Does your hospital have a problem with STAT pre-transfusion testing orders for elective scheduled surgery?

A blood banker who works at a facility in California is trying to address the issue of an overwhelming number of STAT pre-transfusion testing orders for elective surgery scheduled surgery received by their Transfusion Service. The inquiring blood banker's institution is a large tertiary care facility with a Level 1 trauma service, liver, heart and lung transplant services, and multiple outpatient locations where patients are transfused. A problem that confronts this institution is that pre-operative blood orders for elective scheduled surgery are ordered STAT an inordinate amount of the time. This ordering practice has required that pre-operative Type and Screen (T&S) and/or crossmatches be done STAT for otherwise elective scheduled surgeries. The inquiring blood banker reports that for 60% of the elective scheduled surgical cases for which a pre-operative T&S is ordered, a specimen is not collected until the patient shows up in the pre-operative holding area on the day of surgery. To make matters worse, in some cases there is no specimen in the lab to begin a T&S until the surgery is about to begin! Other patients have been in the middle of major surgery (elective scheduled cases) when a positive antibody screen is discovered. One surgeon has brought in patients that he KNOWS have warm autoantibodies, and has not bothered to send the pre-operative T&S until the patient is in pre-operative holding. In some instances, patients had to receive uncrossmatched blood for their elective scheduled surgery, because a T&S and crossmatches could not be completed in time! The blood bank has a restriction of requiring that T&S samples be collected at a hospital lab to ensure proper identification. This is frequently raised by physicians as an impediment to having the sample collected in advance. The inquiring blood banker believes that the Institution's Administration now sees the above situation as an issue that JCAHO would want resolved, because in some circumstances scheduled surgical cases have had to receive uncrossmatched blood, simply because the pre-operative specimen did not make it to the lab fast enough. The inquiring blood banker would like to know what other facilities are experiencing in terms of STAT ordering of pre-operative testing for elective scheduled surgery, what impact this is having on using uncrossmatched blood use for elective scheduled surgery, and what steps are being taken to resolve the problem?

The following replies were submitted in response to the above question.

1. Editor's note; please review the discussions at the two links below, as they contain information that is germane to the current discussion:
   • Type and screen for scheduled elective surgical cases
   • Preoperative Antibody Screens - How to Ensure Timely Receipt ... Consistently?
     
     
2. A blood banker in the Pacific Northwest reports that a hospital in her region has a very similar situation to that described by the California blood banker, with about 45% of the pre-transfusion testing ordered STAT. The bulk of patients for whom this STAT testing is done are scheduled for elective surgery. Apparently, the hospital is trying to avoid the cost of an extra day's admission by performing pre-transfusion testing on the day (morning) of surgery. In order to discourage excessive STAT pre-transfusion testing, a fee has been added for STAT testing, but the responding blood banker does not think that the STAT fee will ever be high enough to match the cost of an extra night's stay in a hospital. She laments that education about the dangers of starting surgery without having completed pre-transfusion testing seems to be the only other thing that they can try.
   
   
3. A blood banker in Minnesota reports that during the 1980s his hospital had a similar situation as described by the California blood banker, and by 1989 they had solved the problem! However, as the two papers shown below point out, the solution required that the clinical people cooperate to ensure that patients did not show up at the last minute before surgery for their pre-surgical sample collection.
   • Moore S B et al, Morning Admission to Hospital for Same Day Surgery: A Practical Problem for the Blood Bank. Transfusion 1987;27:359-361.
   • Moore S B et al, Morning Admission for a Same-Day Surgical Procedure: Resolution of a Blood Bank Problem. Mayo Clinic Proceedings 1989; 64: 406-408.
   Like many plans that worked for a while, after about 2 years they noticed some "slippage" in compliance because of great financial pressures to keep patients out of the hospital and to minimize any inconvenience they might experience. Thus, the Minnesotan reports that the original problem returned despite frequent pleadings, cajoling etc. Many patients come from far away to have their elective surgery and to arrive the day before surgery in time for blood samples to be drawn is considered a hardship for those who would have to stay a night in a hotel merely so that they could be phlebotomized. One solution which the Minnesotan says they are about to implement is to set up a system to collect a sample for screening (and subsequent crossmatching) at the time of surgical listing of a patient, up to 28 days pre-surgery. If transfusion is expected, the system will require the physician listing the patient electronically to ask the question "have you been pregnant or transfused in the last three months?" The answer must be recorded electronically. If they fail to elicit a response the surgical listing process cannot proceed. Although not specifically stated by the Minnesotan, it is assumed by the web master that this information will be used to either permit storage and use of pre-transfusion samples for greater than three days for patients who have no history of recent transfusion or pregnancy, and/or to encourage submission of pre-transfusion samples far enough in advance of elective surgery to discover unexpected antibodies that have been induced by previous transfusion or pregnancy.
   
