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 Table of Contents  
Year : 2017  |  Volume : 2  |  Issue : 1  |  Page : 47-51

Optimization of blood transfusion services: Analysis of blood requisition and utilization practices in cardiac surgical patients in a tertiary care hospital, India

Department of Blood Transfusion Services, Sri Balaji Action Medical Institute, New Delhi, India

Date of Web Publication22-Mar-2017

Correspondence Address:
Sadhana Mangwana
Department of Blood Transfusion Services, Sri Balaji Action Medical Institute, New Delhi
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/2468-8398.202713

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Objective: Blood products are vital resources to health-care institutions with constantly growing demands. Gross over-ordering of blood causes exhaustion of valuable supplies and resources and add financial burden to patients undergoing surgical procedure. Aims: Study was undertaken to evaluate blood requisition, utilization, and management in cardiac surgery patients in a tertiary care hospital. Materials and Methods: Prospective study was conducted in cardiac surgery patients over 3 years from 2013 to 2015. Blood utilization indices were computed. Cross match to transfusion ratio (C:T) ratio of 2.0 and below, transfusion index (TI) value of 0.5 or more, and transfusion probability (%T) value of 30% and above were considered indicative of significant blood usage. Statistical analysis was done using Student's t-test. Results: During the study, a total of 15,392 patients' requisitions were received. Out of 25,190 units of blood cross-matched, 18,741 units were issued (C:T ratio 1.34) implying that overall 25.60% of blood was unutilized. From a total of 2752 units cross-matched for cardiac surgery cases, only 1296 units were transfused with C:T Ratio 2.12 implying that 52.91% of blood was unutilized which was much higher and statistically highly significant than in total patients. Overall TI was 1.22 and %T as 83.07% while for cardiac patients, TI was 2.32 with %T as 85.84%. Conclusions: Blood transfusion plays a major role in resuscitation and management of cardiac surgery patients. Blood transfusion services need to adopt blood conserving policies. Efforts should be made to adopt more conservative transfusion thresholds, conduct regular auditing, and periodic feedback to improve blood ordering, handling, distribution, and utilization practices of this scarce resource.

Keywords: Cardiothoracic vascular surgeries, crossmatch to transfusion ratio, maximum surgical blood order schedule, transfusion index, transfusion probability

How to cite this article:
Mangwana S, Bedi N, Yadav P, Chugh R. Optimization of blood transfusion services: Analysis of blood requisition and utilization practices in cardiac surgical patients in a tertiary care hospital, India. Glob J Transfus Med 2017;2:47-51

How to cite this URL:
Mangwana S, Bedi N, Yadav P, Chugh R. Optimization of blood transfusion services: Analysis of blood requisition and utilization practices in cardiac surgical patients in a tertiary care hospital, India. Glob J Transfus Med [serial online] 2017 [cited 2022 May 26];2:47-51. Available from: https://www.gjtmonline.com/text.asp?2017/2/1/47/202713

  Introduction Top

Blood and blood products are the most precious resource to any healthcare institution. Judicious use of these limited resources is necessary and significant to preserve adequate supply. Excessive over-ordering of blood preoperatively is a very common problem in elective surgeries. Type and crossmatch are the routine protocol in Asian countries in contrast to electronic type and screen protocols followed in western countries. This causes the blood to be unavailable for the emergency patients for at least 48–72 h, increased workload on the technicians, reagent wastage, and added financial burden on the patient undergoing the elective surgery.

