Reducing blood utilization by implementation of a type-and-screen transfusion policy a single-institution experience

Improving documentation of blood product administration using a standardized electronic health record-based system: a single-institution experience

OBJECTIVES

To improve documentation of blood product administration by assessing the completion status of blood transfusions. In this way, we can ensure compliance with the Association for the Advancement of Blood & Biotherapies standards and facilitate investigation of potential blood transfusion reactions.

METHODS

This before-and-after study includes the implementation of an electronic health record (EHR)-based, standardized protocol for documenting the completion of blood product administration. Twenty-four months of retrospective data (January-December 2021) and prospective data (January-December 2022) were collected. Meetings were held before the intervention. Ongoing daily, weekly, and monthly reports were prepared, and targeted education to deficient areas as well as spot in-person audits by the blood bank residents were conducted.

RESULTS

During 2022, 8,342 blood products were transfused, of which 6,358 blood product administrations were documented. The overall percentage of completed transfusion order documentation improved from 35.54% (units/units) in 2021 to 76.22% (units/units) in 2022.

CONCLUSIONS

Interdisciplinary collaborative efforts helped produce quality audits to improve the documentation of blood product transfusion through a standardized and customized EHR-based blood product administration module.

Economic impact of a machine learning-based strategy for preparation of blood products in brain tumor surgery

Background

Globally, blood donation has been disturbed due to the pandemic. Consequently, the optimization of preoperative blood preparation should be a point of concern. Machine learning (ML) is one of the modern approaches that have been applied by physicians to help decision-making. The main objective of this study was to identify the cost differences of the ML-based strategy compared with other strategies in preoperative blood products preparation. A secondary objective was to compare the effectiveness indexes of blood products preparation among strategies.

Methods

The study utilized a retrospective cohort design conducted on brain tumor patients who had undergone surgery between January 2014 and December 2021. Overall data were divided into two cohorts. The first cohort was used for the development and deployment of the ML-based web application, while validation, comparison of the effectiveness indexes, and economic evaluation were performed using the second cohort. Therefore, the effectiveness indexes of blood preparation and cost difference were compared among the ML-based strategy, clinical trial-based strategy, and routine-based strategy.

Results

Over a 2-year period, the crossmatch to transfusion (C/T) ratio, transfusion probability (Tp), and transfusion index (Ti) of the ML-based strategy were 1.10, 57.0%, and 1.62, respectively, while the routine-based strategy had a C/T ratio of 4.67%, Tp of 27.9%%, and Ti of 0.79. The overall costs of blood products preparation among the ML-based strategy, clinical trial-based strategy, and routine-based strategy were 30, 061.56$, 57,313.92$, and 136,292.94$, respectively. From the cost difference between the ML-based strategy and routine-based strategy, we observed cost savings of 92,519.97$ (67.88%) for the 2-year period.

Conclusion

The ML-based strategy is one of the most effective strategies to balance the unnecessary workloads at blood banks and reduce the cost of unnecessary blood products preparation from low C/T ratio as well as high Tp and Ti. Further studies should be performed to confirm the generalizability and applicability of the ML-based strategy.

Routine Preoperative Group Crossmatching and Postoperative Check Hemoglobin Is not Necessary in Patients Undergoing Total Knee Arthroplasty

This study aims to find out if routine preoperative group crossmatch and postoperative check hemoglobin for total knee arthroplasty (TKA) patients is necessary. A retrospective analysis was performed on patients who underwent unilateral TKAs for osteoarthritis from January 1, 2004 to December 31, 2014. The main outcome measures were postoperative hemoglobin levels and transfusion requirements. Patients' demographics, comorbidities, laboratory results, and surgical details were analyzed. A total of 955 TKAs were included in this study (males = 207, females = 748; mean age = 66.1 years, standard deviation [SD] = 7.7). A total of 79 (8.27%) cases required postoperative blood transfusion, and the crossmatch-transfusion ratio was 17.5. Significant predictors for postoperative transfusion included lower preoperative hemoglobin levels (p < 0.001) and advanced age (p < 0.001). Receiver operating characteristic (ROC) curve and Youden's Index analyses identified the preoperative hemoglobin cut-off value for females to be 12.1 g/dL (relative risk (RR): 5.65, p < 0.001) in predicting postoperative blood transfusion requirement, and 12.4 g/dL (RR: 11.71, p < 0.001) for males. For age, the identified cut-off value was 68 years (RR: 3.18, p < 0.001). The largest decline in hemoglobin levels was noted on postoperative day (POD) 3 (31.8%), and smallest on POD 1 (18.8%). The postoperative transfusion requirements in TKA are low and do not justify routine perioperative blood investigations. However, these investigations should be reserved for patients with the identified risk factors, in particular advancing age (68 years and above) and lower preoperative hemoglobin (below or equal to 12.1 and 12.4 g/dL for females and males, respectively). In the event that postoperative hemoglobin level needs to be checked, it should be performed beyond the first POD.

