looks at types and screens
for scheduled surgeries
Surgery used to be such a big deal that people would schedule
it far in advance and spend a day or two in the hospital for prep
work before the procedure.
Today, many surgeries, especially elective ones, are performed
in a single day, and the prep work is completed in the hectic hours
before the patient enters the operating room.
With the shift to same-day surgery, Richard Friedberg, MD, PhD,
chairman of the Department of Pathology at Baystate Health System,
Springfield, Mass., became concerned about a potential problem.
In many same-day surgeries, blood may be required on relatively
short notice, which means a type and screen needs to be performed
for the patient.
Dr. Friedberg’s concern is that if those T&Ses are being done
just prior to surgery, compatible blood might not be immediately
available if the patient has an alloantibody or a rare blood type.
"People are coming into the hospital or clinic early in the morning,
getting their T&S collected, and then going into the OR," he says.
"The surgeon fully expects blood to be available." In the past,
blood was almost always accessible because hospitals had days to
do the workup. With that no longer the case, Dr. Friedberg wanted
to determine if surgeries were being delayed or patient care compromised
because blood -wasn’t available.
Dr. Friedberg was able to find the answer in a just-completed
CAP Q-Probe, "Type and screen completion for scheduled surgical
procedures" (QP15). Dr. Friedberg, a member of the CAP Quality Practices
Committee, which oversees Q-Probes, and a member of the Transfusion
Medicine Resource Committee, together with Bruce Jones, MD, chair
of the Quality Practices Committee, designed the Q-Probe as a systematic
method to assess the scope of the problem. What they found was disturbing,
though not wholly surprising.
The Q-Probe studied 8,941 types and screens and found that 64.6
percent were collected before the day of surgery. The median laboratory
completed about 69 percent of its T&S testing for scheduled surgeries
at least one day before the surgery. Of those T&Ses collected on
the day of surgery, the median laboratory completed almost 23 percent
after the start of surgery. But for the poorest performing 10 percent
of participants, more than three-fourths of all T&Ses collected
on the same day as surgery were not complete until after the latest
point that the hospital was comfortable not having blood available.
Furthermore, for nearly nine percent of patients in the study,
which encompassed more than 100 institutions, surgeries had been
started without a completed T&S. In his author’s commentary, Dr.
Friedberg stated that for those nine percent of patients, the vast
majority were at risk in large part because the T&&S was collected
on the same day as surgery.
The greatest risk occurred in the two percent of patients with
positive antibody screens. More than a third of that group required
special efforts to obtain blood, and 17 percent of those special
efforts resulted in delayed surgeries.
"Surgeons may not recognize the time and effort needed to identify compatible
blood," Dr. Friedberg wrote in his commentary. So, "without proper intervention
by the laboratory . . . patients may be unnecessarily placed at risk by inadequate
mechanisms to ascertain available blood for surgery."
Another influence on the T&S is the so-called three-day rule,
a standard issued by the American Association of Blood Banks. For
a patient who has been transfused or may have become pregnant within
the preceding three months, or if the patient’s history is uncertain
or unavailable, "a sample shall be obtained from the patient within
three days of the scheduled transfusion."
Dr. Friedberg believes this rule can complicate efforts to obtain
T&Ses before surgery. Furthermore, the blood banking association
does not specify how long a T&S sample may be stored for a patient
who has not been pregnant or transfused within the preceding three
To comply with the AABB three-day rule, many hospitals collect
T&S specimens for all patients on the day of surgery, anticipating
they won’t have a problem identifying novel antibodies or finding
the needed blood.
Other hospitals collect a sample well in advance of surgery and
confirm with patients on the day of the procedure that they have
not been transfused or become pregnant. A third option is to collect
a T&S specimen early and then repeat it on the day of surgery.
Dr. Friedberg does not endorse any particular process in his Q-Probe
comments, but he does say that "the need for a well-devised solution
Institutions usually respond by having on hand large supplies of O negative
blood, he says. "But O negative doesn’t address the problem of an alloantibody.
The real answer," he adds, "is improved communication and having protocols in
place to make sure a T&S is collected in advance of surgery."
Reconsidering the rule
Dr. Friedberg has suggested that the AABB consider changing the
three-day rule. He points out that blood banking authorities in
Britain and Australia allow longer time frames for collecting blood.
"In these days of same-day surgery, we have to consider whether
this rule still makes sense. What risk are you taking versus the
risk of doing the T&S within 30 minutes of surgery?" he asks.
Others, however, believe it’s hospital practices that should be
reconsidered. "I think the problem can be handled without changing
the rule," says James AuBuchon, MD, professor and chair of pathology
at Dartmouth-Hitchcock Medical Center, Leb-anon, NH, and vice chair
of the CAP Transfusion Medicine Resource Committee.
"The reasons patients didn’t have their samples collected -wasn’t
because of the three-day rule. It was because the hospitals -hadn’t
adopted an approach to draw samples before surgery," he says. "There
are ways around it."