To reduce this excessive blood wastage, medical centers need to adopt blood conserving policies such as maximum surgical blood order schedule (MSBOS), surgical blood order equation, or type and screening of blood which would lead to better utilization of blood products. MSBOS first published by Friedman in 1979[1] to guide ordering practices has universally resulted in substantial reduction of direct and indirect costs.[2]

Frank et al.[3] analyzed optimization of preoperative blood ordering with MSBOS and anesthesia information management system (AIMS) - acquired data and found that all cardiac surgery cases were at risk for major bleeding. It was recommended that all patients be cross-matched preoperatively and concluded that MSBOS with AIMS-acquired data can be used to implement blood ordering protocols leading to improved operating rooms efficiency, enhance patient safety, and reduction in costs.[3]

The primary objective of this study was to evaluate the blood requisition, blood utilization, and utilization management by analyzing crossmatch to transfusion ratio (C:T). Transfusion probability (%T) was calculated to determine the likelihood of a patient requiring transfusion. Transfusion index (TI) was also calculated to determine average number of units transfused. Using these data, we created our institution-specific MSBOS for cardiothoracic vascular surgery (CTVS) cases to be implemented that would decrease unnecessary cross matching.

  Materials and Methods Top

A hospital-based prospective study was conducted in elective and emergency cases of CTVS patients in the tertiary care hospital over a period of 3 years from January 2013 to December 2015. Details of blood requisition and transfusion of cases were collected and reviewed. Patient's age, sex, number of units cross-matched and transfused, number of patients cross-matched and transfused, and type of surgery were noted. Blood utilization indices were computed with the following equation.

  1. C:T ratio = Number of units cross-matched/number of units transfused
  2. TI = Number of units transfused/number of patients cross-matched
  3. Transfusion probability (%T) = Number of patients transfused/number of patients cross-matched × 100
  4. MSBOS = 1.5 × TI.

C:T ratio of 2.0 and below, TI value of 0.5 or more and %T value of 30% and above were considered indicative of significant blood usage. Excessive cross matching was considered when these indices were above thresholds for appropriate blood usage, i.e., C:T ratio >2.0 and TI <0.5.

All data were processed and analyzed with the software programs Microsoft Excel 2007 (v12.0) and statistical analysis was done using Student's t-test. P< 0.05 was considered statistically significant.

  Results Top

During the study of 3 years, a total of 15,392 patients' requisitions were received in Department of Blood Transfusion Services. 25,190 units of packed red blood cells were cross-matched for these patients of which 18,741 units were issued (C:T ratio 1.34) implying that overall 25.60% of the blood cross-matched was not transfused. Overall TI was 1.22 and %T as 83.07%.

Out of total blood requisition received, requisition for cross matching was received for 558 cardiac patients, majority (74.37%) were males with only 25.63% females. Age distribution showed that 33.69% of patients were in the age group of 61–70 years age group, 30.64% of patients in 51–60 years age group, 15.23% of patients in more than 70 years, 14.16% of patients in 41–50 years age group, 3.76% in 31–40 years, 1.43% in 21–30 years and 1.07% in <20 years age group, illustrated in [Figure 1].
Figure 1: Age sex distribution

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Distribution of various CTVS indications is depicted in [Figure 2]. Highest numbers of cardiac surgical patients (74%) were for coronary artery bypass graft (CABG) followed by valve repair (12.54%), vascular surgeries (3.94%), CABG with valve repair (3.58%), and thoracic surgeries (1.97%) patients.
Figure 2: Cardio thoracic vascular surgery procedures distribution

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The C:T ratio for CTVS patients was 2.12 which were statistically significantly higher (P < 0.00001) than the overall C:T ratio for all patients including the cardiac cases which was 1.34 [Table 1]. Among the cardiac patients, the patients undergoing vascular surgeries had the highest C:T ratio (3.75), followed by other CTVS surgeries (2.64) (which included atrial septal defect closure, ventricular septal defect closure, patent ductus arteriosus closure, percutaneous transluminal coronary angioplasty, acute coronary syndrome), thoracic surgery (2.58), CABG (2.22), valve repair (1.77), and CABG with valve repair (1.41) [Table 1]. Blood was cross-matched for four patients planned for CABG but these patients expired before surgery. Transfusion indices were calculated separately for these patients and found to be 2.12 (C:T Ratio), 1.5 (TI), and 50% (%T).
Table 1: Transfusion indices and maximum surgical blood order schedule for various indications

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The C:T ratio for vascular, thoracic, and CABG with valve repair surgery were statistically significant (P < 0.00001, P< 0.05, P< 0.05 respectively) as compared to CABG alone. C:T ratio for vascular surgeries was significantly higher than CABG alone, CABG with valve repair, valve repairs (P < 0.00001), thoracic and other surgeries (<0.05).

