Maximum Blood Order Schedule Research Articles

Pre-operative blood ordering – Choose wisely!!

A multi-specialized research health center needs to implement a standard blood ordering schedule for elective surgeries and perform regular audits on blood ordering practices to ensure the judicial usage of resources. This retrospective study is a step towards implementing a maximum blood-ordering schedule in our Institute. Blood ordering and utilization of 10 surgical specialties (performing over 180 different surgical procedures) were analyzed for 1 year to formulate an institutional maximum blood-ordering schedule. Out of 7967 patients, the cross match- transfusion ratio, transfusion probability, and transfusion index were 2.5, 34.5%, and 0.7 respectively. There was a gross over-ordering of blood units pre-operatively (82.4%). Sixty-seven percent of the elective surgeries can be performed safely with type and screen alone saving 77% of the total expenditure if we were to cross-match the exact number of units demanded. Hence, this study reiterates the importance of regular auditing of blood requisition patterns and the introduction of maximum blood-ordering schedule to prevent wastage of precious blood bank resources.

A retrospective analysis of blood requisition versus utilization practices at national blood bank, jigme dorji wangchuck national referral hospital, Thimphu, Bhutan

Background and Objectives: Although National Guidelines on Clinical Use of Blood has been developed, it is a common practice to order blood based on the subjective anticipation of blood loss, instead of evidence-based requirement at National Referral Hospital, Thimphu. However, National Blood Bank follows the maximum surgical blood ordering schedule, thereby saving the resources and making blood available for emergency patients. Nonetheless, the need-based assessment is not conducted to determine the efficacy of the practice. This study aimed to assess the effectiveness of the current practice of following the national guidelines on maximum surgical ordering of blood by evaluating the blood requisition versus utilization practice. Materials and Methods: A hospital-based retrospective study was conducted at national blood bank over a 1-year period (January–December 2018). Demographic data, such as age and sex, and clinical wards with maximum transfusion done were recorded. Blood utilization indices were computed for cross-match-to-transfusion ratio (C:T, <2.5), transfusion index (TI, >0.5) and transfusion probability (%T, >30) to indicate significant blood usage. All data were processed and analyzed with software programs Microsoft Excel 2013 and GraphPad Prism (v 7.04). Results: Of 4012 blood units cross-matched, 3205 blood units were transfused to patients (C:T ratio 1). Majority (65.33%) of the patients were females and 34.66% were males. The overall TI was 1.49 and %T was 73.07%, implying significant blood usage. The maximum request for blood was made from gynecological and obstetrics ward, emergency, and daycare blood transfusion unit. Similarly, the patients transfused with the cross-matched units were also found to be highest for these wards. Conclusion: The study demonstrates that the current practice of maximum blood ordering schedule is effective in saving valuable time and resources. However, there is a need to sensitize the requesting physician on rational order for effective management of the blood inventory.

Pattern of blood procurement and utilization in a university hospital in Southeast Nigeria

Background: Blood is a scarce commodity and every effort needs to be made to use it judiciously and avoid wastage. This study reviewed the pattern of blood procurement, ordering, and utilization at a hospital-based blood bank. Materials and Methods: This was a retrospective study in which data on blood procurement methods, pattern of requisition of blood, and outcome of issued blood were obtained from blood bank registers over a 2-year period at the Nnamdi Azikiwe University Teaching Hospital blood bank. Results: Approximately, 99% of donors were family replacement donors. In 2014, total blood donated was 4003 which exceeded the request for red blood cell (RBC) transfusion by 921 units. The highest request for blood was from the accident and emergency and 90% of blood issued were used. Overall percentage wasted of RBCs was 19.8% and the major contributors to these were antenatal clinic and labor ward both having 80% and 55.8% issued blood returned to blood bank unused. Conclusion: The proportion of wasted units of RBC is high. Designing and adhering to maximum blood ordering schedule and blood transfusion guidelines with efforts toward converting family replacement donors to voluntary blood donors will help in maintaining a steady supply of safe blood.

