Abstract
Over ordering blood is a common practice in medicine. This can be corrected by a simple means of changing the blood ordering pattern. A retrospective study was carried out in a tertiary care hospital of Armed Forces for a three year period to study the blood ordering strategies in the hospital. The total units demanded and the corresponding units issued were estimated. Thereafter, transfusion probability and ratio of units cross-matched to actual units transfused (C/T ratio) was calculated. In this study, using Mead's criterion, transfusion probability and C/T ratio, transfusion guidelines for all cases requiring transfusion is proposed. The study also identifies the common cases where ‘Type and Screen’ (T&S) procedure could be introduced in cases where the transfusion probability is low. The other group where transfusion probability is high, a maximum surgical blood ordering schedule (MSBOS) has been determined to identify the number of units to be cross-matched and kept ready before the procedure. The implementation of this proposal will avoid over-ordering of blood and will promote maximum utilization.
Key Words: Maximum surgical blood ordering schedule, Transfusion protocol, Type & Screen
Introduction
The primary goal of blood transfusion centres has been to provide adequate and safe supply of blood products. In recent years, influenced by an increasing demand for cost-effectiveness, there has been an increased awareness of the need for optimum distribution and utilization of safe blood and blood products. A variety of strategies for ordering blood and blood products have been proposed and developed to supply safe blood products in adequate amount as efficiently and as economically as possible. Therefore, a revision of blood ordering strategy is considered the mainstay of improving blood utilization while maintaining safety.
Blood ordering before surgery is clearly excessive. There is a tendency amongst surgeons, particularly trainee surgeons to ‘play it safe’ by keeping cross-matched blood always available even for relatively minor procedures. A transfusion service may follow any of the several policies that lead to more efficient use of blood inventory control and consequently a reduction in blood bank operating costs. The most important policy is the ‘Type and Screen’(T & S) whereby units are not cross matched until an actual need for transfusion occurs [1].
Another policy that has proved to be successful in the practice of blood banking is the maximum surgical blood order schedule (MSBOS). This is a criterion developed from institutional usage statistics providing a figure for the number of units to be cross matched for any given surgical procedure [2].
Material and Methods
A retrospective study was carried out by scrutiny of records of the Blood Bank in a tertiary care hospital of the Armed Forces for a three year period to study the blood ordering strategies in the hospital. The blood requisitioned for surgical, medical, obstetrics and gynaecological (Obs & Gyne), orthopaedics and burns cases was compiled and reviewed. The total units demanded and the corresponding units of blood issued were estimated. Thereafter, the transfusion probability was calculated. A ratio of units cross-matched to the actual unit transfused, (C/T ratio) was calculated with a view to review the transfusion policy. After compilation of cases requiring transfusion and calculation of C/T ratio, the cases were classified as those where the probability of transfusion was low and could be managed by ‘T & S’ and those where the probability of transfusion was high, MSBOS was determined.
Results
The detailed analysis of the overall blood demand and issue schedule with transfusion probability and C/T ratio for a three year study period for different broad groups and the commonly encountered sub groups amongst them is depicted in Table 1, Table 2, Table 3, Table 4, Table 5.
Table 1.
Surgical cases
| Year | Units demanded | Units transfused | Transfusion probability | C/T ratio |
|---|---|---|---|---|
| 1st year | 1215 | 380 | 31% | 3.3:1 |
| 2nd year | 1308 | 388 | 29% | 3.4:1 |
| 3rd year | 1180 | 361 | 31% | 3.3:1 |
| Common subgroups | ||||
| Benign Prostrate Hypertrophy | ||||
| 1st year | 112 | 27 | 24% | 4.2:1 |
| 2nd year | 98 | 15 | 15% | 6.5:1 |
| 3rd year | 103 | 19 | 18% | 5.4:1 |
| Cholecystectomy | ||||
| 1st year | 182 | 13 | 07% | 14:1 |
| 2nd year | 239 | 25 | 15% | 9.5:1 |
| 3rd year | 176 | 31 | 17% | 5.7:1 |
| Renal calculus | ||||
| 1st year | 95 | 25 | 26% | 3.8:1 |
| 2nd year | 58 | 14 | 24% | 4.1:1 |
| 3rd year | 116 | 11 | 09% | 10.5:1 |
| Neurosurgical procedures | ||||
| 1st year | 236 | 77 | 33% | 3.1:1 |
| 2nd year | 167 | 55 | 32% | 3:1 |
| 3rd year | 70 | 27 | 35% | 2.8:1 |
| Oncosurgical procedures | ||||
| 1st year | 171 | 91 | 53% | 1.9:1 |
| 2nd year | 217 | 92 | 42% | 2.4:1 |
| 3rd year | 274 | 125 | 45% | 2.2:1 |
| Kidney transplantation | ||||
| 2nd year | 52 | 03 | 06% | 17.3:1 |
| 3rd year | 50 | 03 | 06% | 17.3:1 |
Table 2.
