Mission accomplished: RhlG protocol streamlined.

Interdepartmental cooperation operation and communication always have been essential in health care. In recent years, however, the need for greater efficiency in delivering that health care has brought new importance to these collective endeavors.

Part of the ongoing search for ways to decrease costs has resulted in hospitals dramatically reducing the length of stay for many patients. Mothers with no complications whose hospital stay used to be five to six days after delivery now in many facilities are discharged the same day or just hours after delivery.

Mothers receiving Rh immune globulin (RhIG) traditionally have remained in the hospital longer. It came as no surprise, therefore, when a member of our OB department called early last year wondering whether the staff could store its RhIG on the nursing floor to give to Rh-negative mothers immediately after delivery, rather than waiting for blood banking to dispense it. As a result of this call, we examined our RhIG procedure and made some adjustments that have expedited the process yet allowed the laboratory to maintain control of both RHIG inventory and administration.

Former RhIG protocol

At the time of the inquiry from the OB department, our procedure for administering RhIG was as follows:

1. Cord blood specimens were collected from all infants upon delivery and brought to the laboratory by delivery room personnel.

2. A cord blood study was performed on all infants born to Rh-negative mothers, or on babies whose records lacked that information. In addition, other tests routinely performed included ABO, Rh, direct antiglobulin test (DAT), complete blood count, reticulocyte count, and neonatal bilirubin.

3. If the cord blood study was Rh-positive, an RhIG workup was ordered on the new mother immediately, a post-delivery blood specimen was taken, and the following four tests were performed: ABO, antibody screen, Rh, and fetal test (FBST). If the FBST results were positive, it was quantitated with a Kleihauer-Betke acid-elution test.

4. Upon completing these tests, the appropriate dose of RhIG was prepared for the mother and her nurse was notified.

5. The nurse came to the laboratory, picked up the RhIG, and returned to the floor to administer the dose to the patient.

6. After 24 hours, another specimen was obtained from the mother and a post-RhIG antibody screen (PRABSC) was run to assure efficacy of the dose.

A review of our records for a recent month showed the average time between delivery and administration of RhIG was just over 11 hours. Added to the 24 hours it took to do the PRABSC, the total stay required to complete the RhIG protocol amounted to at least 35 hours after delivery. Obviously, we could not discharge patients in 24 hours or less using these same procedures. Having long tried to eliminate the PRABSC from the RHIG protocol be cause of its lack of specificity, we now had another reason to discontinue its use.

Dissecting the delays

To help us determine specific causes for delays in the preparation of RhIG, we broke the process into three steps:

1. Time between birth and receipt of cord blood in the laboratory

2. Time between receipt of the cord blood specimen and completion of cord blood testing

3. Time between completion of cord blood testing and issuance of RHIG to the nursing unit for injection.

A retrospective review of patient records for one month indicated step 1 averaged 3 hours, 21 minutes, step 2, 3 hours, 24 minutes, and step 3, 4 hours, 19 minutes (for a total elapsed time of 11 hours and 4 minutes from the time of delivery to the time of RhIG issuance). The time between issuance of RhIG and injection was, in all cases, no more than a few minutes, which is essentially the time it takes a nurse to walk back to the patient's room.

For starters, we indicated a need for nursing to expedite delivery of the cord blood specimen to the lab. When presented with these data, nursing agreed to effect this.

Next, we assigned a much higher priority to cord blood testing in the laboratory. Since we had been unaware of the ramifications of slow turnaround time on these tests, laboratory personnel sometimes relegated these tests to the bottom of their work list. A short inservice helped us all understand the need for prompt attention to cord bloods.

Further, in light of information we reviewed in the 16th edition of the Standards of the American Association of Blood Banks (AABB), we have eliminated the antibody screen from the maternal testing and retained only the ABO, Rh, and FBST. According to this literature, the AABB requires only that all women undergoing delivery, abortion, or invasive obstetric procedures should have their Rh type determined" (J10.100) and that a postpartum maternal blood sample from all Rh-negative women at risk should be tested to detect a fetomaternal hemorrhage in an amount sufficient to require more than a single dose of RhIG for effective prophylaxis" (J20.210).