Blood requisition and utilization practice in obstetric patients at tertiary care center from South India: A descriptive study

BACKGROUND: Although blood ordering is a common practice in surgical field, in obstetric patients too requests are commonly made to crossmatch units of blood for patients in whom bleeding is anticipated and to provide precautionary cover for cesarean section. This was a prospective study on blood requisition and utilization practice among obstetric patients at our center. METHODS: Data collection pro forma was used to collect information from antenatal case notes on demographics, transfusion request, units transfused, reason for transfusion, and related laboratory data. Blood utilization was calculated using crossmatch to transfusion ratio (C/T), transfusion probability (%T), and transfusion index (TI) indices for all obstetric conditions. The maximum blood ordering schedule (MBOS) was used to develop algorithm for obstetric conditions. RESULTS: The incidence of red blood cells transfusion among all obstetric admissions was 708 out of 17275 (4.1%). Only 18% of blood requested for obstetric patients actually received transfusion. The overall C/T ratio, transfusion probability, and TI in obstetric patients during the study were 3.5%, 19.3%, 0.35%, respectively. Transfusion algorithm by classifying all obstetric conditions into three categories was developed based on MBOS for obstetric indications at our center. CONCLUSION: Although blood was reserved for the most obstetric patients, majority of the patient did not require transfusion. Hence, a new blood reservation and pretransfusion policy were recommended to minimize overordering and needless operating expenses for blood banks.

Arranging blood for elective thyroid surgeries: dilemma continues in the developing world

BackgroundCross matched blood is frequently ordered based on a subjective anticipation of blood loss for a procedure. Excessive blood arrangement and wastage overburdens the blood bank in terms of work load and storage of blood, increases cost of medical care and results in injudicious use of a limited resource. The aim of this short report is to assess the current practice for arranging cross matched blood in elective thyroid surgeries by comparing cross match to blood transfused ratio.FindingsMedical records for all patients from January 2009 to December 2014 undergoing thyroid surgery were retrieved and reviewed through electronic health information management system (HIMS). A total of 91 patients were included in the study, out of which 18 (19.7%) were male and 73 (80.2%) were female. A total of 107 units of blood were arranged and only 9 were transfused. 47 patients underwent a total thyroidectomy, while 44 underwent a hemithyroidectomy. The cross match to transfusion ratio came out to be 11.88.ConclusionsRoutine arrangement of cross matched blood is not required in elective thyroid surgeries. All institutions should have a maximum blood ordering schedule planned for elective procedures, and blood products should be arranged accordingly to avoid unnecessary cross matching.

A retrospective study of transfusion practices in a Tertiary Care Institute.

Background and Aims:Excessive requests for cross matching blood which is more than the blood required for transfusion are usually based on worst case assumptions leading to overestimation of blood usage. We investigated the blood ordering pattern and transfusion practices so as to incorporate a blood ordering schedule for streamlining the use of blood in various hospital departments.Methods:The study was conducted over a period of 19 months in a 350 bedded tertiary teaching hospital. Source of data was blood bank requisition forms and blood bank registers of patients who underwent elective or emergency procedures in the hospital, for which blood was ordered. Data were entered in MS Excel and analysed using SPSS version 20.Results:The blood bank was requested to prepare 10,594 units of blood for 2556 patients. The blood utilised was 16.04% of total cross matched blood, leaving 83.9% of units cross matched but not transfused to patient for whom it was prepared, i.e., wasted. The surgery department had the highest number of units cross matched and transfused. The least number of units cross matched and wasted due to non-transfusion were from the Department of Oncology.Conclusion:The current deficiency of explicit maximum blood order schedule in our hospital is the major factor responsible for high cross match: transfusion ratio. Therefore, a maximal surgical blood order schedule has been suggested to the hospital transfusion committee to implement maximum surgical blood order schedules for selected procedures.

Development of the M.B.O.S. Master Smartphone App to Increase Compliance with Maximum Blood Ordering Schedule (M.B.O.S.), Reduce red Cell Crossmatch to Transfusion Ratio, and Improve Follow up of Pre-Operative Blood Test Results

