Reducing unnecessary preoperative blood orders and costs by implementing an updated institution-specific maximum surgical blood order schedule and a remote electronic blood release system. Anesthesiology. 2014;121:501-509. [PMID: 24932853 DOI: 10.1097/aln.0000000000000338]

Risk factor stratification for urgent and nonurgent transfusion in patients giving birth

BACKGROUND

A common approach to attempt to reduce maternal morbidity from hemorrhage is to recognize patients at increased risk, and to make advance preparations for possible blood transfusion in these patients. Preparation may consist of a hold clot, type, and screen, or crossmatch. Most hospitals, including ours, have pathways or guidelines that lay out which of these preparations should be made at the time a patient is admitted to labor and delivery. These are often based on risk factors for hemorrhage but do not take into account the probability that transfusion will be needed. The cost-effectiveness of performing a type and screen or routine crossmatch on patients admitted for delivery has been questioned. Several studies have shown that the chance of transfusions in individuals giving birth is very low. In terms of the need for routine blood preparation, the need for urgent transfusion is most relevant. This has not been included in studies of transfusion rates.

OBJECTIVE

The purpose of this study was to quantify the relative importance of risk factors present on admission for needing a blood transfusion and to develop a formula to define each individual's risk. This could then be used to decide an appropriate level of initial blood preparation for patients at different risk levels.

STUDY DESIGN

Risk factors for hemorrhage and the level of transfusion preparation were extracted from the medical records of a cohort of 89,881 patients delivering in an 18-hospital healthcare system over 40 months. We tabulated the number who required at least one RBC transfusion and the number needing an urgent transfusion-defined as receiving blood during labor or within 4 hours after delivery. Odds ratios for requiring a transfusion were calculated for each risk factor. We then calculated the probability of needing a transfusion for each patient based on their risk factor profile.

RESULTS

A total of 643 patients had any transfusion during their hospitalization (0.72% of deliveries), and 311 had an urgent transfusion (0.35% of deliveries). The calculated probability of needing a transfusion was less than 1% in 87.8% of patients and was greater than 5% in 1.2% of patients. The chance of needing a transfusion was highest for placenta accreta spectrum, admission Hgb <8.0, and placenta previa. A second tier of risk factors included abruption, bleeding with no specific diagnosis, and Hgb between 8.0 and 10.0.

CONCLUSION

In our cohort, very few patients received a transfusion. Applying a formula derived from patient-specific risk factors, we found that almost all patients have a very low probability of needing a transfusion, especially an urgent transfusion. Based on these results, we suggest that a hold clot be used except for the highest-risk patients or in settings with barriers to procuring blood in the rare case of urgent transfusion need. Making this change would greatly reduce hospital blood bank charges.

Challenges in reliable preoperative blood ordering: A qualitative interview study

BACKGROUND

Presurgical blood orders are important for patient safety during surgery, but excess orders can be costly to patients and the healthcare system. We aimed to assess clinician perceptions on the presurgical blood ordering process and perceived barriers to reliable decision-making.

METHODS

This descriptive qualitative study was conducted at a single large academic medical center. Semi-structured interviews were conducted with surgeons, anesthesiologists, nurse anesthetists, nurse practitioners working in preoperative assessment clinics, and transfusion medicine physicians to assess perceptions of current blood ordering processes. Interview responses were analyzed using an inductive open coding approach followed by thematic analysis.

RESULTS

Twenty-three clinicians were interviewed. Clinicians felt that the current blood ordering process was frequently inconsistent. One contributor was a lack of information on surgical transfusion risk, related to lack of experience in ordering clinicians, insufficient communication between stakeholders, high turnover in academic settings, and lack of awareness of the maximum surgical blood ordering schedule. Other contributors included differing opinions about the benefits and harms of over- and under-preparing blood products, leading to variation in transfusion risk thresholds between clinicians, and disagreement about the safety of emergency-release blood.

CONCLUSION

Several barriers to reliable decision-making for presurgical blood orders exist. Future efforts to improve ordering consistency may benefit from improved information sharing between stakeholders and education on safe transfusion practices.

Is Preoperative Type and Screen High-value Care? A Cost-effectiveness Analysis of Performing Preoperative Type and Screen Prior to Urogynecological Surgery

INTRODUCTION AND HYPOTHESIS

Routine preoperative type and screen (T&S) is often ordered prior to urogynecological surgery but is rarely used. We aimed to assess the cost effectiveness of routine preoperative T&S and determine transfusion and transfusion reaction rates that make universal preoperative T&S cost effective.

METHODS

A decision tree model from the health care sector perspective compared costs (2020 US dollars) and effectiveness (quality-adjusted life-years, QALYs) of universal preoperative T&S (cross-matched blood) vs no T&S (O negative blood). Our primary outcome was the incremental cost-effectiveness ratio (ICER). Input parameters included transfusion rates, transfusion reaction incidence, transfusion reaction severity rates, and costs of management. The base case included a transfusion probability of 1.26%; a transfusion reaction probability of 0.0013% with or 0.4% without T&S; and with a transfusion reaction, a 50% probability of inpatient management and 0.0042 annual disutility. Costs were estimated from Medicare national reimbursement schedules. The time horizon was surgery/admission. We assumed a willingness-to-pay threshold of $150,000/QALY. One- and two-way sensitivity analyses were performed.

RESULTS

The base case and one-way sensitivity analyses demonstrated that routine preoperative T&S is not cost effective, with an ICER of $63,721,632/QALY. The optimal strategy did not change when base case cost, transfusion probability, or transfusion reaction disutility were varied. Threshold analysis revealed that if transfusion reaction probability without T&S is >12%, routine T&S becomes cost effective. Scenarios identified as cost effective in the threshold and sensitivity analyses fell outside reported rates for urogynecological surgery.

CONCLUSIONS

Within broad ranges, preoperative T&S is not cost effective, which supports re-evaluating routine T&S prior to urogynecological surgery.

Development of a machine learning model to predict intraoperative transfusion and guide type and screen ordering

STUDY OBJECTIVE

To develop an algorithm to predict intraoperative Red Blood Cell (RBC) transfusion from preoperative variables contained in the electronic medical record of our institution, with the goal of guiding type and screen ordering.

DESIGN

Machine Learning model development on retrospective single-center hospital data.

SETTING

Preoperative period and operating room.

PATIENTS

The study included patients ≥18 years old who underwent surgery during 2019-2022 and excluded those who refused transfusion, underwent emergency surgery, or surgery for organ donation after cardiac or brain death.

INTERVENTION

Prediction of intraoperative transfusion vs. no intraoperative transfusion.

MEASUREMENTS

The outcome variable was intraoperative transfusion of RBCs. Predictive variables were surgery, surgeon, anesthesiologist, age, sex, body mass index, race or ethnicity, preoperative hemoglobin (g/dL), partial thromboplastin time (s), platelet count x 109 per liter, and prothrombin time. We compared the performances of seven machine learning algorithms. After training and optimization on the 2019-2021 dataset, model thresholds were set to the current institutional performance level of sensitivity (93%). To qualify for comparison, models had to maintain clinically relevant sensitivity (>90%) when predicting on 2022 data; overall accuracy was the comparative metric.

MAIN RESULTS

Out of 100,813 cases that met study criteria from 2019 to 2021, intraoperative transfusion occurred in 5488 (5.4%) of cases. The LightGBM model was the highest performing algorithm in external temporal validity experiments, with overall accuracy of (76.1%) [95% confidence interval (CI), 75.6-76.5], while maintaining clinically relevant sensitivity of (91.2%) [95% CI, 89.8-92.5]. If type and screens were ordered based upon the LightGBM model, the predicted type and screen to transfusion ratio would improve from 8.4 to 5.1.

CONCLUSIONS

Machine learning approaches are feasible in predicting intraoperative transfusion from preoperative variables and may improve preoperative type and screen ordering practices when incorporated into the electronic health record.

