Type and screen for scheduled elective surgical cases

A blood banker wants to know if there is a practice standard requiring that if a Type and Screen (T&S) has been ordered for a patient who is scheduled for elective surgery, that the T&S is COMPLETED and blood is available prior to starting the surgical case. If no such standard exists, what is the experience of facilities regarding patients having scheduled elective surgeries started prior to completion of an ordered T&S, and presumably prior to knowing that an adequate number of RBC units are available for the patient's surgery?

Editor's NOTE: For an interesting discussion about patients going to surgery BEFORE an ordered type and screen has been completed, please visit the previous discussion on our forum. In addition, the e-network should be aware that the College of American Pathologists' Quality Practices Resource Committee has developed a Q-Probe for 2002 entitled "Type and Screen Completion for Scheduled Surgical Procedures" to identify critical issues surrounding this matter. For more information about this Q-Probe, please go to that page. Broad participation in this Q-Probe is encouraged to see what practices are being followed, how often problems arise, and what practices are associated with better outcomes and performance.

Before sending this question to the entire e-Network Forum, input was requested from a blood banker who is quite knowledgeable about this topic, and who now works in the Northeastern US. According to this blood bank physician, there is no standard other than good medical practice to dictate that if it is anticipated that blood will be needed for an elective scheduled surgical patient, the process for making certain that blood is available must be initiated in time. He goes on to say "Blood is a drug that must be ordered by an authorized provider. The lab cannot address this without the cooperation of the providers. If providers believe that blood is always available on 10 minutes notice (which they may see as a standard of practice), they will expect the blood bank to provide that standard of practice. The blood bank medical leadership must communicate with the providers to indicate when that standard cannot be met (e.g., unexpected antibodies, no T&S, inventory concerns, etc.)" The reason that the above is important is that there have been deaths at well respected, major institutions because of this problem.

Please submit your comments, opinions, and/or examples of problems (and solutions) associated with completion of Type and Screen testing for scheduled elective surgical procedures.

The following response has been received:

1. A blood banker from Texas wrote that in his opinion "the standard of care is to ensure that there is a safe and adequate supply of blood prior to beginning an elective procedure. This can only be done if the antibody screen is completed prior to the initiation of surgery. In our facility, we developed a system that allows a blood sample to remain current for 7 days if the patient has not been transfused or pregnant in the last 3 months. This time limit is not based on science, rather our system needs. There is no reason why the time limit could not be even longer. I do know of a nearby facility that uses pre-admission antibody screens and crossmatching for up to 2 weeks for patients without recent blood exposure."

Submit comments to the e-Network Forum at enetworkforum@cbbsweb.org

Ira A. Shulman, MD
CBBS e-Network Forum Senior Editor & Moderator

W. Tait Stevens, MD
CBBS e-Network Forum Editor & Moderator

Elizabeth M. St. Lezin, MD
CBBS e-Network Forum Associate Editor & Moderator