IntroductionElectronic crossmatch is not available in all United Kingdom hospitals potentially leading to a large number of manual serological crossmatches relative to the number of red cell units actually transfused. In 2011 it was observed that there was a high Red Cell crossmatch to transfusion ratio (C:T ratio) at a large London teaching hospital (St George’s Healthcare NHS Trust serves a population of 1.3 million across South West London and includes services such as cardiothoracic surgery, and renal transplantation).An initial activity to reduce the C:T ratio was the introduction of a Maximum Surgical Blood Ordering Schedule (MBOS) that gives pre-operative guidance on how many red cell units should be crossmatched for each procedure. Over corresponding 5 month periods in 2011 and 2012 there was a decrease of 200 units ordered pre-operatively, and a drop in C:T ratio from 5:1 to 4:1. There was also a decrease in the ordering of red blood cell stock of 200 units/month which equates to a cost saving of £24,600 (US$ 41,532) per month.Re-audit in 2014 showed the improved C:T ratio was maintained but still too high at 4:1. A survey showed a lack of awareness of the MBOS, poor access to the MBOS because it is buried in an Intranet with large amounts of content, and 28% pre-operative anaemia. Furthermore, strict limits on junior doctor working hours led to loss of continuity of care with blood test results not being looked at in a timely manner, potentially leading to unnecessary transfusion. This was discussed at the London Regional Transfusion Committee (RTC) (with members from 90 hospitals) and it was agreed that a smartphone Application (‘App’) would stimulate further improvement.MethodTwo RTC members and one St George’s representative jointly developed an iOS App called ‘MBOS Master’. Significant time was spent writing a detailed software specification to clarify the required functions of the App and how these functions would operate. Subsequently a prototype was demonstrated to key stakeholders, including staff in the pre-operative clinics and the London RTC through its regular meetings.ResultsStakeholder feedback was used to improve the user interface and functionality. Comments were made about the convenience of the MBOS in this format for both clinical and laboratory teams, how it would support communication between the different areas, and allow consistency of information to users. Improvements were made to the display of information to increase visibility of essential information. MBOS Master was enhanced by the addition of functions that support the handover of a list of blood tests taken pre-operatively (hopefully to improve continuity of care).MBOS Master allows: 1.The RTC to send messages to all MBOS Master users within the region, such as blood product warnings, and upcoming meetings2.The local hospital to upload its own customised MBOS just for users within that hospital3.The local hospital to upload information that is tailored to its local users, such as important phone numbers, and hospital transfusion committee meetings4.Easy navigation of the MBOS with the opportunity for individual users to store a Favorites list of frequently used recommendations5.The user to make multiple lists of patient hospital numbers and set reminders to chase results of pending blood tests, or to email the lists to colleagues.DiscussionThis project illustrates the importance of clearly defining the aim and functions of an App methodically, hands on development of the App by health professionals who are in touch with day to day transfusion practice, and the iterative process of testing with future users to maximise the ease of use and functionality of an App for healthcare purposes.The pre-release version is undergoing further testing by key stakeholders and is anticipated to be available in autumn 2014 through Apple’s App Store, with an Android version soon to follow. Ordering of red cells in relation to the MBOS will be reaudited 6 months after the App is launched to assess its impact on C:T ratio.In future the App will be assessed in terms of impact on the C:T ratio, blood stocks, and early treatment of pre-operative anemia. DisclosuresNo relevant conflicts of interest to declare.

Audit of Blood Transfusion Services (BTS) in Total Knee Replacement (Tkr) And Total Hip Replacement (Thr) Surgery: A Prospective Study

Total knee and total hip arthroplasty surgery make up a significant proportion of elective orthopaedic surgery in our hospital. The blood transfusion services (BTS) are very important for the successful outcome of these surgeries. The present study was undertaken to monitor the Maximum Blood Order Schedule (MSBOS) and cross match transfusion ratio (C:T ratio) in 349 patients of TKR & THR in our hospital. Majority of the patients with pre-operative haemoglobin of more than 13 g/dL in both the categories (TKR and THR) did not receive any transfusion. C:T ratio of THR (1.3:1) was better compared to TKR (1.44:1). The MSBOS of 2 units of red cells for TKR is appropriate while for THR it should be 3 units of red cells for unilateral THR and 4 units of red cells for bilateral THR especially for patients with pre-operative haemoglobin less than 11 g/dL.

Recidivism in Transfusion Quality Improvement: Support for the Role of Transfusion Nurses

Aim To evaluate longer term outcomes of a quality improvement strategy in transfusion. Method A Clinical Health Improvement Program (CHIP) quality improvement project was conducted in a 290 bed acute general hospital, to decrease the rate of transfusions with high pre-transfusion haemoglobins. Strategies for improvement included: formation of a Transfusion Committee; development of transfusion pathway; implementation of a Maximum Blood Order Schedule; educational strategies targeting clinical staff at all levels; promulgation of the NHRMC Clinical Practice Guidelines on the Use of Blood Components; and feedback to clinicians. The CHIP project was superseded by the ACT Haemovigilance Project, and an ACT wide concurrent transfusion audit was undertaken. There was no formal feedback on clinician performance during, or for 6 months prior to, the Haemovigilance audit. Red cell transfusion was assessed for compliance with the NHMRC Guidelines and compared with CHIP results. Result The CHIP project demonstrated successful implementation of the selected strategies, leading to a reduction in transfusions with pre-transfusion haemoglobins greater than 90 g/L. Follow up auditing commencing six months later demonstrated a progressive, and statistically significant, increase in inappropriate transfusions over the following six months. Conclusion Although improvement in transfusion practice was demonstrated with a multi-factorial approach to quality improvement, the improvement was not sustained in the medium term. Our results indicate the need for organisational commitment to long term quality improvement strategies in transfusion, and support the development of Transfusion Officers or Nurses to improve bedside clinical practice.