Blood Utilization Trends in Obstetrics and Gynecology: A Seven-Year Retrospective Study in a Teaching Hospital in Sikkim, India

INTRODUCTION

Unutilized cross-matched blood due to excess cross-match requisitions results in unnecessary wastage of inventory, time, labor, and financial resources. This retrospective cross-sectional study aims to assess the blood utilization practices in obstetrics/gynecology (OB/GYN) over a period of seven years with respect to "blood utilization indices" and standard recommendations.

MATERIAL AND METHODS

Cross-match requisitions from the OB/GYN Department over a period of seven years (2012-2018) were selected and included in the study using a suitable sampling technique. Patient details were retrieved from the Hospital Information System (HIS) database. The preoperative crossmatch requisitions and blood utilization data were recorded. "Blood utilization indices" and whole blood/component utilization patterns were analyzed.

RESULTS

A total of 894 units of blood were cross-matched for 523 patients included in the study. A total of 305 of these patients were transfused with 445 units. During the initial phase of the study (2012-2014), the average cross-match-to-transfusion ratio (CTR, 6.6), transfusion probability (12.3), transfusion index (0.23), and component utilization (4%) were in marked deviation from recommended "blood utilization indices." This was in contrast with the later phase of the study (2015-2018) wherein the average CTR (1.5), transfusion probability (69.3), transfusion index (1.3), and component utilization (91.8%) were compliant with recommended "blood utilization indices."

CONCLUSION

A progressive improvement in blood utilization practices was observed in the OB/GYN Department during the study period. Awareness campaigns have contributed to the implementation of rational and judicious blood transfusion practices in our center.

Targeting patient blood management's first pillar: A multicentric retrospective study on preoperative anemia

INTRODUCTION

Anemia is a common issue in surgical patients and has been associated with worse clinical outcomes, such as a higher probability of transfusions and longer hospital stay. Therefore, Patient Blood Management programs are actively aiming to achieve early identification and treatment of anemia, previous to the surgery.

METHODS AND MATERIALS

In this study, preoperative hemoglobin within the Blood Order Schedule (BOS) at 16 blood centers in several Brazilian regions were retrospectively evaluated. Data regarding hemoglobin, age, gender and Brazilian regions were further analyzed.

RESULTS

From the 20,201 BOSs evaluated, the mean age was 55.65 ± 23.52 years old, with an overall prevalence of preoperative anemia of 60.9%. Women had a lower mean preoperative hemoglobin (11.74 ± 2.84 for women and 12.27 ± 3.06 for men) and higher prevalence of anemia than men (66% of females and 52.2% of males). The individuals over 65 years old and under 18 were the most affected by preoperative anemia. All regions had a high prevalence of preoperative anemia, without any direct association with the Human Development Index.

CONCLUSION

In summary, upon evaluating the BOS, our study showed a high prevalence of preoperative anemia in all Brazilian regions, regardless of the gender and age group, but that women and individuals less than 18 or over 65 years old have an even higher prevalence of preoperative anemia. This information can identify the institutions in which preoperative anemia is a critical issue and in which new strategies, such as preoperative screening clinics, might be helpful.

Cost-effectiveness of routine type and screens in select urological surgeries

PURPOSE

To evaluate the cost-effectiveness of obtaining a preoperative type and screen (T/S) for common urologic procedures.

METHODS

A decision tree model was constructed to track surgical patients undergoing two preoperative blood ordering strategies as follows: obtaining a preoperative T/S versus not doing so. The model was applied to the National (Nationwide) Inpatient Sample (NIS) data, from January 1, 2006 to September 30, 2015. Cost estimates for the model were created from combined patient-level data with published costs of a T/S, type and crossmatch (T/C), a unit of pRBC, and one unit of emergency-release transfusion (ERT). The primary outcome was the incremental cost per ERT prevented, expressed as an incremental cost-effectiveness ratio (ICER) between the two preoperative blood ordering strategies. A cost-effectiveness analysis determined the ICER of obtaining preoperative T/S to prevent an emergency-release transfusion (ERT), with a willingness-to-pay threshold of $1,500.00.

RESULTS

A total of 4,113,144 surgical admissions from 2006 to 2015 were reviewed. The overall transfusion rate was 10.54% (95% CI, 10.17-10.91) for all procedures. The ICER of preoperative T/S was $1500.00 per ERT prevented. One-way sensitivity analysis demonstrated that the risk of transfusion should exceed 4.12% to justify preoperative T/S.

CONCLUSION

Routine preoperative T/S for radical prostatectomy (rate = 3.88%) and penile implants (rate = .91%) does not represent a cost-effective practice for these surgeries. It is important for urologists to review their institution T/S policy to reduce inefficiencies within the preoperative setting.

Red Blood Cell Transfusion in Patients With Placenta Accreta Spectrum: A Systematic Review and Meta-analysis

OBJECTIVE

To evaluate red blood cell use during delivery in patients with placenta accreta spectrum.

DATA SOURCES

We searched MEDLINE, EMBASE, CINAHL, Cochrane Central, ClinicalTrials.gov, and Scopus for clinical trials and observational studies published between 2000 and 2021 in countries with developed economies.

METHODS OF STUDY SELECTION

Abstracts (n=4,275) and full-text studies (n=599) were identified and reviewed by two independent reviewers. Data on transfused red blood cells were included from studies reporting means and SDs, medians with interquartile ranges, or individual patient data. The primary outcome was the weighted mean number of units of red blood cells transfused per patient. Between-study heterogeneity was assessed with an I2 statistic. Secondary analyses included red blood cell usage by placenta accreta subtype.

TABULATION, INTEGRATION, AND RESULTS

Of the 599 full-text studies identified, 20 met criteria for inclusion in the systematic review, comprising 1,091 cases of placenta accreta spectrum. The number of units of red blood cells transfused was inconsistently described across studies, with five studies (25.0%) reporting means, 11 (55.0%) reporting medians, and four (20.0%) reporting individual patient data. The weighted mean number of units transfused was 5.19 (95% CI 4.12-6.26) per patient. Heterogeneity was high across studies (I2=91%). In a sensitivity analysis of five studies reporting mean data, the mean number of units transfused was 6.61 (95% CI 4.73-8.48; n=220 patients). Further quantification of units transfused by placenta accreta subtype was limited due to methodologic inconsistencies between studies and small cohort sizes.

CONCLUSION

Based on the upper limit of the CI in our main analysis and the high study heterogeneity, we recommend that a minimum of 6 units of red blood cells be available before delivery for patients with placenta accreta spectrum. These findings may inform future guidelines for predelivery blood ordering and transfusion support.

SYSTEMATIC REVIEW REGISTRATION

PROSPERO, CRD42021240993.

Maximum surgical blood order schedule for flap reconstruction in oral and maxillofacial cancer patients

BACKGROUND

We established a MSBOS for flap reconstruction in oral and maxillofacial cancer patients.

METHOD

We enrolled 2080 cases of oral and maxillofacial flap reconstruction from January 1, 2010 to December 31, 2021. Patient data were collected, including age, sex, BMI, preoperative Hb levels, ASA grade, T stage, flap type, tumor location, and bone flap. Scoring criteria were established based on a multivariate model of independent risk variables and their odds ratios. Two flap-type groups were divided into low-risk, intermediate-risk and high-risk groups by the scoring criteria, and analyzed using univariate and multivariate logistic regression. Perioperative transfusion analysis identified independent risk factors at various Hb levels. The cumulative percentage of patients requiring perioperative blood transfusion for each surgical procedure was calculated to establish the MSBOS.

