would be aware that there may still be errors on these reports. Do you know their method of antibody screen? Their level of sensitivity? And how long has it been since pre-natal workup. These are pregnant females and may form antibody during their pregnancy.....We have had un-reported antibodies and mis-typed females (ABO +Rh). So I would recommend always performing your own work. The one mistyped patient- I did report back to management of the reference lab for investigation of their process.

As far as cost savings, our L+D patients have BB sample drawn upon admission, and sent to BB as "clot to hold"- no charges are generated unless they get into trouble and request T+S and crossmatches...then we have a properly labeled specimen- drawn under less stressful circumstances, and the blood can be prepared as ordered. This has cut down on mislabeled specimens from nurse draws when it hits the fan....

Edited June 4, 2010 by Linb132

[David Saikin]

I can't believe that it is the lab's responsibility to ensure prenatal testing is done in a CLIA lab. The MD sends the patient/specimen where he wants. The history comes from the MD (unless you get the resutls from the testing site - which I also find hard to believe will happen). THe lab is not responsible for work done outside the lab - unless the lab itself is sending it to a reference site . . . then it would be your responsibiltiy.

[L106]

I totally agree with David's points. Yes, I care about whether patient testing is done accurately, and I'm sure that most of us on the site feel that no one else can do as good a job as our own lab does, but I don't control where the physician sends his/her patients for their prenatal testing. (Wish I could, but I can't.)

It frustrates me when we receive a Type & Screen sample on a patient in the Delivery Room (that we have never tested before) and find a strong Anti-E. Did the "send-out reference lab" find the antibody during prenatal testing? Were antibody titrations performed? Did the physician even order an Antibody Screen since the patient was O Pos? (Everyone knows that only Rh Negative people can make any antibodies, right?) If the physician was aware of the patient's antibody, why did he order a Type & Screen (instead of Crossmatches?) Was the physician aware of the patient's antibody, but didn't think that it might be a good idea to share that information with us (where the woman will deliver her baby)? Ahh.....but the send-out reference lab's prices are a little lower than ours.......

OK, I feel better now......

[Deny Morlino]

Amen!

[mjshepherd]

Thanks all for some great advice! Off to the transfusion committee meeting...wish me luck!

[John C. Staley]

I totally agree with David's points. Yes, I care about whether patient testing is done accurately, and I'm sure that most of us on the site feel that no one else can do as good a job as our own lab does, but I don't control where the physician sends his/her patients for their prenatal testing. (Wish I could, but I can't.)

It frustrates me when we receive a Type & Screen sample on a patient in the Delivery Room (that we have never tested before) and find a strong Anti-E. Did the "send-out reference lab" find the antibody during prenatal testing? Were antibody titrations performed? Did the physician even order an Antibody Screen since the patient was O Pos? (Everyone knows that only Rh Negative people can make any antibodies, right?) If the physician was aware of the patient's antibody, why did he order a Type & Screen (instead of Crossmatches?) Was the physician aware of the patient's antibody, but didn't think that it might be a good idea to share that information with us (where the woman will deliver her baby)? Ahh.....but the send-out reference lab's prices are a little lower than ours.......

OK, I feel better now......

I'm glad you feel better. Now something to think about. Most of our surprises came from women who saw the doctor the first time when they were admitted to L&D. There was no prenatal testing!!

It is a hard fact that no blood banker has ever trusted the work of someone else. Never have been sure I understood this but that's just the way it is. This being the case, a Type and Screen on every L&D patient is extreme over kill. This is one easy example of the excesses of the US Health Care System. It's called "Just In Case" medicine. Our protocol was to collect a blood bank tube with the admitting labs so it was available if needed. It was seldom if ever needed for anything more than prenatal testing that had never been done. The rare occasion, and I do mean rare, that it was needed do to excessive bleeding it gave us a sample to start testing immediately. For the one or two L&D patients we lost in the 30+ years of my blood bank career having 50 units of blood crossmatched and ready would not have made any difference in the out come.

This rambled a little more than usual. Hope you could follow along.

[L106]

As usual (again!), I agree with you, John.

Donna

[Deny Morlino]

When the OB/Gyn decides to take the patient for a c-section or if a c-section was scheduled is the time we perform a type and screen. Other than that we collect a tube and patient is banded but no testing performed until necessary. In short I agree with John's take on this.

[Mary**]

:disbeliefI agree, John. I am surprised that insurance payers don't complain if the patient did not have a C-section.

[Bill]

Very well stated John!

[clmergen]

Our nursing policy states that if the blood type does not come from an acceptable source, it must be repeated stat upon admission. Acceptable was defined as having a copy of the actual report from a laboratory. We are on an EMR now and have discovered that nursing can "enter" lab results in. They are clearly marked as having been manually entered. Then I noticed the compiliation prenatal H/Ps. So I got really worried about meeting the standard because we do leave the responsibility of identifying these women to the nurses. I did an audit of every woman in our post delivery nursing units of our 6 hospitals. Although a good portion of them had hand-entered results, all of them had a blood type from our system. I no longer worry about our nursing staff not meeting the standard. (and not all were from the current admission, we are a reference lab too, so some were prenatal care).