Corners cut, not quality

To further expedite the process, the laboratory now delivers RhIG to the nursing unit as soon as an infant's Rh is found to be positive. The time it took a nurse to get from the floor to the laboratory and back to the patient care area often caused a delay -- not only because of the physical distance between the two departments but also because some nurses cannot leave their patients for that length of time.

Because someone from our laboratory has to go to the patient's room to obtain the maternal specimen anyway, that same laboratorian now delivers the RhIG to the nurse at the same time. This new protocol change saves the nurses a trip, gets RHIG doses to the patients much quicker, and has done wonders for laboratory nursing relations.

Not only do we deliver the RhIG dose, but we do it without waiting for all non-blood-bank testing on the cord blood to be completed. Upon arrival in the lab, the specimen comes directly to the blood bank. The ABO, Rh, and DAT are run immediately, and if Rh-positive, the mother becomes a candidate for RhIG. An order is generated, a dose of RhIG is assigned, and a phlebotomist is dispatched to collect the specimen and deliver the dose. Then the nurse can inject the RhIG.

Because of our extremely low incidence of Rh typing errors and the lack of adverse effects should an Rh-positive woman receive RhIG, we've decided to administer the dose before maternal Rh is confirmed. Both pathologists and OB staff agreed the benefits far outweigh the risks. (To date, we have not administered RhIG inappropriately.)

Perhaps most significantly, we discontinued running the PRABSC. If this screen is positive, we believe it indicates an excess of anti-D is present and all D-positive cells have been coated and removed from circulation. If this screen is negative, it indicates all the antibody has been used.

The potential, therefore, exists for D-positive cells to remain in circulation, necessitating a second dose. But numerous reports in the literature indicate the presence or absence of circulating anti-D in a 24-hour post-injection specimen is a function of the rate of absorption rather than the number of D-positive cells present.

A brief in-service by the blood bank supervisor at an OB staff meeting, together with a multiple dose rate much higher than reported in the literature, demonstrated the inadequacy of this method to monitor the size of fetal bleeds accurately. And because we already test for large fetal bleeds with our FBST, the information we thought the PRABSC provided is readily available elsewhere.

Changes view time goals

To determine the efficacy of our changes and provide a guideline for performance, we've established one hour goals for each step in our process. Ideally, every mother should receive her dose within 3 hours of delivery, at which time all testing related to RhIG administration should be complete. Of course, in those rare cases where multiple doses are necessary, more time is required.

After several weeks of training, becoming accustomed to the new changes, and addressing questions from both nursing and laboratory personnel, we again collected data to determine the time between delivery and injection. Improvement was dramatic. Eliminating the PRABSC immediately reduced the required hospital stay by 24 hours. Also, the changes in the RhIG protocol further reduced the average total time after delivery from 11 hours, 4 minutes, to 2 hours, 16 minutes. So instead of requiring a 35-hour stay to complete the protocol, it was possible to discharge after 2 hours and 16 minutes.

Steps 2 and 3 each average 31 minutes to complete, but a significant number of cases still are taking longer than we had hoped. Almost one-third of cases (29%) didn't meet our one-hour goal for step I (receipt of cord blood in the lab following delivery). Average time for this step is 1 hour, 14 minutes. For step 2, 21% of cases have fallen short of the goal, and one-quarter (25%) haven't met the goal where step 3 is concerned. Clearly we still need to increase the number of patients whose RhIG is administered within our defined time goal. Improvement efforts will continue, and another review is scheduled for July of this year.

Perhaps better than any other recent situation in our laboratory, this protocol change illustrates the value of effective communication and cooperation between departments. To realize our goal of delivering quality, cost-effective care, laboratory and OB staffs were willing to look at a problem together and make adjustments. The result was a reduction in the length of stay and improved patient care at lower costs.

Not incidentally, the Joint Commission on Accreditation of Healthcare Organizations looks favorably on this sort of quality improvement project. JCAHO surveyors like to see documented instances of interdepartmental performance improvement efforts. We're proud to report that's what we've achieved.