   
4. A blood banker from Massachusetts reports that the Quality Practices Committee of the College of American Pathologists (CAP) has been particularly concerned with this issue. Thus, one of the Q-Probes (New Q-Probe looks at types and screens for scheduled surgeries- CAP TODAY) for 2002 deals with this directly. That Q-Probe ran earlier this year and the data are pending publication. However, in early 2001 a pilot (or beta) version of the Q-Probe took place at 22 sites, with 17 submitting data on more than 700 T&S orders. The pilot data were analyzed for surgical procedures that were scheduled and elective (no trauma, emergency, add-ons, etc.). The analysis looked at the time relative to the start of surgery that a T&S was actually completed. The data were also analyzed for the incidence rate of positive antibody screens revealing clinically significant antibodies, and the delay of surgery due to last minute T&S testing. Recognizing that the beta study was just a pilot, and that the real Q-Probe was improved markedly based on the results from the beta study, the data must be considered anecdotal. Nonetheless, it was found that ~20% of T&S testing was completed AFTER the start of surgery with ~3% of the testing uncovering a novel significant antibody (again AFTER the start of surgery). The responding blood banker reports knowledge of at least one tertiary care medical center that had a fatality due to not having a T&S available for elective same day surgery. The responding blood banker concludes by mentioning a 1987 article by Moore, et al., (Transfusion 27:359-61, 1987) which identified 70 serologic problems over a 4 month period representing 2.4% of all patients admitted for same day surgery. Obviously, the surgeries performed as same day procedures have evolved significantly since then, and the responding blood banker believes that today's patients are at even greater risk from not having a T&S done in an appropriate time frame ahead of scheduled surgery.

ADDENDA April 16, 2002

5. A blood banker reported experiencing the same problems as those described by the inquiring blood banker. As of last August they required that pretransfusion samples for elective surgery must be collected by 5 PM the day prior to surgery. Prior to implementation of this policy they contacted physician offices by telephone and fax'ed each physician to explain the reasons for the policy change. Since implementation of the new policy there has been a dramatic reduction (94%) in the number of samples collected on the day of surgery.

ADDENDA Dec. 30, 2005

6. A Transfusion Service Supervisor reports that his hospital currently holds hard and fast to a '3-day rule' for how long a pre-transfusion blood sample is 'good' for compatibility testing. However, this '3-day rule' creates a dilemma for them in that their hospital policy requires all pre-op patients to come in at least seven to ten days prior to their scheduled surgery to have 'pre-op' lab work drawn and any other necessary evaluations. In addition, in order to have an 'elective' surgery placed on the schedule, all of the requisite pre-op work must be completed and reviewed no less than 7 days prior to the surgery. Consequently, the transfusion service requires patients who need crossmatched blood or a Type & Screen to have a second blood sample drawn within 3 days of their scheduled surgery. The inquiring colleague wonders how other institutions address pre-transfusion testing for their scheduled surgical cases.
   
   
7. Editor's NOTE: please review the discussion below, as welll as those listed in addendum 1 above, as they contain information that is germane to the current discussion.
   • Management of pre-admit surgery patients known to have previously identified antibodies

ADDENDA Dec. 31, 2005

8. Dr. Sunita Saxena, Chair of both the Blood Utilization Committee (BUC) and the Patient Safety Committee at the Los Angeles County+USC Medical Center (attribution used with permission) reports that their BUC developed a system in collaboration with the Operating Room Committee to define and improve the process of completing pre-surgical/pre-admission Type and Screen (T&S) testing as part of the pre-op preparation of patients scheduled for elective surgery. A list of surgical procedures that might require blood transfusion was created and provided to the Pre-op Clinic staff, including physicians and nurses. The Pre-op Clinic was instructed to send a blood specimen for baseline T&S for each patient who was scheduled to have a surgical procedure that was included on the list. Because at LAC+USC these baseline samples are only 'good' for 3 days, and because many of the pre-op patients are processed by the Pre-op clinic more than 3 days in advance of surgery, a second pre-transfusion specimen is required to be collected at the time the patient is admitted for the scheduled surgery, so that the laboratory has a current specimen for compatibility testing, in case an RBC transfusion is needed.  The aforementioned process has achieved essentially 100% success in providing baseline T&S samples for scheduled elective surgical procedures, and had the extra benefit of providing a second separately collected pre-transfusion sample so that the ABO/Rh of scheduled surgical patient's can be verified before they receive a transfusion.
   
   
9. Editor's NOTE: The discussions, Should pre-transfusion ABO/Rh testing be performed twice, and if so, on different samples or by different personnel? and A network dialogue on the question of using a second blood sample to verify a patients ABO/Rh type may provide insights into the benefit of providing a second separately collected pre-transfusion sample so that the ABO/Rh of scheduled surgical patient's can be verified before they receive a transfusion.

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

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