RESULTS

(1) Regression analysis showed that BMI, tumor T staging, ASA grade, preoperative Hb level (male: Hb < 130 g/L, female: Hb < 120 g/L), and bone flap were independent risk factors for perioperative blood transfusion. (2) Regression analysis showed that independent risk factors for perioperative transfusion included the following: BMI, tumor T3-T4 stage, ASA III, IV grade, and free flap/pediculated flap/bone flap in patients with different Hb levels; T3-T4 stage, ASA grade III-IV in mildly anemic patients; and ASA grade III-IV in moderately anemic patients. (3) A MSBOS was established for flap reconstruction in head and neck cancer patients.

CONCLUSION

A MSBOS for head and neck cancer procedures was reduced by approximately 30% perioperative blood preparation while ensuring that clinical blood use standards were met. It help optimize blood inventory, and save blood resources.

Personalized Surgical Transfusion Risk Prediction Using Machine Learning to Guide Preoperative Type and Screen Orders

BACKGROUND

Accurate estimation of surgical transfusion risk is essential for efficient allocation of blood bank resources and for other aspects of anesthetic planning. This study hypothesized that a machine learning model incorporating both surgery- and patient-specific variables would outperform the traditional approach that uses only procedure-specific information, allowing for more efficient allocation of preoperative type and screen orders.

METHODS

The American College of Surgeons National Surgical Quality Improvement Program Participant Use File was used to train four machine learning models to predict the likelihood of red cell transfusion using surgery-specific and patient-specific variables. A baseline model using only procedure-specific information was created for comparison. The models were trained on surgical encounters that occurred at 722 hospitals in 2016 through 2018. The models were internally validated on surgical cases that occurred at 719 hospitals in 2019. Generalizability of the best-performing model was assessed by external validation on surgical cases occurring at a single institution in 2020.

RESULTS

Transfusion prevalence was 2.4% (73,313 of 3,049,617), 2.2% (23,205 of 1,076,441), and 6.7% (1,104 of 16,053) across the training, internal validation, and external validation cohorts, respectively. The gradient boosting machine outperformed the baseline model and was the best- performing model. At a fixed 96% sensitivity, this model had a positive predictive value of 0.06 and 0.21 and recommended type and screens for 36% and 30% of the patients in internal and external validation, respectively. By comparison, the baseline model at the same sensitivity had a positive predictive value of 0.04 and 0.144 and recommended type and screens for 57% and 45% of the patients in internal and external validation, respectively. The most important predictor variables were overall procedure-specific transfusion rate and preoperative hematocrit.

CONCLUSIONS

A personalized transfusion risk prediction model was created using both surgery- and patient-specific variables to guide preoperative type and screen orders and showed better performance compared to the traditional procedure-centric approach.

EDITOR’S PERSPECTIVE

Cost-Effectiveness of Routine Type and Screens in Select Endonasal Skull Base Surgeries

Objective The study aimed to evaluate the cost-effectiveness of obtaining preoperative type and screens (T/S) for common endonasal skull base procedures, and determine patient and hospital factors associated with receiving blood transfusions.

Study Design Retrospective database analysis of the 2006 to 2015 National (nationwide) Inpatient Sample and cost-effectiveness analysis.

Main Outcome Measures Multivariate regression analysis was used to identify factors associated with transfusions. A cost-effectiveness analysis was then performed to determine the incremental cost-effectiveness ratio (ICER) of obtaining preoperative T/S to prevent an emergency-release transfusion (ERT), with a willingness-to-pay threshold of $1,500.

Results A total of 93,105 cases were identified with an overall transfusion rate of 1.89%. On multivariate modeling, statistically significant factors associated with transfusion included nonelective admission (odds ratio [OR]: 2.32; 95% confidence interval [CI]: 1.78–3.02), anemia (OR: 4.42; 95% CI: 3.35–5.83), coagulopathy (OR: 4.72; 95% CI: 2.94–7.57), diabetes (OR: 1.45; 95% CI: 1.14–1.84), liver disease (OR: 2.37; 95% CI: 1.27–4.43), pulmonary circulation disorders (OR: 3.28; 95% CI: 1.71–6.29), and metastatic cancer (OR: 5.85; 95% CI: 2.63–13.0; p < 0.01 for all). The ICER of preoperative T/S was $3,576 per ERT prevented. One-way sensitivity analysis demonstrated that the risk of transfusion should exceed 4.12% to justify preoperative T/S.

Conclusion Routine preoperative T/S does not represent a cost-effective practice for these surgeries using nationally representative data. A selective T/S policy for high-risk patients may reduce costs.

Blood utilization and quality indicators at a university hospital in the Eastern Province of Saudi Arabia

Background

Blood transfusion is a common, essential procedure when treating many different medical and surgical conditions. Efficient utilization of blood bank facilities by frequent auditing is crucial; however, few studies have examined blood utilization in Saudi Arabia. We aimed to review the blood ordering patterns and transfusion practices, and blood bank audit effectiveness at a single center in Saudi Arabia and compare our results with those of a similar study performed in the same center 20 years ago.

Materials and methods

This study was a retrospective descriptive chart review of all healthy blood donors and recipients from January 1, 2016, to December 31, 2020. We evaluated the crossmatching-to-transfusion ratio (C/T) as an indicator of blood bank utilization and compared the findings with those of the previous study. We also evaluated changes in blood bank utilization during the coronavirus disease 2019 pandemic.

Results

Findings from 27,414 donors (men, 94.9%; mean age, 32.2 + 9.6 years) showed a 71% increase in blood donations compared to that of 2000. The donations gradually increased over the years, peaking just before COVID-19 pandemic started in March 2020. For 3,836 patients, 13,324 units of blood were crossmatched (average, 3.47 crossmatch/patient), with 23% of the crossmatch requests from surgical departments. The average C/T ratio, transfusion index, and transfusion probability (T%) were 1.37, 2.55, and 73.2%, respectively. The C/T ratio decreased by 54% between 2000 and 2020. During the pandemic, crossmatching decreased by 26% between 2019 and 2020, but with comparable C/T ratio in 2019 (1.45) and 2020 (1.39).

Conclusion

Our hospital blood bank utilization improved over the past 20 years, showing increased donations, reduced C/T ratio, and increased T%. This improvement emphasizes the importance of blood donation campaigns, blood bank auditing, restrictive transfusion guidelines, and physician education.

Development and validation of a machine learning method to predict intraoperative red blood cell transfusions in cardiothoracic surgery

Accurately predicting red blood cell (RBC) transfusion requirements in cardiothoracic (CT) surgery could improve blood inventory management and be used as a surrogate marker for assessing hemorrhage risk preoperatively. We developed a machine learning (ML) method to predict intraoperative RBC transfusions in CT surgery. A detailed database containing time-stamped clinical variables for all CT surgeries from 5/2014-6/2019 at a single center (n = 2410) was used for model development. After random forest feature selection, surviving features were inputs for ML algorithms using five-fold cross-validation. The dataset was updated with 437 additional cases from 8/2019-8/2020 for validation. We developed and validated a hybrid ML method given the skewed nature of the dataset. Our Gaussian Process (GP) regression ML algorithm accurately predicted RBC transfusion amounts of 0 and 1-3 units (root mean square error, RMSE 0.117 and 1.705, respectively) and our GP classification ML algorithm accurately predicted 4 + RBC units transfused (area under the curve, AUC = 0.826). The final prediction is the regression result if classification predicted < 4 units transfused, or the classification result if 4 + units were predicted. We developed and validated an ML method to accurately predict intraoperative RBC transfusions in CT surgery using local data.

