Surgical Blood Order Schedule

[jhaig]

We currently have a maximum surgical blood order schedule (MSBOS) in place in our facility and I'm in the process of updating it. Our med exec. committee seems to want to steer away from it, stating that the physician knows their patient better than the blood bank and will order blood products as they deem appropriate.

Is having an MSBOS like ours a requirement from AABB or CAP? I can't seem to find anything specifically that requires us to have one. Or is it just one of those "good ideas" from the age of dinosaurs set up as a safety net for patient orders that may fall through?

I'd like to ditch the whole thing if possible, but I have no ammo to back it up yet. Quite frankly, I'm not comfortable with ordering blood products on my own without getting in some kind of regulatory trouble. I'd just as soon leave it in the hands of the doctors while maintaining patient safety at the same time.

[tbostock]

I recommend having one; not only does it prevent docs from wanting too many units crossmatched that are never used, but it also protects patients from physicians not ordering enough units (for example aneurysm surgery).

[L106]

I'm at exactly where you are, jhaig. Years ago we used to encourage surgeon to order "X" number of donor units for a particular type of surgery, and we would call the surgeon if no donor units were crossmatched for a particular case, etc. But times have changed........ BB staff doesn't have the time to monitor the surgery schedule and track down who to call (surgeon or Anesthesiologist???), many surgical patients don't come in until the morning of surgery, new surgical procedures, changes in surgical technology and techniques, etc.

Unless you have a very involved and assertive Pathologist who is willing to take the time to be calling surgeons and anesthesiologists and encouraging compliance with the MSBOS, MSBOS has become just a couple pages in the Blood Bank Procedure Manual. The BB staff can't prevent a surgeon from ordering as many crossmatches as he/she wants, and of course BB staff can't actually order crossmatches. Yes, I will call & notify the Surgery Dept if I notice a big case on the schedule that has no blood set up (and I'm sure I always will do that), but I'd like to drop MSBOS from the Blood Bank Procedure Manual also.

It will be interesting to see comments from others on this topic. Maybe we will hear some good suggestions of how to handle MSBOS compliance (and noncompliance), or maybe many others feel that MSBOS no longer belongs under Blood Bank's jurisdiction (and perhaps cite some references that jhaig and I can use to ditch the procedure.)

Edited May 11, 2009 by L106
Typo

[Franklyn]

We put one together a few years ago (minimum blood order schedule, the Docs can always order more...). We got the list of surgical patients for a 9 month period and linked that to RBC use day of surgery and the next day and grouped that by specialty and procedure. We were then able to come up with a schedule that meets the needs of something like 85% of all cases. The Blood Bank reviews the schedule and verifies that we have a valid sample and blood available for each case. The Blood Bank can initiate the order if none exists. The goal is avoid surprises and delays in surgery which increases patient satisfaction and safety. It does, however, take staff. I strongly suggest any MSBOS be based on hard data. The "feelings" of what the surgeons needed for each case were so far off from the facts it was amazing.

[Diane Derm]

I would reference you to the NYSDOH Guidelines for Transfusion Committees, 3rd edition, 2006, page 2, B. It states the following: "The committee may establish guidelines for reservation of blood and for typing and screening pf patients scheduled for commonly performed elective surgical procedures for which blood transfusion may be anticipated. At a minimum, the committee must establish guidelines for each surgical procedure performed more than five times in the preceding calendar year, and set the maximum number of hours that crossmatch blood will be held on reserve."

Hope this helps!

[Linda0623]

I am in the process of reinstating our MSBOS.....We are a predominently orthopedic surgery based hospital, and what we found over the last couple of years is that without an effective MSBOS, blood management has become a nightmare. Most of the blood set-up for surgery, 85-90%, is currently not used peri-operatively. Because these units are "tied up" for the surgical suite, inventory for routine medical or post-op requests have become an issue. We could (and do) double- crossmatch and then issue based on need, but that has it's own problems.