The transfusion probability (%T) for the cardiac patients was 85.84% while that for all patients requiring crossmatch was 83.07% indicating that %T for cardiac patients is significantly higher (P < 0.05) than the total patients requiring transfusion. Among the cardiac patients, patients undergoing valve repair had highest %T of 97.14% followed by patients for CABG with valve repair (95%) and CABG (87.41%).

TI for cardiac patients (2.32 ± 0.47) was significantly higher (P < 0.00001) than that for all the surgical patients (1.22 ± 0.009).

When cost was analyzed for patients anticipated of requiring transfusion and blood was unutilized, it was found that average financial resource wastage was more in CTVS patients with Rs. 965/patient (average Rs. 179,573/annum) than in all patients with financial resource wastage as Rs. 155/patient (average Rs. 795,376/annum).

After assessing annualized resource wastage, the new MSBOS is calculated for various indications of cardiothoracic surgeries. MSBOS for CABG is three units, CABG with valve repair - six units, valve repair - five units, vascular intervention - one unit, thoracic surgeries and other surgeries - two units each.

  Discussion Top

Blood transfusion undoubtedly plays a major role in resuscitation and management of cardiac surgical patients but overestimation of anticipated blood loss results in over-ordering of blood leading to artificial shortage of reserves and wastage of supplies and resources in terms of time and reagents. A number of studies available show gross over ordering of blood in 40%–70% patients transfused.[4],[5],[6],[7],[8]

All patients undergoing cardiac procedures do not have an equal risk of bleeding or blood transfusion. Evaluation of each patient for these risks is an important part of blood resource management. Despite the awareness about risk categories suggested by “The Society of Thoracic Surgeons 2011, blood estimation guidelines,”[9] cardiac surgeons and anesthesiologists feel more comfortable having excess blood products available than not having enough blood.

The use of C:T ratio was first suggested by Boral Henry in 1975.[10] Ideally, this ratio should be 1.0 but a ratio of 2.5 and below is considered to be indicative of efficient blood usage. The overall C:T ratio for all patients (including the cardiac patients) in our study is much lower compared to other developing countries such as Iran (3.71), Ethiopia (2.3), Nigeria (3.3), Sri Lanka (6.6), and Egypt (3.9).[11],[12],[13],[14],[15] It is also lower than other Indian studies wherein C:T ratio was 2.5 and 4.3.[8],[16] C:T ratio in cardiac surgical patients in this study is 2.12 while it is higher (2.7) in study conducted by Ibrahim et al. in Egypt.[15] This indicates better utilization and utilization management in our hospital as compared to other above-mentioned studies.

C:T ratio >2.0 means that <50% cross-matched units are transfused. Overall C:T ratio of 1.34 in current study is indicative of efficient blood usage but in cardiac surgical cases C:T ratio was 2.12. This study revealed that overall 25.60% of cross-matched blood was unutilized which rose to nearly 53% in cardiac surgery cases.

The results of the present study demonstrated that C:T ratio varied widely across various cardiothoracic surgical indications. The C:T ratio for the patients undergoing CABG (2.22) and valve repair (1.77) were lower than those in studies conducted by Jayaranee et al. (7.7; 4.2),[17] Chawla et al. (4.77; 2.8)[18] and Ural et al. (11.7; 3.75, respectively)[19] and while it was more than CABG patients in Taiwan (1.2).[20] Similarly, C:T ratio vascular surgery in our institute was 3.75 while studies conducted by Jayaranee et al. (4.0) and Chawla et al. (9.0) showed higher indices.[17],[18]

Data from developing countries; Nigeria, (69.7%), Egypt (74.8%), India (76.8%), and Nepal (86.4%),[13],[15],[16],[21] have shown gross over ordering of blood. The current study revealed only 25.6% of blood was unutilized in total patients, and nearly 53% of blood in cardiothoracic surgery cases was unutilized which is relatively low compared to the studies in various countries as mentioned above. This indicates that malpractice is common in developing countries while better utilization and management in this institute.