A Prospective Single Centre Study of Preoperative Blood Ordering Versus Actual Usage Among Patients Undergoing Elective Curative Oncological Resections in a Tertiary Care Hospital in India

This study was a prospective, observational study aimed to look at the preoperative ordering schedule, pattern of usage of blood products for elective oncological surgeries in order to develop an institutional maximal surgical blood ordering schedule (MSBOS) in a tertiary university setting teaching Hospital. All biopsy proven, consenting, cancer patients of age 18 to 80 years who underwent elective curative cancer surgery over a period of 1 year were included. Various details such as nature of procedure, preoperative haemoglobin, intraoperative blood loss, duration of surgery, and number of units cross-matched and used were recorded and analysed. For each procedure, cross-match to transfusion (CT) ratio, transfusion index (TI), and transfusion probability (T%) were calculated using standard formulas. In all, 740 patients underwent elective curative cancer surgery in 1 year, majority being women and head and neck cancer being most common site. Overall, 312 patients received blood or component transfusion in the intraoperative and/or postoperative (within 48 h) period constituting 42% of all patients, although 70% of patients had preserved packed cells and 55% had preserved fresh frozen plasma (FFP). Cross-matching of blood was adequate only in cases of liver surgeries, maxillectomy, staging laparotomy for ovarian carcinoma, and urological malignancies with a desirable CT ratio falling within 2.5. An institution specific-MSBOS was developed. The study found a significant over-ordering of blood products. By implementing MSBOS, one can plan the collection and stocking of blood products thereby saving money, labour, and time.

Demonstration of a U.S. nationwide reduction in transfusion in general surgery and a review of published transfusion reduction methodologies

BACKGROUND

Red blood cell transfusions in surgical procedures can be lifesaving. However, recent studies show transfusions are associated with a dose-dependent increase in postoperative morbidity and mortality; hospitals and physicians have attempted to reduce them. We sought to determine the success of these efforts and review and summarize published reduction methods employed.

STUDY DESIGN/METHODS

An analysis of transfusion data from ACS-NSQIP public use files of general surgical procedures for 2012 and 2018; a retrospective review of the literature surrounding general surgical transfusion reduction from 2008 to 2018.

RESULTS

The rate of general surgical transfusion in the NSQIP dataset decreased from 5.5% in 2012 to 4.0% in 2018, a 27% relative reduction in transfusion. After extensive multivariable adjustment for patient risk and operative complexity, this effect remained (Odds ratio 0.65, 95% CI 0.63-0.67, p < .001). Furthermore, there was a positive correlation between specific procedure decreases in transfusion and decreases in 30-day morbidity (rho =0.41, p = .003) and mortality (rho = 0.37, p = .007). There were 866 published studies matching our search term "red blood cell transfusion reduction." Forty-four were relevant to general surgery. Seven dominant strategies for transfusion reduction by descending frequency of report included restrictive transfusion thresholds, management of preoperative anemia, perioperative interventions, educational programs, electronic clinical decision support, waste reduction, and audits of transfusion practices.

CONCLUSION

Our study demonstrates a 27% decrease in general surgery transfusion between 2012 and 2018 with associated reductions in morbidity and mortality, suggesting published employed strategies have been successful and safely implemented.

Reducing unnecessary crossmatching for hip fracture patients by accounting for preoperative hemoglobin concentration

BACKGROUND

Maximum surgical blood order schedules were designed to eliminate unnecessary preoperative crossmatching prior to surgery in order to conserve blood bank resources. Most protocols recommend type and cross of 2 red blood cell (RBC) units for patients undergoing surgery for treatment of hip fracture. Preoperative hemoglobin has been identified as the strongest predictor of inpatient transfusion, but current maximum surgical blood order schedules do not consider preoperative hemoglobin values to determine the number of RBC units to prepare prior to surgery.

AIM

To determine the preoperative hemoglobin level resulting in the optimal 2:1 crossmatch-to-transfusion (C:T) ratio in hip fracture surgery patients.

METHODS

In 2015 a patient blood management (PBM) program was implemented at our institution mandating a single unit-per-occurrence transfusion policy and a restrictive transfusion threshold of < 7 g/dL hemoglobin in asymptomatic patients and < 8 g/dL in those with refractory symptomatic anemia or history of coronary artery disease. We identified all hip fracture patients between 2013 and 2017 and compared the preoperative hemoglobin which would predict a 2:1 C:T ratio in the pre PBM and post PBM cohorts. Prediction profiling and sensitivity analysis were performed with statistical significance set at P < 0.05.

RESULTS

Four hundred and ninety-eight patients who underwent hip fracture surgery between 2013 and 2017 were identified, 291 in the post PBM cohort. Transfusion requirements in the post PBM cohort were lower (51% vs 33%, P < 0.0001) than in the pre PBM cohort. The mean RBC units transfused per patient was 1.15 in the pre PBM cohort, compared to 0.66 in the post PBM cohort (P < 0.001). The 2:1 C:T ratio (inpatient transfusion probability of 50%) was predicted by a preoperative hemoglobin of 12.3 g/dL [area under the curve (AUC) 0.78 (95% confidence interval (CI), 0.72-0.83), Sensitivity 0.66] in the pre PBM cohort and 10.7 g/dL [AUC 0.78 (95%CI, 0.73-0.83), Sensitivity 0.88] in the post PBM cohort. A 50% probability of requiring > 1 RBC unit was predicted by 11.2g/dL [AUC 0.80 (95%CI, 0.74-0.85), Sensitivity 0.87] in the pre PBM cohort and 8.7g/dL [AUC 0.78 (95%CI, 0.73-0.83), Sensitivity 0.84] in the post-PBM cohort.

CONCLUSION

The hip fracture maximum surgical blood order schedule should consider preoperative hemoglobin in determining the number of units to type and cross prior to surgery.

Examining the Utility and Cost of Routine Type and Screen Prior to Minimally Invasive Hysterectomy

Background and Objectives:

Pre-operative type and screen (T&S) is typically obtained if a patient is expected to require a blood transfusion; however, in cases of minimal blood loss, routine T&S may be unnecessary. The objective of our study was to examine the utility and cost of routine pre-operative T&S prior to minimally invasive hysterectomies (MIH).

Methods:

We performed a retrospective chart review of all MIH from January 1, 2018 to December 31, 2019. Patient demographics and surgical parameters were abstracted. The proportion of MIH with a preoperative T&S was compared to the rate of peri-operative blood transfusion. Statistical tests were used where appropriate. Logistic regression was used to examine the relationship between pre-operative hemoglobin (Hgb) and peri-operative transfusion.

Results:

Patients (n = 307) with a mean age of 54 (standard deviation = 12.6) underwent MIH. T&S was ordered in 42.7% of cases, with 2.9% requiring a blood transfusion. Two-thirds of women receiving a transfusion had a history of anemia (p = .004). Women with a pre-operative Hgb < 10.6 gm/dL (n = 30) had a 27% probability of a transfusion, while those with a pre-operative Hgb > 10.6 gm/dL (n = 264) had a 99% probability of no transfusion. A T&S costs ∼$190 at our institution; if routine T&S was eliminated prior to MIH, cost savings is projected to be ∼$11,590 annually.

Conclusion:

Approximately 42.7% of MIH had T&S ordered, but only 2.9% received transfusions. Most patients who required a transfusion had a history of anemia. Significant cost savings could be incurred if routine T&S was eliminated prior to MIH.

Group & save sampling in lumbar decompression: A review into current practice

The risks, benefits and technical aspects of surgery require careful consideration. One element of this is the requirement of postoperative blood transfusion. Patients who undergo elective lumbar decompression are at a low risk of requiring a postoperative transfusion yet undergo multiple preoperative group & save tests. For those who are at a low risk of bleeding, a single group & save sample may be adequate. This review analysed the postoperative blood loss and transfusion rate associated with lumbar decompression surgery without fusion in one institution. A subsequent cost analysis and review of the literature was performed. The aim was to assess whether single group & save sampling, within the context of lumbar decompression, was cost effective and amenable to the patient without impacting patient care. Average blood loss was estimated as a drop in Hb of 12.3g/dl. Six patients (14%) had Hb loss of over 20g/dl. No patients underwent a blood transfusion. Through examination of medical records, we found that 65% of patients (35) were suitable for single group & save sampling, estimating a saving of £2415.95 (53%). Selective group & save testing holds economic potential and safeguards patients from undergoing unnecessary testing. The next step after this review would be a prospective multi-centre study.