What I chose to do was to create a Blood Bank/OR Services PI project, that looked at/for inefficiencies in the services the Blood Bank provides to the OR. This project has the backing of the Hospital Performance Improvement Commitee, as well as is sponsored and monitored by the Transfusion Committee. One piece of this project was to strentghen the use and basis for the MSBOS. It has meant a lot of work up front to try to ensure 3 basic things: 1.) Standardize Ordering practices across the hospital system for pre-op patients, 2). Reflects the Dept. Of Anesthesia's expectations of blood needs for each procedure, and 3.) Patient Safety: Nothing worse than an inpatient being sent down for an add-on procedure where bleeding is encountered and no clot let own any blood products are available.The MSBOS has a guideline attached that allows for MD discretion for patients' with higher acuity. This has been well-received by anesthesia, and the in-patient floors find it helpful as a guideline for what a patient might need if no updated order has been written and the OR calls them to add on their patient to that day's schedule. It takes a lot of team building outside of the Blood bank to make this a success, and I can see that being difficult in larger institutions that service multiple critical areas, but with enough dedicated people to the process, it can be done. Our chief of anesthesia has played a pivotal role in the development of this, and has gotten consensus from the Dept. of Surgery. It is now going to our Medical Executive Committee for final implementation and approval. The buy-in from the surgical dept is, in my opinion, the key to this. If you get the consensus, and put the proper monitors in place, I think the MSBOS can serve a facility well. I know that thus far, our cross-departmental team building on this project has helped to give the Blood Bank a presence in the clinical team, as opposed to being a 'back-ground' ancillary service. Only time will tell how successful this will be long term, but at present, I have hopes of actually seeing a more efficient streamlined process so that the Blood Bank can provide even better service than in previous years.......we'll see......

Oh, and I almost forgot......the regulatory basis that I used to get all the parties together was the CAP TRM question regarding service agreements between the BB and the clinical areas such as ER, OR, L&D, where communication of patient problems, dept. expectations, and TAT are expected to be outlined..........sorry I don't have the checklist question # right handy!!!!

Edited May 13, 2009 by Linda0623
add regaulatory weight to the discussion

[AMcCord]

I am not allowed to see the daily surgical schedule - I don't have a "need to know"! Yet I have to pull a rabbit (instant crossmatched blood) out of a hat...Voila!...on a fairly regular basis. I can't change the relevant minds, so we just do the best we can do. Never have been able to figure this one out.

[L106]

"I feel your pain....."

We had the same thing happen 3 or 4 years ago....The "powers-that-be" decided other departments couldn't see the surgery schedule because of "confidentiality". Fortunately, our Lab Director convinced them that Blood Bank should be on the "need-to-know" list.

[jhaig]

It blows my mind to think that the BLOOD BANK should not be in the loop when it comes to providing BLOOD for surgery! It's like trying to fly a plane without having access to the weather report.

[jhaig]

I would reference you to the NYSDOH Guidelines for Transfusion Committees, 3rd edition, 2006, page 2, B. It states the following: "The committee may establish guidelines for reservation of blood and for typing and screening pf patients scheduled for commonly performed elective surgical procedures for which blood transfusion may be anticipated. At a minimum, the committee must establish guidelines for each surgical procedure performed more than five times in the preceding calendar year, and set the maximum number of hours that crossmatch blood will be held on reserve."

Hope this helps!

Can I find these guidelines on-line or do I need to purchase them? (Oops, It's NY, I should know this already:cool:)

[bbbirder]

I am not allowed to see the daily surgical schedule - I don't have a "need to know"! Yet I have to pull a rabbit (instant crossmatched blood) out of a hat...Voila!...on a fairly regular basis. I can't change the relevant minds, so we just do the best we can do. Never have been able to figure this one out.

We had a similar situation several years ago. We weren't allowed to see the surgery schedule. Then, we got approved to see it, all of the names were blacked out! Too funny.

After a back surgery case (an Oneg with multiple antibodies and we had the history on file) had to be canceled because we couldn't provide blood that day, they changed so we now get the schedule. (They also started bringing those patients in before the day of surgery for Type & Screen).

Linda Frederick