The impact of a 10-year audit cycle on blood usage in a district general hospital.

As clinical governance moves from concept to practice, it is emerging as a realistic strategy to promote and improve quality within the National Health Service, as well as satisfying the demand for external accountability. In the context of blood transfusion, the area of responsibility encompasses product liability, as well as efficient use of blood as a resource and transfusion as an appropriate clinical response. Clinical governance may be a modern catch phrase, but the principles it enshrines have long been established within blood transfusion, and in other aspects of haematology. Here, an audit cycle comprising four audits over a 10-year period to monitor the use of cross-matched blood in a large district general hospital is described. Initially, blood use was considered by hospital site, and by the surgical procedure for which it was requested. Later, the scope of the audit was expanded to consider usage by individual consultant. A standard of efficient use of cross-matched blood was taken to be a cross-match to transfusion ratio of < 1.5. The information was reviewed by the hospital transfusion committee, who have a key role in co-ordinating and assessing the practice of transfusion within a hospital. In this hospital, audit has been one of the main tools for improving practice, in particular by enabling the implementation and continuous revision of a maximum blood order schedule. Further, as the process of audit has developed, problem areas have been highlighted, and strategies to improve usage have been brought in with encouraging results. The audit is now being expanded again to include a greater focus on usage of cross-matched blood in the nonsurgical setting.

Infrastructure for monitoring blood transfusion practice in New South Wales hospitals.

To determine the existing infrastructure for monitoring blood transfusion practices in New South Wales hospitals. A questionnaire survey conducted in August 1998. All healthcare facilities known to have used blood products from the Australian Red Cross Blood Service--New South Wales in the 12 months before the survey. Existence of a transfusion committee and policies and procedures to ensure appropriate use and issue of blood products; monitoring expiry rates of red blood cells, platelets and fresh frozen plasma; using a maximum blood ordering schedule (MBOS); and measuring the crossmatch to transfusion ratio (CT ratio). 224 hospitals were surveyed and 144 responses were received (64%). Twenty-five hospitals (17%) had a transfusion committee; 60 (42%) monitored expiry rates of red cells, and 39 (27%) and 42 (29%), respectively, monitored these rates for platelets and fresh frozen plasma. Thirty-three hospitals (23%) used an MBOS and 43 (30%) measured the CT ratio. However, over 70% of the larger hospitals (> 200 beds) had all these aspects of transfusion infrastructure in place, and 35% had transfusion committees. Our survey showed that, overall, there was a lack of transfusion infrastructure in NSW hospitals. However, most of the hospitals with more than 200 beds had infrastructure in place to monitor transfusion practices, but only a minority had established transfusion committees.

地方中規模病院におけるＭＳＢＯＳ，Ｔｙｐｅ ａｎｄ Ｓｃｒｅｅｎ導入の試み

To make the most of the blood products, we have introduced maximum blood order schedule (MSBOS) and Type and Screen (T & S) into Nagahama City Hospital. By investigating the transfused blood products according to major surgical procedures of last 2 years, we set up MSBOS and the procedure of blood preparations for elective surgery in our hospital.As a result of one year's experience, the cross-match to transfusion ratio (C/T ratio) in many surgical procedures and that of red cell products in our hospital have decreased, and the effective use of red cell products has elevated.However, because our hospital dose not have the blood products in deposit system and we can not return the products, it was impossible to decrease the out-date.

THE RATIONAL USE OF HOMOLOGOUS BLOOD IN ELECTIVE SURGERY

The supply of homologous blood in Australia is limited, but the demand for blood and blood products is steadily increasing. Elective surgery is a major part of this demand. In many institutions the blood ordering practices for elective surgery have been haphazard. This study was undertaken to document current patterns of blood use in a major city teaching hospital. A retrospective analysis of blood ordering and transfusion for elective surgical procedures was carried out over a 12 month period. As in several previous studies, an inefficient use of blood was demonstrated. Possible strategies to rationalize the use of blood in elective surgery have been proposed. These include the use of a 'group and screen' procedure instead of a full cross-match when transfusion is unlikely to be necessary, and ordering according to a 'maximum blood order schedule' when transfusion is usually required for a procedure.