Preoperative Type and Screen is Unnecessary in Elective Anatomic Lung Resection and Esophagectomy

BACKGROUND

Preoperative type and screen (TS) is routinely performed before elective thoracic surgery. We sought to evaluate the utility of this practice by examining our institutional data related to intraoperative and postoperative transfusions for two common, complex procedures.

MATERIALS AND METHODS

A single-center, retrospective review of a prospective thoracic surgery database was performed. Patients who underwent consecutive elective anatomic lung resection (ALR) and esophagectomy from January 2015 to April 2018 were included. Perioperative characteristics between patients who received transfusion of packed red blood cells and those who did not were compared. The rates of emergent and nonemergent transfusions were evaluated. Cost data were derived from institutional charges and Centers for Medicare & Medicaid Services fee schedules.

RESULTS

Of 370 patients, 16 (4.3%) received a transfusion and four (1.1%) were deemed emergent by the surgeons and 0 (0%) by blood bank criteria. For ALR (n = 321), 13 (4.0%) received a transfusion, and four (1.2%) were emergent. For esophagectomies (n = 49), three (6.1%) received a transfusion, and none were emergent. Patients who underwent ALR requiring a transfusion had a lower preoperative hemoglobin (11.7 versus 13.4 gm/dL, P = 0.001), higher estimated blood loss (1325 versus 196 mL, P < 0.001), and longer operative time (291 versus 217 min, P = 0.003) than nontransfused patients. Based on current volumes, eliminating TS in these patients would save at least an estimated $60,100 per year.

CONCLUSIONS

Emergent transfusion in ALR and esophagectomy is rare. Routine preoperative TS is most likely unnecessary for these cases. These results will be used in a quality improvement initiative to change practice at our institution.

In the Era of Tranexamic Acid, are Type and Screens for Primary Total Joint Arthroplasty Obsolete?

BACKGROUND

Advances in technique and perioperative blood management have improved transfusion rates following unilateral primary total joint arthroplasty and led some centers to change their preoperative blood ordering protocols. The purpose of this study is to determine whether deleting type and screens (T&S) from preoperative order sets was safe for patients undergoing primary total knee (TKA) and total hip arthroplasty (THA) and to identify patients who required allogenic blood transfusion.

METHODS

Prospectively collected data were reviewed to identify any patient with a hemoglobin (Hgb) drawn within 30 days of surgery who received a transfusion following a unilateral primary TKA or THA.

RESULTS

A total of 1255 patients met inclusion criteria. Of the total, 682 (54%) were TKAs and 573 (46%) were THAs. The mean preoperative Hgb was 11.5 g/dL with an average delta Hgb of 3.6 g/dL on postoperative day 1. No patient required an intraoperative transfusion. Fourteen patients (mean age and body mass index, 67.9 and 29.0) required a transfusion (1.1%) for postoperative blood loss anemia. Of those transfused, 13 (93%) of the patients underwent THA with the mean estimated blood loss of 378.6 mL. The total cost for a patient obtaining a T&S is $191.27.

CONCLUSION

In our series, the risk of blood transfusion was rare (1.1%) and occurred only secondary to postoperative blood loss anemia. There were no cases of intraoperative complication requiring urgent or emergent blood transfusion. Removing T&S from standard order sets for patients undergoing primary TKA or THA appears to be a safe and cost-effective practice.

Establishing a Satellite Transfusion Service Within an Academic Medical Center

OBJECTIVES

Increasingly complex medical care requires specialized transfusion support close at hand. Hospital growth can necessitate expansion of blood bank services to new locations to ensure rapid delivery of blood products. We describe the opening of a new satellite transfusion service designed to serve the needs of a pediatric hospital.

METHODS

Institutional transition teams and stakeholders collaborated to discuss options for providing blood at a new pediatric hospital. A staffed satellite transfusion service met the diverse needs of multiple services and was considered a compromise between a full new transfusion service and automated solutions.

RESULTS

Initial challenges in establishing the laboratory included regulatory uncertainty and interactions between two hospitals' information technology services. Laboratory scientist staffing and actual use required adapting the satellite service to an emergency release-only model.

CONCLUSIONS

A flexibly staffed satellite transfusion service met the most urgent needs of a pediatric hospital expansion. Review of implementation revealed potential process improvements for future expansions, including comprehensive routine and massive transfusion simulations. The challenges experienced in supplying staff and specialized blood products track with national trends. Other institutions may consider establishing a satellite transfusion service in the context of both increasingly sophisticated automated solutions and complex blood needs.

Prediction of perioperative transfusions using an artificial neural network

BACKGROUND

Accurate prediction of operative transfusions is essential for resource allocation and identifying patients at risk of postoperative adverse events. This research examines the efficacy of using artificial neural networks (ANNs) to predict transfusions for all inpatient operations.

METHODS

Over 1.6 million surgical cases over a two year period from the NSQIP-PUF database are used. Data from 2014 (750937 records) are used for model development and data from 2015 (885502 records) are used for model validation. ANN and regression models are developed to predict perioperative transfusions for surgical patients.

RESULTS

Various ANN models and logistic regression, using four variable sets, are compared. The best performing ANN models with respect to both sensitivity and area under the receiver operator characteristic curve outperformed all of the regression models (p < .001) and achieved a performance of 70-80% specificity with a corresponding 75-62% sensitivity.

CONCLUSION

ANNs can predict >75% of the patients who will require transfusion and 70% of those who will not. Increasing specificity to 80% still enables a sensitivity of almost 67%. The unique contribution of this research is the utilization of a single ANN model to predict transfusions across a broad range of surgical procedures.

Optimal preoperative autologous blood storage volume required in surgeries for placenta previas and low-lying placentas

AIM

The high rate of stored preoperative autologous blood wastage is concerning. This study analyzed patients who provided preoperative autologous blood donations (PABDs) for massive bleeding during surgery for placenta previas and low-lying placentas, and investigated the optimal PABD storage volume required to avoid allogeneic transfusion.

METHODS

Of 386 patients who provided PABDs at our hospital from 2008 to 2013, 269 patients with placenta previas or low-lying placentas were retrospectively analyzed. The PABD storage volumes were stratified into four groups based on the amounts stored, and the allogeneic transfusion usage frequencies were compared.

RESULTS

A total of 124 patients (46.1%) received PABDs and 12 patients (4.5%) received allogeneic transfusions. The average PABD volume wasted was 23 940 mL/year. The allogeneic transfusion utilization rate was significantly higher in the 1- to 300-mL group (17.2%) than in the 301- to 600-mL (1.69%), 601- to 900-mL (3.82%), and 901- to 1200-mL (0%) groups (P < 0.05). The PABD cut-off volume for avoiding allogeneic blood transfusion was 300 mL, and the odds ratio for ≤300-mL PABD in a multivariate analysis was 14.3 (95% confidence interval 1.3-149.3; P = 0.03). The maximum surgical blood order schedule was 2.16 units (432 mL), and the surgical blood order equation was 2.15 units (430 mL).

CONCLUSION

The allogeneic transfusion utilization rate did not differ between the 600-mL group and the groups with higher PABD storage volumes; hence, storing 600 mL of PABD was appropriate for surgery for placenta previas and low-lying placentas.

Electronic remote blood issue supports efficient and timely supply of blood and cost reduction: evidence from five hospitals at different stages of implementation

BACKGROUND

This multicenter international study evaluated electronic remote blood issue (ERBI) for blood unit collection in hospitals.

STUDY DESIGN AND METHODS

Retrospective data were collected from the ERBI software databases and blood bank information systems. Prospective "time-and-motion" data collection methods simulated the delivery of red blood cell units to determine the staff time for each step.