Medical cases
| Year | Units demanded | Units issued | Transfusion probability | C/T ratio |
|---|---|---|---|---|
| 1st year | 1005 | 581 | 58% | 1.7:1 |
| 2nd year | 1068 | 811 | 76% | 1.3:1 |
| 3rd year | 1244 | 778 | 62% | 1.6:1 |
| Common subgroups | ||||
| Anaemia (of all causes) | ||||
| 1st year | 301 | 222 | 74% | 1.4:1 |
| 2nd year | 507 | 341 | 67% | 1.5:1 |
| 3rd year | 406 | 288 | 71% | 1.4:1 |
| Haematological malignancies | ||||
| 1st year | 186 | 152 | 82% | 1.2:1 |
| 2nd year | 302 | 208 | 69% | 1.4:1 |
| 3rd year | 185 | 150 | 81% | 1.2:1 |
| Other oncological cases | ||||
| 1st year | 118 | 81 | 69% | 1.5:1 |
| 2nd year | 140 | 100 | 71% | 1.4:1 |
| 3rd year | 221 | 157 | 71% | 1.4:1 |
| Biopsy (kidney/liver) ERCP | ||||
| 1st year | 160 | 03 | 02% | 53:1 |
| 2nd year | 120 | 15 | 12% | 8:1 |
| 3rd year | 088 | 05 | 06% | 17.6:1 |
| Upper gastrointestinal bleeding | ||||
| 1st year | 141 | 68 | 48% | 2.1:1 |
| 2nd year | 128 | 69 | 54% | 1.8:1 |
| 3rd year | 071 | 71 | 52% | 1.9:1 |
Table 3.
Obstetrics and Gynecological
| Year | Units demanded | Units issued | Transfusion probability | C/T ratio |
|---|---|---|---|---|
| 1st year | 505 | 109 | 22% | 4.6:1 |
| 2nd year | 508 | 98 | 19% | 5.2:1 |
| 3rd year | 622 | 123 | 19% | 5.0:1 |
| Common subgroups | ||||
| Hysterectomy | ||||
| 1st year | 201 | 47 | 23% | 4.3:1 |
| 2nd year | 175 | 27 | 15% | 6.5:1 |
| 3rd year | 265 | 54 | 20% | 4.9:1 |
| LSCS | ||||
| 1st year | 171 | 11 | 06% | 15.5:1 |
| 2nd year | 199 | 21 | 10% | 9.5:1 |
| 3rd year | 223 | 15 | 07% | 15:1 |
| Pregnancy with anaemia/sepsis | ||||
| 1st year | 26 | 16 | 61% | 1.6:1 |
| 2nd year | 12 | 09 | 75% | 1.3:1 |
| 3rd year | 25 | 12 | 48% | 2.1:1 |
| PPH/APH | ||||
| 1st year | 18 | 11 | 61% | 1.6:1 |
| 2nd year | 12 | 05 | 42% | 2.4:1 |
| 3rd year | 15 | 07 | 47% | 2.1:1 |
Table 4.
Orthopedics
| Year | Units demanded | Units issued | Transfusion probability | C/T ratio |
|---|---|---|---|---|
| 1st year | 295 | 122 | 41% | 2.4:1 |
| 2nd year | 171 | 63 | 37% | 2.7:1 |
| 3rd year | 231 | 102 | 44% | 2.3:1 |
| Common subgroups | ||||
| All fractures | ||||
| 1st year | 238 | 92 | 39% | 2.6:1 |
| 2nd year | 148 | 56 | 38% | 2.6:1 |
| 3rd year | 184 | 70 | 38% | 2.6:1 |
| Amputations | ||||
| 1st year | 33 | 22 | 67% | 1.5:1 |
| 2nd year | 11 | 06 | 55% | 1.8:1 |
| 3rd year | 40 | 28 | 70% | 1.4:1 |
Table 5.
