Our Transfusion Service currently dispenses RHIG to all patients.  We are working on a process where the RHIG will now be dispensed from the pharmacy.  We are trying to come with a method to let the pharmacy know when a patient needs RHIG (i.e. Rh neg mom who delivered Rh pos baby, Rh neg pt who recevied Rh pos platelet product, RH neg pt in ER who is miscarrying) so that they can follow thru to make sure they receive the appropriate order and the patient actually receives the product.  Currently our BB computer system is not interfaced with any other system, so we can't use that to send test results out.  I was thinking of coming up with some type of form we could fax to the pharmacy with the needed info, but was wondering if anyone out there has a better/different method.  Ideally it would be a method we could track to show it was done.  Any suggestions? 

Our pharmacy dispenses RHIG.  We are not notified at all.  The nurses/physicians notify pharmacy. So do the nurses in family birth or ER ask you if the patient needs RHIG, or do they just order it and you dispense it?  If they just order it, they could order it from the pharmacy just as easily. We are not involved in the calculation of dose either, as we send out fetal Hgb F.  So it is the physician's decision.  Not very helpful, I know, but an informed letting everyone know what the process will be should work. 

We dispense it but we don't call the medical staff to tell them that they need it. Its up to them to read the report sent with fetal  Hgb results or Mon's  bl od type, whatever which they can read from their monitors.

AABB Standard 5.30 Rh Immune Globulin

The transfusion service shall have a policy for Rh Immune Globulin prophylaxis

for Rh-negative patients who have been exposed to Rh-positive red

cells.

The AABB requires Blood Bank involvement in the Rh Immune Globulin process, even if Pharmacy has it. It just worked better for us to keep it in the Blood Bank. But as long as you have some type of communication process that you are keeping an eye on the patients that should have it; I'm not sure if the doctor or Pharmacy forgot to give it that you would be totally off the hook.

We are not AABB, just CAP and it says:

TRM.40780 There is a system to identify all potential Rh immune globulin candidates.

NOTE: Information about every pregnant woman's Rh type should be available when the possibility of alloimmunization and subsequent Rh disease of the newborn may occur. The INSTITUTION (my caps) must ensure that all Rh-negative women receive the manimum protection against Rh immunization.

There's more but I think this sums it up. Since it is nursing and pharmacy who are involved, they have the policies.

We moved our Rh Immune Globulin to Pharmacy many, many years ago.  Our Pathologist at the time felt that it should be handled as a drug (which requires a doctor's prescription/order, etc.)  I originally opposed moving it from Blood Bank to Pharmacy, but I have become very comfortable with the change.  We in our Blood Bank do not routinely have access to patients' diagnoses.

 

I have a question to those Blood Banks who do control/dispense RhIg:  If Blood Bank is responsible for generating the order to give RhIg, how does the Blood Bank staff become aware of patients' diagnoses?  (ie:  Say you get a Type & Screen order on an Emergency Dept patient.  How does Blood Bank know it a miscarriage or a post-abortion?)

 

As mollyredone wrote above, the institution is responsible for identifying candidates for Rh immunization and ensuring that they receive it, etc.  So the institution has to have appropriate policies/procedures, which our Nursing staff has (and the policies were approved by the OB/GYN Medical Staff, etc.)

 

Donna

Thank you all, for your responses! 

We dispense RhIG from blood bank and we do kind of a mix of the above.

-Per P&P, the physician is ultimately responsible for IDing candidates (ED patients with miscarriages etc). Our blood order form (paper, soon to be electronic) has a checkbox for RhIG along with RBC, FFP etc.

-BB takes care of issuing RhIG when we give D- patients D+ platelets.

-Back in the day when we had maternity, we would test moms and kids and calculate dosages to be dispensed, and let the floor know the stuff was ready.

We have a canned comment on our results that says to give one dose of RhIG if Mom Rh neg and baby Rh pos.  If we do a KB, and the mom is Rh neg, then we calculate the RhIG dosage on the report.  Then nursing requests the dose from Pharmacy.  Any case not involving cord blood testing is handled by nurses and doctors under institutional policies.  We are AABB inspected and they have had no problem with our policy being that Pharmacy issues it.

It does drive me insane that we are expected to wipe their backsides for them... I mean, it is their responsibility to request blood products - we don't say 'oh the Hb is 45, let's issue a few units', so why are we expected to tell them to give Anti-D?

Edited May 8, 201510 yr by Auntie-D

I never really understood when it became the blood bank's responsibility to make sure the RHIG is given. Granted it was considered a blood product derivative and we did have to cross match it when RHIG was first made available. But somehow the blood bank ended up being responsible to make sure the patient recieved it. Maybe because us blood bankers are obsessive?

We had a report in one of our old computer systems (Mabel should remember this) that would list the women who possibly need RHIG.