Enhancing the utilization of packed red blood cells stock in maternity hospitals

OBJECTIVES

To assess and enhance the efficiency of transfusion services in maternity hospitals.

METHODS

A case control study was conducted from January to December 2016. A corrective policy of replacing preoperative type and hold step with blood transfusion request (BTR) hold was used only on healthy patients undergoing elective cesarean sections (c-section). The crossmatch/transfusion (C:T) ratio and a cost comparison were the evaluating factors. Data were analyzed using an Excel spreadsheet and SPSS statistical software.

RESULTS

A total of 1,200 BTRs were analyzed, comprising 659 before implementation of the corrective policy and 541 blood transfusion requests after implementation of the corrective policy. From January to March, the C:T ratio of c-sections was nearly 7 times the American Association of Blood Banks recommended limit of 2.5. Most of the blood units (94%) were damaged due to repeated booking. After implementation, the cost-e ectiveness of erythrocyte transfusion was greatly enhanced as all the ordered blood units were used and the C:T ratio was reduced to the ideal limit of one. The number of destroyed units was drastically decreased from 450 units to zero; as a result, 83% of the transfusion costs were saved.

CONCLUSION

The policy enhances the cost-effectiveness of erythrocyte transfusion and laboratory testing, and saves on additional, unnecessary costs.

An Evaluation of the Practice for the Requisition of Blood Products and its Utilization in Neurosurgical Patients Undergoing Elective Surgery at a Tertiary Care Hospital

Background

Neurosurgical procedures are associated with profound blood loss that necessitates need for intraoperative and postoperative blood transfusion. Excessive ordering of blood based on physicians' habitual practice may lead to unintentional misuse of blood bank services. For the optimal use of blood resources, transfusion practices have to be appropriate.

Aims

The aim of this study is to study the cross match to transfusion ratio and to review the blood utilization practices (transfusion index and maximal surgical blood order schedule) in elective neurosurgical procedures.

Settings and Design

A prospective, observational study comprising 740 patients undergoing elective neurosurgical procedures.

Materials and Methods

Blood requisition forms and patient records were analyzed of patients undergoing elective neurosurgical procedures from December 2017 to December 2018. A review and note was made of the patient's age, sex, and diagnosis. The number of units prepared, cross matched, and transfused were noted.

Statistical Analysis

Statistical analysis was performed with the IBM SPSS software version 21.0. Blood utilization indices were computed and expressed as percentage.

Results

A total of 740 patients underwent elective surgical procedures. Among these, 346 patients were requested to prepare 614 units of blood. Out of these 740 patients, there were 56 patients who were in the pediatric age group. A total of 178 units were transfused in 102 patients. One hundred and forty-two units were transfused in the intraoperative period, whereas as 36 units were transfused in the postoperative period.

Conclusion

There is an efficient usage of blood for patients undergoing surgery for meningiomas, posterior fossa tumors, spinal dysraphism, and craniovertrebral junctional anomalies. However, the blood resources were poorly utilized in patients undergoing surgery for subarachnoid hemorrhage and pituitary tumors. A revision of blood transfusion policy within the hospital is needed.

Improved Cost-Effectiveness and Blood Product Utilization From Instituting a Blood Ordering Algorithm for Cardiac Surgical Cases

BACKGROUND

Results of a previous study revealed an over-ordering of blood products for cardiac surgery and led to the creation of a new blood ordering algorithm. This follow-up study has been conducted to evaluate improvement in ordering practices.

METHODS

Retrospective data were collected for 171 patients who underwent coronary artery bypass grafting or valve surgery from March 2015 to March 2016 to determine the crossmatch-to-transfusion ratio (C:tx) and potential cost savings. Results were compared with pre-algorithm values and considered statistically significant if the 95% confidence interval did not include zero.

RESULTS

Prior to the algorithm, 100% of patients undergoing cardiac surgery were crossmatched. After instituting the algorithm, this decreased to 15%. The overall C:tx decreased from 7.97 to 2.14. Cost savings were calculated as $114.79 (coronary artery bypass grafting) and $129.05 (valve surgery) per patient.

CONCLUSIONS

The creation of a new algorithm to guide ordering practices has significantly improved the C:tx, reduced unnecessary crossmatching, and lowered costs.

