Management of dispensing Rh Immune Globulin (RhIg) through Pharmacy

The Technical Supervisor at a community hospital in northern Illinois reports they have closed their birthing center. They plan on moving the process of dispensing Rh Immune Globulin (currently use Rhophylac®) to Pharmacy, and are looking for input how to best serve the needs of their active ER. For other facilities that have already done so, she is most curious about RhIg for Rh(D) prophylaxis in pregnant or postnatal females. What blood bank tests are performed? How is this information provided to Pharmacy prior to dispensing product?

The Editors believe that the prior question, Should the hospital pharmacy participate in the dispensing of Rh Immune Globulin (RhIg), is germane to this discussion.

The following comments have been submitted.

ADDENDA May 15, 2009

1. A transfusion medicine physician at a busy hospital in Los Angeles reports that the author of the question correctly points out that the prophylactic use of Rh immune globulin is not limited to post-partum women originating in the hospital birthing center. There is often concern surrounding pregnant, Rh negative women who present to the Emergency Department (ED) bleeding or post trauma. As in the post-partum setting, the fetal screen and/or Kleihauer-Betke) KB tests can be used to determine fetal maternal hemorrhage and a dose of Rh immune globulin calculated. The question assumes that the blood bank lab can still do this type of testing. If, for administrative reasons, it is necessary to move the distribution of Rh immune globulin to the Pharmacy, the responding physician believes that the best course of action is to have a meeting between representatives of the ED, Blood Bank and Pharmacy to determine a protocol and procedure to communicate between the departments efficiently and to know what to do with information that is communicated.
   
   The protocol could be set up in a variety of ways. Most consistant with other lab tests would be to report the results of fetal screen/KB and calculated dose directly to the ED physician, who would, in turn, order from the pharmacy. However, it could be set up so that the blood bank would communicate that information to the Pharmacy who would issue the correct dose.
   
   In many hospitals the pharmacy currently distributes WinRho, the IV-only preparation of RhIg approved for ITP. The addition of the obstetric preparation may be confusing and should be addressed in the protocol. At the responding physician's institution they use a commercial RhIG that can be administered either IM or IV, as they were concerned that a formulation which can only be given IM might be given IV by mistake. The probability of this type of mistake would likely increase if it was distributed by the pharmacy. Additionally, most ED patients have an IV line in place, making administration of an IV preparation easier on the patient.

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