RESULTS

The main benefit of ERBI was found in two hospitals where the blood unit was issued and collected at refrigerators remote from the blood bank (closer to the clinical area) compared with the standard process of blood bank issue (BBI) and blood unit collection in the blood bank. There was a reduction in the time for blood to reach patients (2.02 min compared to 8.43 min at one site [p ≤ 0.0001], 1.57 min compared to 6.54 min at the other [p ≤ 0.0001]). However, there was no reduction in time where ERBI was conducted in the blood bank or where a blood unit issued by the standard BBI was collected at remote refrigerators. In the three hospitals where ERBI was conducted at remote refrigerators, there was an improved issue:transfusion ratio (range of 1.02-1.09 for ERBI compared to 1.48-1.58 for BBI) and a reduction in staff time and costs of between $5,000 and $10,000/year.

CONCLUSION

This multicenter international study builds on findings from studies in single hospitals that ERBI at remote refrigerators improves the efficiency of transfusion by reducing the time taken for blood units to reach patients, staff time, and costs.

Evaluation of the use of blood in surgeries as a tool to change patterns for requesting blood product reserves

OBJECTIVES

Thirty to sixty percent of prepared blood products are not transfused. Blood reserves for surgeries lead to many unused blood products, which increases hospital costs. The aim of this study is to identify the request and use profiles of blood products for elective surgeries in different surgical specialties, the influence of surgery time and demographic, clinical, and laboratory variables on the number of red blood cells (RBCs) used and to calculate the rate of transfused patients (RTP) and cross-matched and transfused (C/T) RBCs.

METHODS

Observational and prospective studies. Sociodemographic, clinical and quantitative data on the request and use of blood products were collected. The influence of the data on the use of RBCs was examined by binary logistic regression. Chi-square, one-way ANOVA and Kruskal-Wallis tests were utilized to compare the data among the specialties.

RESULTS

In total, 822 procedures were included. Most of the requested blood products were not used, even 24 hours postoperatively. Of the 2,483 RBC units, 314 were transfused, leaving 87.6% unused; however, cardiac, digestive tract, vascular, gynecologic, urologic and thoracic surgery procedures transfused 50%, 25%, 16.5%, 11%, 9.5% and 8.1% of requested RBCs, respectively. The factors that influenced the transfusions were age, time of surgery and cardiac surgeries. The RTP was >10% in 22 surgical types and <1% in 24 surgical types, and 88% of samples presented a C/T ratio >2.5.

CONCLUSION

The RTP and C/T ratios can guide RBC requests in the preoperative period. Knowing the standard of use of blood products and developing protocols enables the optimization of reserves, reduction of costs and improvement of care.

BLOOD ORDERS AND PREDICTORS FOR HEMOTRANSFUSION IN ELECTIVE FEMUR FRACTURE REPAIR SURGERY

ABSTRACT Objective: to estimate the incidence of red blood cell concentrate orders in elective femur fracture repair surgeries and to identify predictors for hemotranfusion. Method: retrospective cohort study conducted with 271 patients submitted to femur fracture repair surgery between July 2013 and July 2016. Surgical and transfusion data were obtained from patient charts and the Transfusion Management System. Association between sociodemographic and clinical variables related to the surgical procedure and the occurrence of red blood cell concentrate transfusion was analyzed using descriptive statistics, the chi-squared test, relative risk, and odds ratio. Multivariate analysis was performed using binomial logistic regression. Results: the incidence of blood orders for patients undergoing femur fracture repair surgery was 87%. Ninety-one (33.6%) patients received red blood cell concentrate transfusions. Even though placing blood orders is recommended, given the possibility of intra- or postoperative transfusions, only 52 (47.2%) blood transfusions occurred in the preoperative period. The variables female sex, low preoperative hemoglobin levels and procedure lasting longer than 120 minutes presented statistical significance (p<0.05) and were considered predictors for hemototransfusion. Conclusion: Perioperative nursing must be aware of the importance of blood orders for all patients undergoing femur fracture repair surgery, including in the preoperative period, with special attention to patients who are female, previously anemic and submitted to long-lasting procedures.

A preoperative risk score to predict red blood cell transfusion in patients undergoing hysterectomy for ovarian cancer

BACKGROUND

Patients with ovarian cancer experience a high rate of anemia throughout their treatment course, with rates that range from 19-95%. Blood transfusions offer symptom relief but may be costly, are limited in supply, and have been associated with worse 30-day surgical morbidity and mortality rates.

OBJECTIVE

The purpose of this study was to identify risk factors for blood transfusion with packed red blood cell and to develop a transfusion risk score to identify patients who undergo surgery for ovarian cancer and who are at lowest risk for a blood transfusion. Our aim was to help clinicians identify those patients who may not require a crossmatch to encourage resource use and cost-savings.

STUDY DESIGN

This is a retrospective database cohort study of 3470 patients who underwent hysterectomy for ovarian cancer with the use the National Surgical Quality Improvement Program database from 2014-2016. The association between risk factors with respect to 30-day postoperative blood transfusion was modeled with the use of logistic regression. A risk score to predict blood transfusion was created.

RESULTS

Eight hundred ninety-one (25.7%) patients received a blood transfusion. In multivariate analysis, blood transfusion was associated independently with age (odds ratio, 1.90, P<.01), African American race (odds ratio, 2.30; P<.01), ascites (odds ratio, 1.89; P=.02), preoperative hematocrit level <30% (odds ratio, 10.70; P<.01), preoperative platelet count >400×10⁹/L (odds ratio, 1.75; P<.01), occurrence of disseminated cancer (odds ratio, 1.71; P<.01), open surgical approach (odds ratio, 7.88; P<.01), operative time >3 hours (odds ratio, 2.19; P<.01), and additional surgical procedures that included large bowel resection (odds ratio, 4.23; P<.01), bladder/ureter resection (odds ratio, 1.69; P=.02), and pelvic exenteration (P=.02). A preoperative risk score that used age, race, ascites, preoperative hematocrit level, platelets, presence of disseminated cancer, planned hysterectomy approach, and procedures accurately predicted blood transfusion with good discriminatory ability (C-statistic=0.80 [P<.001]; C-statistic=0.69 [P<.001] for derivation and validation datasets, respectively) and calibration (Hosmer-Lemeshow goodness-of-fit, P=.081; P=.56 for derivation and validation datasets, respectively).

CONCLUSION

Patients who undergo hysterectomy for ovarian cancer experience a high incidence of blood transfusions in the perioperative period. Preoperative risk factors and planned surgical procedures can be used in our transfusion risk score to help predict anticipated blood requirements.

Analysis of red blood cell use in elective surgeries over 12 years in Korea

BACKGROUND

Red blood cell (RBC) transfusion is a lifesaving process for patients with perioperative bleeding, but transfusion can cause adverse events. Effective utilization and management of blood products as a limited resource is essential when considering cost-efficiency and patient safety.

STUDY DESIGN AND METHODS

We analyzed the number of RBC units used during the hospitalization of patients who had undergone surgical procedures from 2002 to 2013 using National Health Insurance Service-National Sample Cohort data, which include a total of 487,238 cases for 206 selected operations.

RESULTS

RBC units were used in 39,637 (8.1%) cases. A total of 60,815 RBC units were transfused with a mean of 0.13 units per patient overall and a mean of 1.53 units per case receiving RBC transfusion. In addition, 56.7% of the RBC units were transfused for females, and 60.1% of RBC units were transfused into patients aged 60 or older. RBC units were used most often in orthopedic surgeries (33.8%), followed by general surgeries (12.0%) and vascular surgeries (11.8%). The number of operations performed in the cohort increased from 27,690 in 2002 to 49,473 in 2013, and the mean number of RBC units used per operation also increased from 0.08 units in 2002 to 0.15 units in 2013.

CONCLUSION

Continuous management for blood preparation and transfusion is needed for efficient utilization of blood. Periodic investigation on the use of blood products through nationwide studies could suggest data applicable to blood product preparation for various elective surgical operations.

