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 Table of Contents  
ORIGINAL ARTICLE
Year : 2021  |  Volume : 6  |  Issue : 1  |  Page : 33-37

Maximum surgical blood ordering schedule for cancer surgeries: An institutional study


Transfusion Medicine, The Gujarat Cancer and Research Institute, Ahmedabad, Gujarat, India

Date of Submission10-Aug-2020
Date of Decision01-Sep-2020
Date of Acceptance01-Mar-2021
Date of Web Publication29-May-2021

Correspondence Address:
Dr. Rima Kusumgar
Transfusion Medicine, The Gujarat Cancer and Research Institute, Ahmedabad, Gujarat
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/GJTM.GJTM_71_20

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  Abstract 


Background and Objectives: Although blood ordering is a common practice in surgical field, the average requirement for a particular procedure is usually based on subjective anticipation of blood loss rather than on evidence-based estimates. In the absence of an explicit maximum blood demand policy, ordering for blood transfusion is frequently based on subjective anticipation of blood loss instead of evidence-based estimates of average requirement in a particular surgery. Maximum surgical blood order schedule (MSBOS) is a criterion developed from institutional usage statistics providing a figure for the number of units to be crossmatched for any given surgical procedure. Aims and objectives of this study were to prepare and implement MSBOS, to increase blood availability to other medical patients and surgical patients. Promote efficient use of blood inventory, workforce, and consumables. This also helps to reduce unnecessary pre transfusion testing and cross match studies. Methodology: A retrospective analysis of various surgeries was done and then, a maximum surgical blood order schedule (MSBOS) was prepared and implemented and various parameters were analyzed in the largest tertiary cancer care hospital of Gujarat over a 2-year period. The goal was to study the blood ordering strategies in the hospital for surgical patients and evolve an MSBOS. The total units demanded and the corresponding units issued were studied for surgical patients. Thereafter, transfusion probability, transfusion index (TI), and ratio of units crossmatched to actual units transfused (C/T ratio) were calculated. Transfusion guidelines for all surgeries requiring transfusions were proposed and implemented. Results: Crossmatch to transfusion ratio improved from 9.54 to 3.68. Transfusion probability was down to 30.04 from 13.24 and TI increased to 0.31 from 0.179. P value by using Z test for all three parameters was <0.05. Conclusions: Z-test calculation showed significant statistical improvement in the above three measures. The study also identified the common cases where “Type and Screen” (T and S) procedure could be introduced in cases where the transfusion probability was low. The implementation of this proposal will avoid over ordering of blood which is beneficial to the institute.

Keywords: Maximum surgical blood ordering schedule, transfusion index, transfusion probability, transfusion protocol, type and screen


How to cite this article:
Kusumgar R. Maximum surgical blood ordering schedule for cancer surgeries: An institutional study. Glob J Transfus Med 2021;6:33-7

How to cite this URL:
Kusumgar R. Maximum surgical blood ordering schedule for cancer surgeries: An institutional study. Glob J Transfus Med [serial online] 2021 [cited 2021 Dec 7];6:33-7. Available from: https://www.gjtmonline.com/text.asp?2021/6/1/33/317176




  Introduction Top


Although blood ordering is a common practice in surgical field, the average requirement for a particular procedure is usually based on subjective anticipation of blood loss rather than on evidence-based estimates. Excessive crossmatching with minimal transfusion practice was observed in elective surgical patients. Injudicious preoperative over ordering of blood can burden the physical and human resources of a health-care facility and increase the cost of medical care.

In the absence of an explicit maximum blood demand policy, ordering for blood transfusion is frequently based on subjective anticipation of blood loss instead of evidence-based estimates of average requirement in a particular surgery. Such practices have greater implications in resource-constrained settings. Data from several developing countries have shown gross over ordering of blood in 40% to 70% of patients transfused. The ratio between blood crossmatching and transfusion (C/T ratio) should ideally be between 2 and 2.5.[1]

This means that at least 30% of the crossmatched blood should have been needed for transfusion. Any figure less than this is not justified. Maximum surgical blood order schedule (MSBOS) is a criterion developed from institutional usage statistics providing a figure for the number of units to be crossmatched for any given surgical procedure.[2]

MSBOS provides guidelines for frequently performed elective surgical procedures by recommending the maximum number of units of blood to be crossmatched preoperatively. MSBOS reduces the preoperative crossmatching of blood in surgical cases in which there is less likelihood of blood transfusion. Implementation of MSBOS has almost universally resulted in a substantial reduction of direct and indirect costs. It has also proven to be an effective tool for quality assurance by reducing the stress on the blood transfusion services, more efficient use of bloodstocks, and reduction in the wastage due to outdating.

