The Crossmatch-to-Transfusion Ratio as a Quality Indicator for Blood Bank Utilization: A Retrospective Analysis

Abstract

Background:

With the rising demand for blood products in India, it is imperative to ensure efficient utilisation of available resources within blood banks. This study aims to assess the crossmatch-to-transfusion (C/T) ratio as a metric for evaluating and optimizing blood utilisation practices. Analysing the C/T ratio across various clinical departments will help identify inefficiencies in blood ordering protocols and support the implementation of corrective strategies to improve overall resource management.

Materials and Methods:

A retrospective observational study was conducted at the Blood Center of Dr. N. D. Desai Medical College & Hospital. Data were collected over one year period from January 2024 to December 2024. The number of cross-matched and transfused data were collected from crossmatch request forms, crossmatch registers, issue registers, and digital medical records. The department wise utilisation of blood and its components C:T ratio were calculated.

Results:

During the study period, 5,402 blood units were crossmatched, of which 2,968 units were issued, yielding an overall hospital C:T ratio of 1.43 and an overall utilisation rate of 54.95%. Department-wise analysis showed substantial variation. Obstetrics and Gynaecology recorded the highest C:T ratio (2.83) with a utilisation rate of 35.3%, followed by Orthopaedics (C:T ratio 1.85; utilisation54.1%), General Surgery (C:T ratio 1.57; utilisation63.8%), ENT (C:T ratio 1.32; utilisation75.8%), and General Medicine (C:T ratio 1.14; utilisation87.8%).

Conclusion:

The study revealed that the overall crossmatch-to-transfusion (C/T) ratio at the hospital is within internationally accepted standards, with particularly elevated ratios observed in the surgical departments. Developing a standardized blood ordering policy, including guidelines for expected blood usage in surgical and elective procedures, can significantly reduce unnecessary blood orders, avoid redundant compatibility testing, minimize the return of unused units, and prevent wastage due to component expiry—ultimately leading to more efficient blood bank management.

INTRODUCTION

Transfusion services are essential in hospitals, treating patients for surgical interventions, chronic diseases, complications related to pregnancies, and malignant conditions.[1] Due to lack of evidence-based guidelines for the transfusion of blood in most developing countries, ordering and transfusion of blood are frequently based on subjective decision-making skills and clinical knowledge.[2,3] Crossmatch transfusion ratio (C/T ratio) is considered an essential quality indicator that can be used to measure the appropriateness or efficiency of blood ordering practices within the blood transfusion services in a hospital.[4] American Association of Blood Banks suggests a C/T ratio of <2.0 is favorable, and value above denotes over-ordering and cross-matching of blood.[5]

This study aimed to evaluate blood utilization practices using the C/T ratio, identify the departments with a high C/T ratio, and develop targeted interventions to improve Transfusion practices in these areas.

MATERIALS AND METHODS

One year retrospective study was carried out from January 2024 to December 2024 at Blood center of Dr. N.D Desai Medical College and hospital. Department wise transfusion requests were made, units cross matched, units issued, units transfused, and units unutilized were evaluated. For this required data were collected from crossmatch request forms, crossmatch registers, issue registers, and digital medical records. The patient’s personal data were not recorded for this study.

Efficacy of blood units utilization was evaluated by using C/T ratio. Equation for this ratio is:

Ratio above two is considered excessive blood ordering, C/T ratios were computed for both hospital and each individual department.

Data were analyzed and presented in tabular and appropriate diagrammatic forms.

Exclusion criteria

Patients who had incomplete or unclear documentation about blood order, cross-match, and transfusion were excluded from indices analysis. Blood requests for hospital transfusions that were not within our hospital were excluded from the study.

RESULTS

During the study period, the hospital blood bank processed 5402 blood unit requests, all of which underwent crossmatching. Of these, only 2968 units (54.95%) were transfused, leaving 45.05% unutilized. As shown in Figures 1, 2 and Table 1, the Department of Obstetrics and Gynaecology submitted the highest number of requests (3,035 units) but transfused only 1071 units (35.3% utilization, C:T ratio 2.83). In contrast, the Department of General Medicine demonstrated a markedly higher utilisationrate, with 1126 of 1282 crossmatched units transfused (87.8%utilisation, C:T ratio 1.14) following orthopedics with 54.10% utilization, 1.85 C;T ratio and General surgery with 63.80% utilization and C:T ratio 1.57.

Figure 1.

Showing department wise C:T ratio

Figure 2.

Showing department wise crossmatch versus utilization

Table 1.

Department wise C:T ration and utilisation

Department		Number of Crossmatches		Number of Transfused units		C/T Ratio		Utilization (%)
Medicine		1282		1126		1.14		87.8
Obstetrics and gynecology		3035		1071		2.83		35.30
General surgery		354		226		1.57		63.80
Orthopedics		335		181		1.85		54.10
TBCD		71		66		1.08		92.96
Ear nose throat		65		49		1.32		75.80
Pediatric		135		127		1.07		94.07
Urology		4		3		1		75.00
Intensive care unit		121		119		1.02		98.35
Total		5402		2968		1.43		54.95

In the present study, the overall C:T ratio was 1.43.

Here’s the color-coded chart — red marks the department that failed standards, orange shows surgical areas with elevated C/T ratios, and green indicates acceptable levels.