Blood transfusion practices in a tertiary care center in Northern India

BACKGROUND

Blood transfusion plays vital roles in the medical and surgical practice. To achieve optimum use of blood, transfusion has to be appropriate and judicious consuming minimal resources and manpower.

OBJECTIVE

To evaluate the pattern of blood transfusion requests and utilization with the aim of determining transfusion practice.

MATERIALS AND METHODS

Blood request forms and cross-match worksheets at the blood bank were analyzed over a 6-month period. Numbers of requisitions, blood units cross-matched, issued out, transfused, and nontransfused were calculated. Nonusage probability (NUP) and the cross-match to transfusion ratio (CTR) for each clinical unit were computed.

RESULTS

Two thousand two hundred and sixty-eight units of blood were cross-matched for 1487 patient's transfusion requests, out of which only 1455 (64.2%) were transfused giving a total CTR of 1.6 for the hospital. The CTR for the various clinical units were: Obstetrics and gynecology (O and G) 2.7, surgery 2.1, orthopedics 1.9, medicine 1.1, pediatrics 1, and oncology 1.

CONCLUSIONS

The overall CTR (1.6) of the hospital was within the optimal range except for the O and G and surgery department which were having very high NUP and CTR indicating their suboptimal transfusion practices. Introducing revised transfusion guidelines, maximum surgical blood ordering schedule and type, screen, save, and abbreviated cross-match method can help toward adequate requisition and utilization of blood thereby reducing wastage of resources, time, and manpower.

The Crossmatch/Issue Ratio: Use of a Novel Quality Indicator and Results of an International Survey on RBC Crossmatching and Issuing Practices

OBJECTIVES

To understand the worldwide scope of RBC crossmatching and issuing practices and measure efficiency using a novel quality indicator, the crossmatch/issue (C/I) ratio.

METHODS

An electronic survey was disseminated to hospital transfusion services collecting details about RBC crossmatching and issuing practices. Respondents were asked to enumerate the number of RBCs crossmatched and issued at their institutions during the 2014 calendar year to calculate the C/I ratio.

RESULTS

Fifty-two survey responses were received, mostly from North American transfusion services (28/52, 54%). The electronic crossmatch was the most common technique (n = 29), and most respondents performed the crossmatch at the time that an order for RBCs was received in the transfusion service (even if an order to issue the RBCs was not received). Data to calculate the C/I ratio were supplied by 22 respondents, and the mean ± SD was 1.30 ± 0.34. There was no difference in C/I ratios between services that use the electronic or serologic crossmatch techniques (P = .49). The ratio was the same at the four sites that crossmatch RBCs at the time of issue compared with the time of order receipt (mean ± SD, 1.11 ± 0.09 vs. 1.35 ± 0.36, respectively; P = .19).

CONCLUSIONS

Electronic crossmatching is common, and the C/I ratio can be an indicator of efficiency.

Tailoring the Blood Ordering Process for Cardiac Surgical Cases Using an Institution-Specific Version of the Maximum Surgical Blood Order Schedule

BACKGROUND

Excess ordering of blood products for surgical cases is expensive and wasteful. Evidence has shown that institution-specific versions of the Maximum Surgical Blood Order Schedule (MSBOS) lead to better ordering practices. Most MSBOSs recommend a crossmatch for a minimum of 2 units of packed red blood cells (PRBCs) for cardiac surgical cases; however, studies have shown that >50% of these patients receive no transfusions. Our aim was to create a blood order algorithm for cardiac surgical cases that would decrease unnecessary crossmatching.

METHODS

Retrospective data was collected for 264 patients from January 2011 through April 2012. The crossmatch-to-transfusion ratio (C:tx), transfusion probability (%T), and transfusion index (TI) were calculated for each type of procedure.

RESULTS

All 264 patients were crossmatched and 98 patients were transfused, resulting in an overall transfusion probability (%T) of 37.12% (95% confidence interval 31.52-43.09). A total of 1175 units of blood were crossmatched, but only 370 units of blood were transfused, resulting in a C:tx of 3.17 (95% confidence interval 2.61-4.03). The average number of units transfused per procedure (transfusion index) was 1.40. C:tx was highest and TI was lowest for CABG, where approximately 11 units of blood were ordered for every 1 unit transfused (C:tx =11.70 ± 3.04), and the TI was 0.32.

CONCLUSIONS

Using the gold standard C:tx of >2:1 as an indicator of inappropriate blood utilization, our analysis confirmed that excessive crossmatching occurred for several procedures. Now a subset of cardiac surgical cases only requires a type and screen order prior to surgery.