Aims and objectives

Prepare and implement MSBOS to

  1. Increase blood availability to other medical patients and to more surgical patients
  2. Promote efficient use of blood inventory, workforce, and consumables
  3. Reduce pretransfusion testing and minimize unnecessary crossmatching.



  Materials and Methods Top


Ethics

After obtaining permission from the Institutional Review Board (IRC/2017/P-108, November 13, 2017), the MSBOS has been developed through retrospective analysis of blood utilized for elective oncology surgeries in our institute.

Audits have been performed on clinical blood use by the blood bank department and the clinical specialties. Blood utilization was calculated using C/T ratio, transfusion probability (%T), and transfusion index (TI). Then, MSBOS was prepared by taking inputs of surgeons, anesthetists, and members of hospital transfusion committee and again, the calculation was done for all the three parameters to study blood utilization. The comparison of data before and after implementation of MSBOS is shown in [Table 1]. Surgeries included were
Table 1: Comparison of data before and after implementation of maximum surgical blood ordering schedule

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  1. General oncosurgeries (includes surgeries of head and neck, breast, gastrointestinal tract, and lung and orthopedic, urology, and plastic surgery) [Table 2] and [Table 3]
  2. Gynec-oncological surgeries [Table 4].
  3. Neuro-oncosurgeries [Table 5].
Table 2: General oncosurgeries

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Table 3: General oncosurgeries

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Table 4: Gynec-oncosurgery

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Table 5: Neuro oncosurgeries

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Note: The above classification is based on general classification followed in the hospital and not any standard classification guidelines.

Patients having hemoglobin <10 g/dl if require urgent surgery, usually, surgeons transfuse 1–2 units with the start of surgery just to improve anemia; hence; such patients are not counted in the study. Patients having coagulation/platelet disorders and patients with surgical complication like rupture of viscera or major vessel during surgery are also excluded.

MSBOS applies only for elective surgeries, the list which is received by blood bank 1 day prior to surgery. Elective surgical procedures include procedures for which patients are determined fit for surgery in the preanesthetist checkup. Blood bank staff compare the demands send by surgeons with MSBOS and reserve/crossmatch the blood accordingly and consult with ordering clinician if an order does not meet recommendations with MSBOS.

The list of surgeries is not exhaustive nor does it supersede clinical judgment. If a patient is under exclusion criteria, extra units of blood may be required. Clinical decisions that override this schedule must be discussed with blood transfusion staff at the time of the request.

All the data related to surgeries were analyzed by using Hospital Management Information software Infomedica version 2, Ms Soft Corner, Ahmedabad, Gujarat, India.

All the data were analyzed by Z test calculator to establish its statistical significance.


  Results Top


The results show that before the implementation of MSBOS, from January to June 2013, the number of surgical patients studied was 3400 who were transfused 609 units of red blood cell (RBC) units. After implementation of MSBOS, patients undergone surgeries were 3523 who were transfused 1120 units. The number of unit crossmatched and number of patients' transfused are also shown in [Table 1] below. CT ratio improves from 9.54 to 3.68. Transfusion probability comes to 30.04 from 13.24 and TI increases to 0.31 from 0.179.


  Discussion Top


The present study is about the first-time preparation and implementation of MSBOS in a teaching institute. Most of the preordering for blood transfusion for surgical patients was done by junior or trainee doctors though all the indexes for effective blood ordering improved, for example, CT ratio from 9.54 to 3.68, %T from 13.24 to 30.08, and TI from 0.179 to 0.31 within a year of its implementation, as shown in [Table 5] (P < 0.05 for all three parameters). However, before the implementation of MSBOS, the number of units transfused is 609 RBC units which increased to 1120 units after implementation. This is attributed to an increase in the proportion of patients undergoing surgeries in the post-MSBOS group in addition to an increase in the number of patients in this group needing transfusion. TI though improved but not achieved its normal range which still has a scope of improvement.