The transfusion probability denoted by %T was first suggested by Mead et al.[7] A value of 30% and above is suggested to be appropriate and signifies appropriateness of number of units cross-matched. According to recommendations in literature, %T value in different CTVS procedures in this study is found appropriate. The overall %T (83.07%) is higher than in studies of Iran (16.83%), Ethiopia (47%), Nigeria (34.29%), and Sri Lanka (14.6%)[11],[12],[13],[14] which is indicative of considerable significant blood usage at our institute. Transfusion probability for cardiac surgical patients in our study (85.84%) is more as compared to the study by Ibrahim et al. (54.2%).[15] Transfusion probability in various CTVS procedures in the current study is found to be very appropriate with highest in valve repair (97.14%) followed by CABG with valve repair (95%), CABG (87.41%) while it was lowest in vascular intervention (36.36) but meeting the recommendations of 30% and above.

Regarding TI, a value of 0.5 or more is indicative of efficient blood usage and appropriateness of number of units transfused.[10] TI reported in the current study for all cases as 1.22 is higher than in studies conducted by Yazdi et al. (0.31), Belayneh et al. (0.77), Ho and Bo (0.63), Gamage et al. (0.2), and Vibhute (0.35).[11],[12],[13],[14],[16] Similarly, in cardiac cases also, it is higher (2.32) than found by Ibrahim et al. (1.10).[15]

Blood conservation measures are routinely employed for cardiac cases at our institution. These measures help contribute to the low transfusion rates seen in our study. It is critical to monitor the unnecessary orders and overall demand of blood.

Implementation of institution-specific MSBOS to decrease unnecessary perioperative blood orders can result in a reduction of hospital cost and financial burden to the patient. Over ordering has led to financial resource wastage, in a resource poor country like India, up to Rs.965 per CTVS patient, a finding similarly evidenced in literature where Frank et al.[22] have shown a reduction of $298,966 per year ($6.20 per patient). Chawla et al. have also suggested possible direct savings, if MSBOS were in place, ranged from 90.87% to 23.33%.[18]

There are some limitations to the present study. The preoperative data including hemoglobin level, comorbidities and antiplatelet therapies and intraoperative data including amount of blood loss and duration of surgeries are very important to correlate the results but due to some logistic issue; such data could not be obtained.

In an era of cost reduction to increasing health-care cost, decrease reimbursement, and pressure to reduce unnecessary investigation and procedures, optimizing the practice of blood ordering is an important aspect in a tertiary care setting.

Blood transfusion services need to adopt blood conserving policies. For continued improvement of transfusion practice, continuous surveillance of utilization pattern is needed. It is recommended that over-ordering of blood should be minimized by changing the blood ordering pattern with the implementation of MSBOS. Efforts should be made to adopt more conservative transfusion thresholds, conduct regular auditing about the effectiveness of blood requesting policy using C:T ratio and periodic feedback to improve blood ordering, handling, distribution, and utilization practices of this scarce resource.

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Conflicts of interest

There are no conflicts of interest.

