A physician in Oklahoma at a hospital with approximately 350-400 beds would like input from colleagues regarding the use of blood storage refrigerators in the operating room (OR). With expansion of his hospital, the OR staff have been pushing for the installation of a blood storage refrigerator for the OR suites to hold blood for patients during their operations. The hospital's current procedure is to maintain RBC units in the OR suites by having the blood bank dispense RBC units in Igloo coolers for one patient at a time, to be kept with each patient in their respective OR suite. The inquiring colleague hopes to discover valid studies that demonstrate the safety 'track record' of using blood storage refrigerators in the OR. The inquiring physician adds that at his previous hospital, they had a blood storage refrigerator in the OR that held crossmatched blood for all of the procedures that were scheduled for that day, and the system seemed to work.

The following responses were received.

1. A nurse who works at a hospital in Seattle reports that in 1998 her institution (approx. 400 beds) began using seven portable blood refrigerators in order to store blood in various hospital locations (including in OR suites) for patients who might need two or more units of RBCs or plasma. These portable refrigerators are on wheels, have 2 shelves, and can hold about 60 units. The rationale for this strategy was:

• to improve blood availability for patients who might suddenly need multiple units of blood,
• to prevent identification errors by stocking a refrigerator with only one patient's blood products at a time, and
• to decrease wastage that occurs if products are returned to the blood bank after sitting out at room temperature for more than 30 minutes.

In 1998, they also added a satellite transfusion support service lab in their OR (equipped with a large non-portable refrigerator). The satelite lab is managed by the Anesthesia Department in accordance with the Department of Laboratory Medicine and is staffed by anesthesia technicians. Blood components that are required for patients in the OR arrive in their main Transfusion Support Services (TSS) lab and are then sent to the satellite OR TSS. An OR schedule is sent to the main TSS lab to ensure that products are in the OR before each case. For emergency surgeries, blood products are sent to the OR from the blood bank as soon as they are crossmatched; if there is insufficient time, uncrossmatched group O RBCs are issued. For surgeries that require large volume transfusions, portable blood refrigerators are issued at the start of the case. The portable blood refrigerators are used by only one patient at a time, with the name and number of the patient prominently displayed on the refrigerator. These refrigerators are taken directly into the operating room, where they serve as an immediate source of blood components while monitored storage takes place. In the case of patients who need to be moved between patient care units and the operating rooms, the portable blood refrigerator can be moved along with the patient. They report keeping 'tight records' so that they can return products back to the main blood bank with confidence that they have always maintained adequate temperature control. If a portable blood refrigerator is needed, the TSS technologist will call for a hospital transporter who will then move the refrigerator to the appropriate patient care location. There is always a portable blood refrigerator available in the OR. Departments other than the OR cannot keep a refrigerator available in their department (e.g. emergency department) at all times. They monitor incidents and blood utilization monthly. The responding colleague reports that the above strategy has decreased wastage and the clinicians are happier because they know the blood is in the room or right down the hall in the satelite TSS if needed. Further details of this hospital's policy are outlined in this PDF file.

2. Dr. Breanndan Moore, a transfusion medicine physician with years of experience at the Mayo Clinic (attribution used with permission) is of the opinion that one should use extreme caution with regard to the question of placing blood bank refridgerators in the OR area. To quote (verbatim):

"We have had lots of experience with surgeons wanting their own little "private" bank either in the OR or else in the various Post Anesthesia Rooms (PAR) here at Mayo with its huge surgical practice. For many years, every time there is any expansion or remodeling of the surgery areas in our two hospitals, this "thorny" question seemed to arise again! We have resisted as much as possible because, our experience over many years has been disquieting to put it mildly. We have repeatedly performed timing studies and presented those data to our surgical colleagues to demonstrate how quickly we can routinely supply blood to the PARs ( our hospital blood bank labs are situated right in the middle of the ORs so that surgery personnel merely come to our window which opens out onto the sterile OR area). Essentially the only times we have given the "wrong" unit of blood to a patient at Mayo over many decades, it has been in the setting where blood was stored in the PAR (not under the direct control of Transfusion Medicine). As you can imagine, when this rare but potentially catastrophic event has happened, there has been the expected hand-wringing, regrets, promises to improve training, etc. However, the root cause has been the ready and convenient access to blood product units by people whose main job is not that of issuing carefully each and every unit of blood or components. The clinical perception of urgent blood need drives the "hurry-up" mentality and the situation becomes one of a clerical type mistake just waiting to happen! Our own institutional committees and event reviewing bodies, for example the Sentinel Event Team, have agreed with the contention by Transfusion Medicine that the placing of separate " private" little banks is to be avoided in virtually all circumstances. Currently, we have only one such refrigerator in the ER and one beside the helicopter pad. In each one we keep 4 units of O Neg RBCs, and Transfusion Medicine monitors the refrigerators and rotates the units. This policy is designed to avoid an ABO mishap should those units be needed before we can do a proper compatibility process. We have a very busy surgical practice which involves all types of solid organ transplantation, orthopedics, general, cardiac and trauma surgery. I suspect that our Mayo surgeons are no less demanding, cantankerous, stressed and unreasonable than those in any other major medical center. However, they have been convinced of the wisdom of our policies in this regard and no longer importune us to let them set up their own satellite blood banks."