DISCUSSION

Effective use of blood and its components with high quality and minimum wastage are the main goals of blood utilization management system[6] and constant monitoring helps supply safe blood and blood products to the patients who are in need preventing over-utilization of this scarce resource.[7]

Several strategies have been established to address the inappropriate utilization of blood and its components, encompassing the formulation of evidence-based guidelines, systematic surveillance of transfusion practices, targeted educational initiatives, and clinician-led self-audits.

Blood transfusion indices be affected by many factors like differences in surgical and anesthetic techniques, preoperative conditions of the patients, and variations in transfusion protocols.[8,9]

Hence, the primary objective of the present study was to evaluate blood requisition and utilization by analyzing the crossmatch-to-transfusion (C:T) ratio.

The use of the crossmatch-to-transfusion (C:T) ratio as a performance indicator for the blood center offers several advantages. It facilitates the identification of patterns in unused crossmatched blood units enabling categorization by department and, when necessary, attribution to individual clinicians.

Indications of blood transfusion depends on clinical status of every patient and their treating clinicians. Lack of clinical audits, blood ordering policies and lack of co-ordination between clinicians and Head of Department of Blood Transfusion Medicine is the most common cause of high C:T ratio.[10]

Overall, the C:T ratio of 1.43 was recorded in present study which was quite lower than that reported from other studies conducted in Egyptv (3.9), Malaysia (5.0), India (2.5), Nigeria (2.2), and Saudi (2.96).[11,12,13,14]

The department-wise analysis of the C/T ratio revealed that the Obstetrics and Gynaecology department had the highest value (2.83), followed by Orthopaedics (1.85) and General Surgery (1.57). The ENT and General Medicine departments recorded C/T ratios of 1.32 and 1.14, respectively.

In the case of Obstetrics and Gynaecology, C/T ratio of 2.83 indicates that the blood center performed nearly three times more crossmatch procedures than the number of units actually transfused. During the study period, this department requested 3035 crossmatches, of which only 1071 units were issued to patients, corresponding to a utilisation rate of 35.30%.

Comparable findings were reported in a study by Kaur et al.,[15] where the highest C/T ratio—3.6:1—was also observed in the Obstetrics and Gynaecology department. In contrast, Trisal et al.[16] reported the highest C/T ratio (2.7:1) in the ENT department, while Kumari et al.[17] documented the highest value (2.8:1) in Gynaecology and Obstetrics.

Overall, the present analysis indicates that the C/T ratio at our institute is within accepted range of internationally accepted standards. Only Obstetrics and Gynaecology department failed to met the standards. Though compare to other departments all surgical departments have high C/T ratios, pointing to a pattern of over-ordering. Overestimating perioperative blood requirements leads to underutilization of crossmatched units, thereby inflating the C/T ratio.[17,18]

In this study, the overall transfusion rate for all surgeries was 54.95%, which is a better trend than a study, done by Aryal et al.[3] who targeted formulating a maximum surgical blood ordering schedule in Obstetrics and Gynecology; they found that the overall transfusion rate for all surgeries was 22.5%. The cause for variation in blood utilization might be in their study the type of procedures included in the study are gynecological and obstetrics surgeries only.

Departments where a high C/T ratio is observed, targeted in-service training or continuing medical education (CME) programs should be conducted to address over-ordering and promote evidence-based transfusion practices. Regular CMEs highlighting optimal transfusion guidelines can enhance the efficiency and reliability of blood transfusion services.

A structured blood ordering policy, such as the Maximum Surgical Blood Order Schedule (MSBOS), should be implemented. The MSBOS provides evidence-based recommendations for the maximum number of units to be crossmatched preoperatively for common surgical procedures. Its adoption can reduce over-ordering, minimize unnecessary compatibility testing, and limit the return of unused blood units to the blood center.[19,20] Chawla, et al.[21] reported that there is a possibility of direct savings of health care costs by 90.87%–23.33% if MSBOS were applied in surgical patients.

When considering a transfusion, clinicians must carefully assess the clinical indication and, if justified, estimate the appropriate number of units required for each patient.[1]

Limitations

The study had certain limitations. Preoperative data, including hemoglobin levels, comorbidities, and antiplatelet therapy history, as well as intraoperative details such as estimated blood loss and duration of surgery, were not available due to logistical constraints. Additionally, the study was conducted over a short duration in a single tertiary care hospital, with a relatively small patient sample, making direct comparison with larger multicenter studies difficult. Furthermore, clinician-dependent transfusion decision-making was not analyzed. As the findings are specific to our institution, they may not be generalizable to other settings.

CONCLUSION

The evaluation of the C/T ratio indicates that our hospital has meet international standards for blood utilization. Only Obstetrics and Gynaecology department failed to met the standards. Though compare to other departments all surgical departments have high C/T ratios—suggest that a substantial proportion of crossmatched blood units are not being effectively utilized. In this study, the C/T ratio served as a quality indicator to assess blood bank resource utilization, highlighting the need to optimize blood ordering practices.

Improving ordering practices can reduce unnecessary compatibility testing, the return of unused units, and wastage due to expiry, while also enabling better workforce management and healthcare cost control. Patient Blood Management strategies and strict adherence to transfusion guidelines are critical to ensuring the efficient functioning of a blood center.

Conflicts of interest

There are no conflicts of interest.

Funding Statement

Nil.