1. Blood Bank/Transfusion Committee Tutorial Marc Zumberg MD The Shands Transfusion Committee November 2007

2. Goal Help us to help you: –Obtain blood necessary for surgeries and patient care –Obtain blood in a timely and efficient fashion –Obtain blood safely By: –Ordering pre-operative type and screen (T&S) –Understanding the role of RBC alloantibodies –Ordering type and cross only when necessary –Ordering only the number of units that are needed

3. RED CELL TRANSFUSION Type and Screen : –Used preoperatively if transfusion is possible –Verifies ABO and Rh type of the patient and screens the patient for alloantibodies Type and Cross : –Used when transfusion is very likely or imminent –Compatible RBC units secured for the patient

4. Type and Screen Tests for the presence of alloantibodies in your patients plasma against red blood cell antigens that may be found in the donated blood

5. Did you Know? A T&S takes approximately 45 minutes to perform If the T&S is active a Type and Cross (ie obtaining units of PRBC) only takes about 15 minutes –This may be delayed if RBC alloantibodies are noted on the T&S Result: If the T&S is kept up-to-date PRBCs can be obtained very quickly

6. Did you know? Most delays in obtaining PRBC in a timely fashion are due to: –Delays in physicians writing the orders –Delays in the order getting placed into the computer system –Delays in the pick up and delivery of the blood from the blood bank –The presence of alloantibodies on the T&S Can be prevented if pre-operative testing is done and good communication is kept with the blood bank

7. Keys Communicate –With the attending physicians and members of the medical team concerning transfusion needs for planned surgeries and ongoing patient care –With the ward clerks the urgency of transfusions –With nursing and couriers if transfusion is urgent –And especially with the blood bank Urgency of the blood product If known alloantibodies

8. Problems Preoperative Type T&S are not always ordered –In the surgery clinics –In the anesthesia pre-op clinics –On the wards This can lead to significant delays if alloantibodies are present and the blood type is rare

9. Alloantibodies Antibodies in your patient’s plasma directed against incompatible RBC antigens of the blood donor –More common in females with prior pregnancies –Anyone previously transfused

10. Alloantibodies When an alloantibody is detected for the first time the blood bank will: –alert the ordering physician –Try to obtain 2 compatible units If the alloantibody is rare then Lifesouth has to screen their stock of RBCs and rare donor registries to find compatible blood –If not available may have to be shipped in from other areas of the country Please note that alloantibodies can lead to significant delays in obtaining compatible blood products

11. Problem The Crossmatch:Transfusion ratio (C:T ratio) at Shands is too high –Lots of blood is being crossmatched and never transfused –We are failing to meet JAHCO recommended standards and are at risk of citations

12. Why is a high C:T ratio bad Securing blood that is never transfused is taxing on the blood bank –Non-transfused blood has to be placed back in the general inventory which is costly and time consuming –Takes time and effort away from the blood banks ability to secure blood for other cases –Replacement blood has to be ordered from Lifesouth when units are secured for Type and cross

13. Solutions: Maximum Surgical Blood Order Schedule (MSBOS)

14. Located on the back of each Blood Bank order form for preoperative blood ordering The MSBOS is approved by the respective division chiefs of each service as the recommended units of PRBC to order for common surgical procedures

15. C/T Ratio Goal is <1.5 C/T Ratio = 1.0 when the number of red cell units crossmatched or setup for the patient is equal to the number of red cell units transfused Many services at Shands are far over the goal of <1.5

16. Keys: Pre-Operative Ordering Order pre-OP Type & Screen (T&S) during pre-surgical evaluation and lab testing –Blood can be ready in <15 min if a pre-OP T&S has been done and found to be antibody negative. Otherwise, the entire process takes 45-60 min. Order Type & Crossmatch (T&S w/ units) at least 1 day before scheduled surgery cases which will require greater than 6 units to be transfused during surgery or if the patient is know to have an antibody.

17. Good Practice Keep Type & Screen order current (every 3 calendar days) Order blood products only when transfusion is certain to keep your C/T Ratio less than 1.5 (C/T Ratio = crossmatch to transfusion ratio) Plan in advance and communicate with the blood bank for patients with antibodies to minimize delay

18. Goal Help the blood bank to help you obtain blood for your patients in a safe, timely, efficient, and cost effective manner