The idea for this project originates from the need for every hospital blood transfusion department to have a MSBOS. An MSBOS is a table of elective surgical procedures which list the number of units of red cells routinely crossmatched for that procedure preoperatively. The schedule was based on a retrospective study of actual blood usage associated with the different surgical procedure. It aims to correlate as closely as possible the amount of blood crossmatched to the amount of blood transfused (T). The CT ratio can be used to monitor the efficiency of the scheme in a surgical setting. A realistic objective for C: T ratio is 1–2:1. A C: T ratio 2.5, %T >50, and TI >0.5, are considered indicatives of significant blood utilization.[2],[3],[4]

Many authors also found that the practice of establishing MSBOS has been observed to be highly successful.[1],[2] Gupta et al. study[5] at armed force hospital also shows that the implementation of this proposal will avoid over ordering of blood and will promote maximum utilization.

Blood ordering pattern for elective procedures needs to be revised and over ordering of blood should be minimized. Moreover, the hospital with blood transfusion committee should formulate maximum surgical blood ordering policies for elective surgical procedures and conduct regular auditing.[6] Where the transfusion rate is <5%, no type and screen (T and S) specimen needs to be processed, where transfusion rate is between 5% and 30%, a specimen is processed and no red blood cells crossmatched, and for procedures with a transfusion rate above 30%, a specimen is required and red blood cells crossmatched.[7] Mead et al.[3] suggested that surgical procedures which would have a <30% probability of using blood be recommended for “TandS” They also recommended that for procedures with a >30% probability of transfusion, the crossmatch orders should not exceed 1.5 times the number of units transfused per patient. Many studies[8],[9],[10] have shown that blood is generally over ordered and the implementation of MSBOS and the introduction of “T and S” procedure has led to a safe, effective, and economic solution to ordering of blood.

Limitation of this study

The type of surgery is not considered individually and also it reflects the blood transfusion for oncology surgeries only. Blood ordering by trainee doctors as is the norm in some teaching institutes may be different from practices in private where blood is ordered by senior experienced consultants. Periodic revision is still needed with implementation of new surgical techniques.


  Conclusions Top


Application of MSBOS is effective and useful for saving preoperatively prepared blood. Analysis with C/T ratio was very useful to recognize the present status of preparations of blood for surgery preoperatively. MSBOS should be re-evaluated regularly because of changes of operative environment such as surgeons, operative methods, preoperative condition of patients, and so on. The study was able to meet the goal of making increased blood available to the medical and surgical patients by better blood utilization and effective inventory management. We were able to reduce unnecessary crossmatches as evidenced by the decrease in C/T ratio.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

1.
Rudmann Sally V. Textbook of Blood Banking & Transfusion Medicine. 3rd ed. Philadelphia: WB Saunders; 1995. p. 298-99.  Back to cited text no. 1
    
2.
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. 2
    
3.
Mead JH, Anthony CD, Sattler M. Haemotherapy in elective surgery. An incidence report, review of literature and alternatives for guideline appraisal. Am J Clin Pathol 1980;74:223-7.  Back to cited text no. 3
    
4.
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. 4
[PUBMED]  [Full text]  
5.
Gupta PK, Kumar H, Diwan RN. Blood ordering strategies in the armed forces. A proposal. MJAFI 2003;59:302-5.  Back to cited text no. 5
    
6.
Chairman D. Voak, Membership J.A.F. Napier, F.E. Boulton, Guidelines for implementation of a maximum surgical blood order system schedule. The British committee for standards in haematology blood transfusion task force. Clin Lab Haematol 1990;12:321-7.  Back to cited text no. 6
    
7.
Sheridan P, Revision and implementation of a maximum surgical blood ordering schedule in a large acute hospital. Thesis. Royal College of Surgeons in Ireland; 2014:37-48.  Back to cited text no. 7
    
8.
Bhutia SG, Srinivasan K, Ananthakrishnan N, Jayanthi S, Ravishankar M. Blood utilization in elective surgery – Requirements, ordering and transfusion practices. Natl Med J India 1997;10:164-8.  Back to cited text no. 8
    
9.
Atrah HI, Galea G, Urbaniak SJ. The sustained impact of a group and screen and maximum surgical blood ordering schedule policy on the transfusion practice in gynaecology and obstetrics. Clin Lab Haematol 1995;17:177-81.  Back to cited text no. 9
    
10.
Mujeeb SA. An audit of blood cross match ordering practices at the Aga Khan University Hospital: First step towards a maximum surgical blood ordering schedule (MSBOS). J Pak Med Assos 2001;51:379-80.  Back to cited text no. 10
    



 
 
    Tables

  [Table 1], [Table 2], [Table 3], [Table 4], [Table 5]



 

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