An audit of perioperative blood transfusions in a regional hospital to rationalise a maximum surgical blood ordering schedule

Appropriate preoperative blood typing and cross-matching is an important quality improvement target to minimise costs and rationalise the use of blood bank resources. This can be facilitated using a maximum surgical blood ordering schedule (MSBOS) for specific operations. It is recommended that individual hospitals develop a site-specific MSBOS based on institutional data, but this is challenging in non-tertiary centres without electronic databases. Our aim was to audit our perioperative blood transfusions to develop a site-specific MSBOS. A retrospective audit of blood transfusions in surgical patients in our regional referral hospital was conducted using five years' coded administrative data. Procedures with higher transfusion rates warranting preoperative testing (type and screen with or without subsequent cross-matching) were identified. There were about 15,000 eligible surgical procedures performed in our institution over the audit period. The need for preoperative testing was identified for only a few procedures, namely laparotomy, bowel resection, major amputation, joint arthroplasty, hip/femur fracture and humerus surgery, and procedures for obstetric complications. We observed a reduction in transfusion rates over time for total joint arthroplasty. The use of coding data represents an efficient method by which centres without electronic anaesthesia information management systems can conduct large-scale audits to develop a site-specific MSBOS. This would represent a significant improvement for hospitals that currently base preoperative testing recommendations on expert opinion alone. As many procedures in regional centres have very low transfusion rates, hospitals with a similar case mix to ours could consider selectively auditing higher-risk operations where local data is most likely to alter testing recommendations.

Transfusion of Red Blood Cells Stored More Than 28 Days is Associated With Increased Morbidity Following Spine Surgery

STUDY DESIGN

A retrospective study.

OBJECTIVE

The aim of this study was to describe the association between storage duration of packed red blood cells (PRBCs) and perioperative adverse events in patients undergoing spine surgery at a tertiary care center.

SUMMARY OF BACKGROUND DATA

Despite retrospective studies that have shown that longer PRBC storage duration worsens patient outcomes, randomized clinical trials have found no difference in outcomes. However, no studies have examined the impact of giving the oldest blood (28 days old or more) on morbidity within spine surgery.

METHODS

The surgical administrative database at our institution was queried for patients transfused with PRBCs who underwent spine surgery between December 4, 2008, and June 26, 2015. Patients undergoing spinal fusion, tumor-related surgeries, and other identified spine surgeries were included. Patients were divided into two groups on the basis of storage duration of blood transfused: exclusively ≤28 days' storage or exclusively >28 days' storage. The primary outcome was composite in-hospital morbidity, which included (1) infection, (2) thrombotic event, (3) renal injury, (4) respiratory event, and/or (5) ischemic event.

RESULTS

In total, 1141 patients who received a transfusion were included for analysis in this retrospective study; 710 were transfused exclusively with PRBCs ≤28 days' storage and 431 exclusively with PRBCs >28 days' storage. Perioperative complications occurred in 119 patients (10.4%). Patients who received blood stored for >28 days had higher odds of developing any one complication [odds ratio (OR) = 1.82; 95% confidence interval (95% CI), 1.20-2.74; P = 0.005] even after adjusting for competing perioperative risk factors.

CONCLUSION

Blood stored for >28 days is independently associated with higher odds of developing perioperative complications in patients transfused during spinal surgery. Our results suggest that blood storage duration may be an appropriate parameter to consider when developing institutional transfusion guidelines that seek to optimize patient outcomes.

LEVEL OF EVIDENCE

3.

A preoperative risk score for transfusion in infrarenal endovascular aneurysm repair to avoid type and cross

OBJECTIVE

Preoperative type and cross are often routinely ordered before elective endovascular aneurysm repair (EVAR), but the cost of this practice is high, and transfusion is rare. We therefore aimed to stratify patients by their risk of transfusion to identify a cohort in whom a type and screen would be sufficient.

METHODS

We queried the targeted vascular module of the National Surgical Quality Improvement Program (NSQIP) for all elective EVARs from 2011 to 2015. We included only infrarenal aneurysms and excluded ruptured aneurysms and patients transfused within 72 hours preoperatively. Two-thirds of the cases were randomly assigned to a model derivation cohort and one third to a validation cohort. We created and subsequently validated a risk model for transfusion within the first 24 hours of surgery (including intraoperatively), using logistic regression.

RESULTS

Between 2011 and 2015, there were 4875 patients who underwent elective infrarenal EVAR, only 221 (4.5%) of whom received a transfusion within 24 hours of surgery. The frequency of transfusion during the study period declined monotonously from 6.5% in 2011 to 3.2% in 2015. The factors independently associated with transfusion were preoperative hematocrit <36% (odds ratio [OR], 3.4 [95% confidence interval, 2.1-5.4]; P < .001), aortic diameter (per centimeter increase: OR, 1.2 [1.03-1.4]; P = .02), preoperative dependent functional status (OR, 2.5 [1.1-5.5]; P = .03), and chronic obstructive pulmonary disease (OR, 1.7 [1.04-2.9]; P = .04). A risk prediction model based on these criteria produced a C statistic of 0.69 in the prediction cohort and 0.76 in the validation cohort and a Hosmer-Lemeshow goodness of fit of 0.62 and 0.14, respectively. A score of <3 of 9, corresponding to a <5% probability of transfusion, would avoid preoperative type and cross in 86% of patients. Of the 4203 patients (86%) with a hematocrit >36%, only 6 (0.1%) had a risk score of >3.

CONCLUSIONS

Perioperative transfusion for EVAR is becoming increasingly uncommon and is predicted well by a transfusion risk score or simply a hematocrit of <36%. Application of this risk score would avoid unnecessary type and cross in the majority of patients, leading to significant savings in both time and cost.

A novel approach to improving efficiency and cost saving in preoperative blood preparation

BACKGROUND

Preoperative ordering of blood products has been an area of optimization due to considerable variability among physicians; overpreparation can lead to extra costs and underpreparation of blood can potentially compromise patient safety.

STUDY DESIGN AND METHODS

We examined the potential cost savings of extending the storage interval of a presurgical type-and-screen sample from 7 to 14 days, thereby reducing the need for a new specimen on the day of surgery.

RESULTS

Sensitivity analysis showed annual cost savings for our institution to be an estimated $38,770 ($22,420-$73,120).

CONCLUSION

These results are even more robust when incorporating the additional potential savings from improved operating room efficiency.

Electronic remote blood issue combined with a computer-controlled, automated refrigerator for major surgery in operating theatres at a distance from the transfusion service

BACKGROUND

The difficulty of supplying red blood cells within an adequate time to patients undergoing surgery is a known problem for transfusion services, particularly if the operating theater is located at some distance from the blood bank. The consequences frequently are that more blood is ordered than required; several units are allocated and issued; and unused units must be returned to the blood bank. Some sparse reports have demonstrated that remote blood issue systems can improve the efficiency of issuing blood.

STUDY DESIGN AND METHODS

This study describes a computer-controlled, self-service, remote blood-release system, combined with an automated refrigerator, installed in a hospital at which major surgery was performed, located 5 kilometers away from the transfusion service. With this system, red blood cell units were electronically allocated to patients immediately before release, when the units actually were needed. Two 2-year periods, before and after implementation of the system, were compared.

RESULTS

After implementation of the system, the ratio of red blood cell units returned to the transfusion service was reduced from 48.9% to 1.6% of the issued units (8852 of 18,090 vs. 182 of 11,152 units; p < 0.0001), and the issue-to-transfusion ratio was reduced from 1.96 to 1.02. An increase in the number of transfused red blood cell units was observed, probably mainly due to changes in the number and complexity of surgical procedures. No transfusion errors occurred in the two periods.

CONCLUSION

The current results demonstrate that the remote blood-release system is safe and useful for improving the efficiency of blood issue for patients in remote operating theatres.