ADDENDA June 1, 2003

3. A transfusion medicine physician in New York agrees entirely with what Dr. Breanndan Moore said in reply #2 above. According to the New York physician (verbatim) "OR refrigerators and the like, unless physically under the control of the transfusion service, are accidents waiting to happen. We use a cooler system, which is not perfect, but provides the needed reassurance and proximity without as much risk."

ADDENDA June 4, 2003

4. A blood bank supervisor in New Jersey is of the opinion that having type specific blood available in the OR is an event waiting to happen. It is her opinion that consistent monitoring of the refrigerator by OR staff is a problem. She reports seeing numerous “out of range” tracings on the temperature graphs, with no action taken and that the daily recording of temperatures is often forgotten. She also reports the instance of release of a general inventory unit of blood instead of a directed donor unit. They ended up removing the refrigerator from their OR.

5. A transfusion medicine physician in Seattle reports that the system of portable refrigerators in Seattle was originally begun in the academic medical center about 11 years ago where the practice involves many cases with "high volume" transfusion of organ transplantation, complicated cardiothoracic, and neurologic surgeries. At that time their experience with OR refrigerators was similar to the scenarios our colleagues outline with such concern: anesthesiologists grabbing the wrong blood out of the OR blood refrigerator, expired FFP in an ICU refrigerator. This led them to remove all “satellite” blood bank refrigerators from various locations around the hospital. Placing the blood services lab across the hall from the Operating Room persuaded the surgeons and anesthesiologists that their supply line was secure. Part of the 'deal' they made to get their agreement was taking the under-counter blood bank refrigerators they were removing and mount them on rolling platforms for dispensing and storing blood for these high volume cases. The surgical teams actually prefer it since the blood for their patient is in the room or anteroom and staff don’t need to run out into the hallway in an emergency. Blood for a post-op patient can follow them directly to the ICU in the refrigerator. This is much preferable to bags of blood we would occasionally find under the sheets after transport. The refrigerators are clearly marked for an identified patient as a cooler would be, but they are continuously monitored and have much longer and more even temperature retention. The program was so successful that five years later they extended it to our County Hospital which is the major trauma center for the Seattle Area mentioned in a previous posting (see posting #1). Here the problem was not only grabbing the wrong blood out of an OR refrigerator, but also waste of uncrossmatched units that were called for and left on the bed too long when the patient expired. At both institutions, any order for uncrossmatched blood is now followed by a portable blood refrigerator. According to the responding physician, both programs have been extremely successful. Also, to the responding physician’s knowledge there has been no mistransfusion out of a portable blood refrigerator. Waste of uncrossmatched emergency units has decreased. Happiest of all, there is less chaos surrounding blood in the operating rooms and surgical teams feel more confident.

ADDENDA June 5, 2003

6. A medical director of a 300 bed facility in Maryland keeps a refrigerator in the OR due to policy developed prior to the responding colleague's arrival.  She laments that each morning the refrigerator is stocked with blood for the day's cases. OR staff record in a log book when units are removed for specific patients.  The responding physician "feels like I am sitting on an accident waiting to happen". She does not like this system, and she has made no bones about it to hospital administration and clinical practice committees.   Because a sentinel event has not yet occurred, no one believes anything “bad” will ever happen. In the hospital where she did her residency, an anesthesia resident took out two units of group B blood that were left behind in the OR refrigerator and infused them into a group A patient. The next day, the OR refrigerator was gone. The Maryland physician continues to impress upon her surgical colleagues that this refrigerator is not promised to them.  She asks, 'Does anyone have any data on errors committed in such settings that I might either use to calm my fears, or better yet, share with my surgical colleagues?'

ADDENDA June 6, 2003

7. A colleague in Palo Alto suggests that the Oklahoma colleague might, if s/he has not already done so, review two articles that discuss transfusion errors and deaths due to transfusion (Linden J, et al., Transfusion 2000;40:1207 and Sazama K, Transfusion 1990;30:583). The Palo Alto colleague says (verbatim) "Although neither article is focused on OR blood refrigerators, both authors discuss that many errors were made in the operating room environment. Sazama states " ... the failure to remove the previous patient's reserved blood from the operating room refrigerator, a factor that was implicated in several ABO deaths as well...". Linden writes "many of the reported errors occurred in the operating room...." An earlier report of transfusion associated fatalities (Honig CL, Bove JR, Transfusion 1980;20;653) found that of deaths due to the error on the part of physicians (approximatley 20% of deaths), the most common site was the operating room." She continues that "until there is a system of storing blood products similar to the currently used electronic systems for recording and dispensing drugs with lock-out of all other products, refrigerators with multiple ABO types outside the direct control of the blood bank or transfusion service are a recognized risk to patient safety."

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Ira A. Shulman, MD
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