The issue isn’t with the three-day rule, but with people interpreting
it too rigidly, adds Ira A. Shulman, MD, director of transfusion
medicine and vice chair and professor of pathology at the Keck School
of Medicine, University of Southern California. Dr. Shulman is co-chair
of the CAP transfusion committee.
The rule is justified because it’s designed to minimize transfusion
reactions in patients who have recently been exposed to someone
else’s blood, Dr. Shulman says. Individuals who don’t have that
exposure are exempt.
"Hospitals prefer to apply the rule to all patients because it’s easier to
standardize one’s approach," he adds. "The way to solve this particular problem
is to look at your system and come up with a solution that works for you."
At Los Angeles County+USC Medical Center, Dr. Shulman says, "We
plan to implement a scheduling process for surgery that includes
an assessment of the likelihood that blood will be needed." This
assessment should occur several weeks before the scheduled surgery.
"And if it appears at all likely that transfusion might be necessary,"
he says, "a T&S would be ordered in advance and the results recorded
in the transfusion service record, which serves as a baseline. The
patient would submit a new sample the morning of surgery to verify
that no new antibody has appeared and to have a fresh sample in
case cross-matching becomes necessary."
With advance testing, "the possibility of the patient going into
surgery without knowing about an antibody is remote," he adds. "We’ve
got early warning if there’s a problem."
Dartmouth-Hitchcock Medical Center adheres to a slightly different
procedure. "We make every effort to get the T&S ahead of time,"
Dr. AuBuchon says. The pre-admission testing office identifies patients
who need samples and collects them as part of the preoperative process.
It also identifies patients for whom an early sample can be used.
On the day of surgery, patients are asked if they have become
pregnant or had a transfusion within the last three months. If the
answer is no, the older sample can be used, Dr. AuBuchon says. Otherwise,
a new sample is drawn.
The hospital takes patients at their word about pregnancy and
transfusion. "If they’ve become pregnant so recently they don’t
know about it yet, the chance for alloantibodies is extremely remote,"
Dr. AuBuchon adds.
The University of California, San Diego, does the T&S three weeks before surgery
and will test again on the day of surgery if there’s any question of an antibody
developing, says Thomas Lane, MD, medical director of transfusion services and
AABB liaison to the CAP transfusion committee. Most institutions "do it somewhere
between three and five weeks, which is perfectly acceptable," he adds, "so long
as the patients haven’t been transfused or become pregnant."
Spreading the findings
Dr. Friedberg and other members of the CAP Transfusion Medicine
Resource Committee plan to disseminate the Q-Probe findings to various
groups, including the AABB and American Society of Anesthesiologists.
Dr. Friedberg will present the findings at the AABB annual meeting
And Chantal Harrison, MD, an advisor to the transfusion committee,
will discuss the findings at the American Society of Anesthesiologists’
Transfusion Practices Committee meeting, also in October.
"We’re going to bring this out into the open," says Dr. Harrison,
who is professor of pathology at the University of Texas Health
Science Center, San Antonio. "There are ways we can address this
problem and alert an-es-the-siologists to take action." Since anesthesiologists
have a surgical checklist they follow before putting the patient
under, "they can add completion of the T&S to that list," she adds.
While anesthesiologists have no direct control over the T&S or
the length of surgery, they can delay a procedure if blood is not
available. Like a bombardier who takes over a plane just before
dropping the bomb, "the anesthesiologist can use the checklist to
make sure surgery doesn’t start without making sure blood is ready,"
Dr. Harrison says.
Dr. Lane plans to submit a written report on the Q-Probe findings
for AABB board members to review at the fall meeting. "This information
will be transmitted to the AABB board, which will determine what
action needs to be taken," he says.
Dr. Lane praises the Q-Probe’s "hard data" showing that "this
is a widespread and significant problem." The findings should intensify
discussion, he says. "Nine percent is quite high, but this is a
preventable problem that doesn’t have to occur. It’s just a matter
of proper planning."
Although problems with same-day surgeries and completion of T&Ses
have been discussed anecdotally for years (see www.cbbsweb.org
for examples from California blood banks), the Q-Probe quantified
"The frequency with which this occurs, as shown by the Q-Probe,
is alarming," says Dr. Shulman. We knew that the problem existed,
he adds, "but the Q-Probe has done a good job in defining the magnitude
of the problem."
The next step, he says, is for each institution that does a T&S
"to look at its own in-house performance and review the process
to see where the control is weak and make appropriate adjustments
if necessary." The Q-Probe design gives institutions a good template
for assessing their own performance, Dr. Shulman adds.
"A year from now, the blood banking community should get better,"
he says. "I hope that the nine percent figure for T&Ses uncompleted
before the start of surgery drops to less than one percent."
Karen Southwick is a writer in San Francisco. For more information
about the Q-Probes program, contact CAP customer service at 800-323-4040,
option 1#, or visit the CAP Web site at www.cap.org.