The effects of a data driven maximum surgical blood ordering schedule on preoperative blood ordering practices

OBJECTIVES

The maximum surgical blood ordering schedule (MSBOS) provides guidelines for pre-operative pre-transfusion testing for elective surgical procedures. This study compared blood ordering and utilization during the period when the MSBOS was created by achieving consensus between the blood bank and the various surgical specialties, and after the introduction of an MSBOS created by using department-specific red blood cell (RBC) transfusion data (data driven MSBOS, dMSBOS).

METHODS

The dMSBOS was created by analyzing 12 months of RBC transfusion data for each procedure across a regional health system. Pre-transfusion testing and the RBC crossmatch:transfusion (C:T) ratios at 8 of the hospitals were compared between the 12 month period before the dMSBOS was introduced, and the 15 months after its introduction.

RESULTS

There were significant reductions in the median monthly number of type and screens not associated with RBC crossmatches (10 714-10 061; p < 0.0001) and the median number of type and screens associated with RBC crossmatches (10 127-9 349; p = 0.0014) on surgical patients after dMSBOS implementation. There were significant decreases in the median number of monthly RBC units crossmatched (2 981-2 444; p < 0.0001) and transfused (890-791; p < 0.0001) to surgical patients after implementing the dMSBOS. The overall system-wide C:T ratio trended down after dMSBOS implementation (from 3.34 to 3.17, p = 0.067).

DISCUSSION

Crossmatching fewer RBC units facilitates more efficient management of the blood bank's inventory.

CONCLUSION

The dMSBOS was effective in reducing the extent of unnecessary pre-transfusion testing before surgery and reduced the number of RBCs that were crossmatched for specific patients.

Maximum surgical blood order schedule for pancreatoduodenectomy: a long way from uniform applicability!

BACKGROUND

Unnecessary preoperative ordering of blood and blood products results in wastage of a valuable life-saving resource and poses a significant financial burden on healthcare systems.

AIM

To determine patient-specific factors associated with intra-operative transfusions, and if intra-operative blood transfusions impact postoperative morbidity.

PATIENTS & METHODS

Analysis of consecutive patients undergoing pancreatoduodenectomy (PD) for pancreatic tumors.

RESULTS

A total of 384 patients underwent a classical PD with an estimated median blood loss of 200 cc and percentage transfused being 9.6%. Pre-existing hypertension, synchronous vascular resection, end-to-side pancreaticojejunostomy and nodal disease burden significantly associated with the need for intra-operative transfusions. Intra-operative blood transfusion not associated with postoperative morbidity.

CONCLUSION

Optimization of MSBOS protocols for PD is required for more judicious use of blood products.

Longer average blood storage duration is associated with increased risk of infection and overall morbidity following radical cystectomy

BACKGROUND

Patients with bladder cancer undergoing radical cystectomy (RC) experience high rates of perioperative blood transfusions (PBTs) and morbidity. The aim of this study was to evaluate the effect of blood storage duration on the risk of adverse perioperative outcomes in this high-risk patient population.

MATERIALS AND METHODS

In a retrospective review of RC patients from 2010 to 2014 who received PBTs, the average storage duration for all units transfused was used to classify patients as receiving older blood using 3 different definitions (≥21 days,≥28 days, and≥35 days). Multivariable Poisson regression models were used to determine the adjusted relative risk of perioperative infections and overall morbidity in those given older blood compared to fresher blood.

RESULTS

Of the 451 patients undergoing RC, 205 (45%) received nonirradiated PBTs. In multivariable modeling, increasing average blood storage duration, as a continuous variable, was associated with an increased risk of infections (risk ratio [RR] = 1.08 per day, 95% CI: 1.01-1.17) and overall morbidity (RR = 1.08 per day, 95% CI: 1.01-1.15). Furthermore, ≥28-day blood storage (vs.<28) was associated with increased infections (RR = 2.69, 95% CI: 1.18-6.14) and morbidity (RR = 2.54, 95% CI: 1.31-4.95), and ≥35-day blood storage (vs.<35) was also associated with increased infections (RR = 2.83, 95% CI: 1.42-5.66) and morbidity (RR = 3.35, 95% CI: 1.95-5.77).

CONCLUSIONS

Although blood is stored up to 42 days, storage≥28 days may expose RC patients to increased perioperative infections and overall morbidity compared with storage<28 days. Prospective cohort studies are warranted in cystectomy and other high-risk surgical oncology patients to better determine the effect of blood storage duration.

Interhospital Variability in Perioperative Red Blood Cell Ordering Patterns in United States Pediatric Surgical Patients

OBJECTIVE

To evaluate perioperative red blood cell (RBC) ordering and interhospital variability patterns in pediatric patients undergoing surgical interventions at US children's hospitals.

STUDY DESIGN

This is a multicenter cross-sectional study of children aged <19 years admitted to 38 pediatric tertiary care hospitals participating in the Pediatric Health Information System in 2009-2014. Only cases performed at all represented hospitals were included in the study, to limit case mix variability. Orders for blood type and crossmatch were included when done on the day before or the day of the surgical procedure. The RBC transfusions included were those given on the day of or the day after surgery. The type and crossmatch-to-transfusion ratio (TCTR) was calculated for each surgical procedure. An adjusted model for interhospital variability was created to account for variation in patient population by age, sex, race/ethnicity, payer type, and presence/number of complex chronic conditions (CCCs) per patient.

RESULTS

A total of 357 007 surgical interventions were identified across all participating hospitals. Blood type and crossmatch was performed 55 632 times, and 13 736 transfusions were provided, for a TCTR of 4:1. There was an association between increasing age and TCTR (R(2) = 0.43). Patients with multiple CCCs had lower TCTRs, with a stronger relationship (R(2) = 0.77). There was broad variability in adjusted TCTRs among hospitals (range, 2.5-25).

CONCLUSIONS

The average TCTR in US children's hospitals was double that of adult surgical data, and was associated with wide interhospital variability. Age and the presence of CCCs markedly influenced this ratio. Studies to evaluate optimal preoperative RBC ordering and standardization of practices could potentially decrease unnecessary costs and wasted blood.

Variation in the use of type and crossmatch blood ordering among patients undergoing hepatic and pancreatic resections

BACKGROUND

The use of preoperative blood orders involved in major gastrointestinal surgery has been poorly studied. The objective of the current study was to analyze compliance with guidelines and factors associated with crossmatch and blood ordering among patients who underwent a hepatic or pancreatic resection.

METHODS

All patients who underwent a hepatic or pancreatic resection between 2010 and 2013 at Johns Hopkins Hospital were identified. Crossmatch to transfusion (C/T) ratios were calculated based on transfusion rates and total units used. A C/T ratio of >2.0 was considered excessive.

RESULTS

Among the 2,629 patients, 11,574 units of packed red blood cells (PRBCs) were crossmatched (mean number of PRBC units crossmatched: 5.9 ± 7.3). Of the 2,629 patients, 34.1% of patients received ≥ 1 PRBCs and 3,611 total units of PRBC were transfused, resulting in an institutional C/T ratio of 2.17 based on the proportion of patients transfused and 3.21 based on the overall number of PRBC units transfused. Using our criterion of excessive C/T ratio of >2.0, we found that 411 patients (45.9%) were "excessively" crossmatched among transfused patients. Among nontransfused patients, 41.0% (n = 711) of patients were crossmatched for >2 units PRBC. Factors associated with receipt of "excess" crossmatch included the presence of multiple comorbidities and an estimated blood loss >450 mL (both P < .05). Provider-level variation among surgeons (C/T ratio range 1.22-3.81) also was associated strongly with "excess" crossmatching ratios (odds ratio 2.56, 95% confidence interval 2.09-3.13; P < .001).

CONCLUSION

More than 1 in 4 patients received crossmatch orders that exceeded institutional and national guidelines. Provider variation both among surgeons and anesthesiologists was an important factor associated with crossmatch variation and excessive ordering of blood for crossmatch in patients undergoing pancreatic and hepatic surgery.