Is the physician or nurse incapable of determining that the mom needs it? It is usually set up as a standing or for OB patients - if Rh negative, baby Rh positive give RHIG.

Have always considered Rh Immune Globlulin Prophylaxis one of the many services provided by Transfusion Services.

At my previous employer, the pharmacy felt very strongly that RhIg is a drug and should be in the pharmacy.  Blood bank recommended the dosage based on testing, but it was dispensed from the pharmacy.

We are not AABB, just CAP and it says:

TRM.40780 There is a system to identify all potential Rh immune globulin candidates.

NOTE: Information about every pregnant woman's Rh type should be available when the possibility of alloimmunization and subsequent Rh disease of the newborn may occur. The INSTITUTION (my caps) must ensure that all Rh-negative women receive the manimum protection against Rh immunization.

There's more but I think this sums it up. Since it is nursing and pharmacy who are involved, they have the policies.

Actually if you look further CAP TRM.40800 says,

 

"There is a mechanism to ensure that Rh immune globulin is administered to all identified candidates within 72 hours of an Rh alloimmunizing event, whenever possible"

 

So blood bank does need to be involved in distribution some how.  This cannot be just left to Pharmacy and nursing staff.  Whether its a followup daily or something else.  If you are not distibuting RhIg, you need to be aware of who is and who isn't receiving RhIg from Pharmacy.

The easy way round this would be to issue it to all post natal women, regardless of the Rh status of the baby. Or is that too simple?

It is simple, but, a) it is a very expensive waste of anti-D and dangerous, in that it is derived from human plasma, and there may be a virus lurking in there that we do not yet know about (remember, new viruses are being found on a regular basis).  If you give this to all of the women, then you WILL get sued by those who did not require it, and who become infected.

Cost of anti-D vs cost of reagents for KB and NB screen (and lab time) must balance. Anti-D isn't that expensive... If it is so dangerous, maybe they should be getting consent before giving anti-D as they do with blood...

 

It's a bit of a non-argument anyway as they are given it routinely during pregnancy and 85% of those women don't need it, so they wouldn't know it it came from the one not required during the pregnancy, or the one not required after the birth.

Well, firstly, the answer is that it MUST be consented, and I would check that if I were you.  It is a blood product, derived from human plasma, and has caused viral infection (and has also caused reactions against IgA come to that), so it is by no means "safe" to give to everyone.

 

Secondly, if the baby is D-Negative, then you don't need to give anti-D immunoglobulin, but neither do you need to perform a KB or NB, and so you don't pay for those reagents.

 

Thirdly, as is already happening in some countries, the Blood Services in the UK are undertaking a pilot study to look at cffDNA in all pregnancies in D-Negative women, to see if the results are accurate enough to dispense with giving antenatal anti-D immunoglobulin when the foetus is shown to be D-Negative, so giving anti-D immunoglobulin routinely in such women is likely soon to be a thing of the past.

I do hope that happens soon Malcolm - would be a gosend.

 

ETA - we seek consent for anti-D but there is a thread that was about recently where there was a few posters claiming that they don't seek consent for 'non-wet' products ie Anti-D, PCC etc

Edited May 7, 201510 yr by Auntie-D

 

Actually if you look further CAP TRM.40800 says,

 

"There is a mechanism to ensure that Rh immune globulin is administered to all identified candidates within 72 hours of an Rh alloimmunizing event, whenever possible"

 

So blood bank does need to be involved in distribution some how.  This cannot be just left to Pharmacy and nursing staff.  Whether its a followup daily or something else.  If you are not distibuting RhIg, you need to be aware of who is and who isn't receiving RhIg from Pharmacy.

 

It does not say that the mechanism has to be in blood bank. There are other checklist items in CAP that are just managed by nursing, and that is how we interpret it. Never had a deficiency about it.

One item I did take up with nursing was TM.41025, regarding transfusionist training. Nursing had nothing in place, so I worked with the educators to create a testing module that is administered by nursing.

We go the same route Molly, with both checklist items.

I still hold that the BB should be involved for checks and balances. Preventing one baby from being affected by Anti-D would make it worth it.

Now this question has been revised by CAP:

 

TRM.40780 "There is a written procedure to identify all potential candidates for Rh Immune Globulin".

I don't have much problem with the Postpartum ones - I have a good Cord Blood procedure and process in place to make sure that the Rh Neg moms of Rh Pos babies receive their doses.  The place where it might slip through is the ED/OR if a miscarriage or ectopic came through and Blood Bank was not aware that it was a pregnancy.

In the explanation it says "....the institution must ensure that all Rh-negative women receive the maximum protection against Rh immunization..." 

So it appears that this piece should fall on the providers - to determine Rh type when a patient comes in with a miscarriage or ectopic or other fetal bleed situation.

I can't find any such policy in the hospital SOP's but perhaps I am not digging deep enough.