  References Top

Friedman BA. An analysis of surgical blood use in United States hospitals with application to the maximum surgical blood order schedule. Transfusion 1979;19:268-78.  Back to cited text no. 1
Napier JA, Biffin AH, Lay D. Efficiency of use of blood for surgery in south and mid Wales. Br Med J (Clin Res Ed) 1985;291:799-801.  Back to cited text no. 2
Frank SM, Rothschild JA, Masear CG, Rivers RJ, Merritt WT, Savage WJ, et al. Optimizing preoperative blood ordering with data acquired from an anesthesia information management system. Anesthesiology 2013;118:1286-97.  Back to cited text no. 3
Lowery TA, Clark JA. Successful implementation of Maximum Surgical Blood Order Schedule. J Med Assoc Ga 1989;78:155-8.  Back to cited text no. 4
Hardy NM, Bolen FH, Shatney CH. Maximum surgical blood order schedule reduces hospital costs. Am Surg 1987;53:223-5.  Back to cited text no. 5
Mintz PD, Lauenstein K, Hume J, Henry JB. Expected hemotherapy in elective surgery. A follow-up. JAMA 1978;239:623-5.  Back to cited text no. 6
Mead JH, Anthony CD, Sattler M. Hemotherapy in elective surgery: An incidence report, review of the literature, and alternatives for guideline appraisal. Am J Clin Pathol 1980;74:223-7.  Back to cited text no. 7
Subramanian A, Sagar S, Kumar S, Agrawal D, Albert V, Misra MC. Maximum surgical blood ordering schedule in a tertiary trauma center in northern India: A proposal. J Emerg Trauma Shock 2012;5:321-7.  Back to cited text no. 8
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Society of Thoracic Surgeons Blood Conservation Guideline Task Force, Ferraris VA, Brown JR, Despotis GJ, Hammon JW, Reece TB, et al. 2011 update to the Society of Thoracic Surgeons and the Society of Cardiovascular Anesthesiologists blood conservation clinical practice guidelines. Ann Thorac Surg 2011;91:944-82.  Back to cited text no. 9
Friedman BA, Oberman HA, Chadwick AR, Kingdon KI. The maximum surgical blood order schedule and surgical blood use in the United States. Transfusion 1976;16:380-7.  Back to cited text no. 10
Yazdi AP, Alipour M, Jahanbakhsh SS, Gharavifard M, Gilani MT. A survey of blood request versus blood utilization at a university hospital in Iran. Arch Bone Jt Surg 2016;4:75-9.  Back to cited text no. 11
Belayneh T, Messele G, Abdissa Z, Tegene B. Blood requisition and utilization practice in surgical patients at university of Gondar hospital, Northwest Ethiopia. J Blood Transfus 2013;2013:758910.  Back to cited text no. 12
Ho O, Bo B. Blood utilization in elective surgical procedures in Ilorin. Trop J Health Sci 2006;13:15-7. Available from: http://www.ajol.info/index.php/tjhc/article/view/36702. [Last accessed on 2017 Mar 01].  Back to cited text no. 13
Gamage CA, Pratheepan P, Sivaganesh S. Rationale for blood request: Cross match versus group and screen. Sri Lanka J Surg 2014;31:24-7.  Back to cited text no. 14
Ibrahim SZ, Mamdouh HM, Ramadan AM. Blood utilization for elective surgeries at main university hospital in Alexandria, Egypt. J Am Sci 2011;7:683-9.  Back to cited text no. 15
Vibhute M, Kamath SK, Shetty A. Blood utilisation in elective general surgery cases: Requirements, ordering and transfusion practices. J Postgrad Med 2000;46:13-7.  Back to cited text no. 16
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Chawla T, Kakepoto GN, Khan MA. An audit of blood cross-match ordering practices at the Aga Khan University hospital:First step towards a Maximum Surgical Blood Ordering Schedule. J Pak Med Assoc 2001;51:251-4.  Back to cited text no. 18
Ural KG, Volpi-Abadie J, Owen G, Gilly G, Egger AL, Scuderi-Porter H. Tailoring the blood ordering process for cardiac surgical cases using an institution-specific version of the Maximum Surgical Blood Order Schedule. Semin Cardiothorac Vasc Anesth 2016;20:93-9.  Back to cited text no. 19
Lin JS, Chen YJ, Tzeng CH, Lyou JY, Lee CH. Revisiting of preoperative blood ordering policy – A single institute's experience in Taiwan. J Chin Med Assoc 2006;69:507-11.  Back to cited text no. 20
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  [Figure 1], [Figure 2]

  [Table 1]

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