Burns and Reconstructive Surgery cases
| Year | Units demanded | Units issued | Transfusion probability | C/T ratio |
|---|---|---|---|---|
| 1st year | 127 | 94 | 74% | 1.4:1 |
| 2nd year | 110 | 75 | 68% | 1.5:1 |
| 3rd year | 80 | 54 | 67% | 1.5:1 |
Discussion
In many blood transfusion centres large number of units of blood are cross matched each day for patients who are most unlikely to require transfusion. To avoid units of blood being reserved unnecessarily the policy in such cases is simply grouping the patient's red cells and screening the serum for abnormal antibodies i.e. ‘T & S’ [1].
The idea of providing pre surgical testing, without cross matching, for elective surgery without significant blood loss is not new. Many authors [3] analyzed blood use in elective surgery and the frequency of antibody detection by screening tests, they demonstrated the safety of substituting ‘T & S’ in place of routine cross matching in a number of elective surgical procedures. In addition, they emphasized the reduction in the hospitalization charges for the patient, improved distribution of blood supplies and the more effective utilization of the time of the blood bank technologist if a ‘T & S’ approach was adopted.
The practice of establishing MSBOS has been observed to be highly successful [1, 2]. In this, the data concerning blood usage for each procedure performed in the hospital is reviewed over several months and the C/T ratio calculated. Ideally a C/T ratio of 1:1 would be most desirable and most efficient, but it is never achievable. Therefore a C/T ratio of 2:1 for all procedures has been accepted as a reasonable goal. MSBOS is a viable option to avoid unnecessary, excessive cross matching of blood for elective surgical procedures.
Mead et al [4] suggested that surgical procedures which would have a less than 30% probability of using blood be recommended for ‘T&S’. They also recommended that for procedures with a greater than 30% probability of transfusion, the cross match orders should not exceed 1.5 times the number of units transfused per patient. It is also pointed out that surgical blood estimates of three units or less were generally unreliable and for these procedures a ‘T & S’ approach was recommended. An estimate of greater than three units was more reliable and usually some blood was used, but even in these cases the C/T ratio was too high.
If a ‘T & S’ policy is implemented as an alternative for elective surgery rarely requiring transfusion, the advantages far outweigh any disadvantages which are more often-perceived than real [5]. The advantages in terms of blood utilization and cost have been well established. It also leads to improved inventory control, which permits more enhanced production of blood components and prevents obsolescence of blood. The perceived disadvantages of a ‘T & S’ procedure, which have been suggested include lack of availability of cross matched blood when urgently needed and decreased hospital blood inventory to cover unexpected disaster or major emergency situations.
The principles behind the development of a standardized schedule for preoperative blood ordering, or MSBOS, popularized by Friedman et al [2] are closely related to those which led to a ‘T & S’ approach. Indeed, the two concepts are usually combined when guidelines for blood ordering are provided to the staff of the hospital. Many studies [6, 7, 8, 9] have shown that blood is generally over ordered and the implementation of MSBOS and the introduction of ‘T & S’ procedure has led to a safe, effective and economic solution to ordering of blood.
Based on transfusion probability in this study, Mead's criterion [4] and C/T ratio, transfusion guidelines for all cases requiring transfusion are proposed in Table 6. The implementation of this will avoid over ordering of blood and will promote maximum utilization of this valuable resource.
Table 6.
Proposed Transfusion Guidelines
| Surgical cases | |
|---|---|
| I. Cholecystectomy | |
| TURP for BPH | |
| Pyelolithotomy for renal calculus | Type and Screen |
| Kidney transplantation | |
| Hernia (inguinal/incisional) repair | |
| II. All oncosurgical procedures | 50% unit demanded |
| Neurosurgical procedures | Cross matched |
| Medicine cases | |
| I. All cases | 80% units demanded |
| Cross matched | |
| II. Biopsy/ERCP | Type and Screen |
| Obstetrical and gynecological cases | |
| I. Total abdominal/vaginal hysterectomy | |
| LSCS | Type and Screen |
| II. Pregnancy with anaemia/sepsis | 70% units demanded |
| PPH/APH | Cross matched |
| Orthopedics cases | |
| I. All fractures | 40% units demanded |
| Cross matched | |
| II. Amputation | 70% units demanded |
| Cross matched | |
| Burns/reconstructive surgery cases | |
| I. All cases | 75% units demanded |
| Cross matched |
The principal aim of this study was to identify the common procedures/conditions where ‘T & S’ can be introduced and to formulate a blood transfusion guideline for these procedures where a complete cross match appears mandatory. The introduction of ‘T & S’ and MSBOS will lead to more efficient transfusion in our hospitals as in other countries [10]. This will also change the blood ordering patterns to attain optimum blood use.
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