Blood Bank Testing Day of Surgery Fatalities

[jerriemc]

Does anyone know where I can find some data about fatalities resulting from patient's not having blood bank testing done prior to surgery? Example patient doesn't have type and screen ordered until day of surgery and the patient has an antibody and the blood bank cannot find compatible blood? Thanks for your help

[rravkin@aol.com]

I do not know of such data however I do have practicle knowledge of two policies/ practices, PAT and MSBOS. The PAT practice is established to ensure out-patient blood bank needs are met prior to thier surgery. It consists of an established time frame from which the specimen to be used for crossmatching is drawn until date of the surgery; in practice I've seen thirty days and twenty days, with certain criteria being met; ie no transfusion during this time, no pregnancy, and negative anitbody screen. If any one or combination of these criteria are not met then the patient would have to have a specimen drawn the date of surgery; this policy would be understood and implimented by the out-patient surgical staff such that the surgery would be delayed until compatible units were assigned.

The other policy/practice is MSBOS (I do not remember what this acrynim stands for), but this essentially is a minimum numbers of blood products needed for a specific surgical procedure and is established by your hospital surgeons and the blood bank medical director. This system is to ensure that a minimum number of blood products are ready for an in-patient surgical procedure.

Both of these practices help to maintain blood bank inventory. I hope this helps a little.

Edited September 6, 2012 by rravkin@aol.com

[DPruden]

The FDA posts fatality statistics, but they are more related to transfusion related fatalities. You might see if Joint Commission or the National Center for Health Statistics (through the CDC) has any posted information.

[jerriemc]

Thanks for your replies. We have had several instances this week where the physician has written an order to do the type and screen day of surgery. This just seems like we are asking for a disaster, but the OR director thinks lab is over reacting so I wanted to give her some data on the importance of having the type and screen done before the patient goes to surgery.

[David Saikin]

We have that scenario as one of our "critical values" in the blood bank, i.e., same day T&S ordered and pt has abs so either a delay or no blood products would be available.

[Malcolm Needs ☆]

WE had a case not too long ago, where the Hospital Blood Bank sent us a sample on a surgical orthopedic case (THR) because it appeared to have an antibody directed against a high-incidence antigen.

THe suregon decided to go ahead anyway.

THR's, as far as I know, are not urgent, but can be bloody on occasions.

Fortunately, the patient did not require blood - they were an Oh!!!!!!!!!

[adiescast]

Half the time when we get a sample for a same day surgery, the patient is already on the table before we even get the sample.

[Mabel Adams]

This is a performance measure that Joint Commission is piloting. Although it is not in force yet, I think it makes the point that JC thinks getting the testing done in advance is advisable.

[TABLE=width: 344]

[TR]

[TD=class: xl23, width: 459, bgcolor: transparent]PBM-07 Preoperative Blood Type Screening and Antibody Testing[/TD]

[/TR]

[TR]

[TD=class: xl22, width: 459, bgcolor: transparent]N: Patients with documentation of preoperative type and

screen or type and crossmatch completed prior to Anesthesia Start Time[/TD]

[/TR]

[TR]

[TD=class: xl22, width: 459, bgcolor: transparent]D:Selected elective surgical patients (Elective

orthopedic & hysterectomy surgeries patients > 18 years of age)[/TD]

[/TR]

[/TABLE]

[Eagle Eye]

PAT and MSBOS is the best way. You can have your midnight staff review schdule cases to make sure at least you have blood available based on MSBOS(Maximum Surgical Blood Order Schedule) for all the in patients. The same day surgery patient in case if you have a history of antibody, you can alert the surgeon. We follow our PAT policy. all same day specimen---we need at least 2 hrs to process and if screen is positive, we notify OR immediately and it is up to them to go ahead with the surgery. of course we document our communication. Our anesthesia team is very good, once they know the blood is not ready for major cases, tey will not start surgery.

I would suggest you to have very clear PAT policy.

[pstruik]

I do not know of such data however I do have practicle knowledge of two policies/ practices, PAT and MSBOS. The PAT practice is established to ensure out-patient blood bank needs are met prior to thier surgery. It consists of an established time frame from which the specimen to be used for crossmatching is drawn until date of the surgery; in practice I've seen thirty days and twenty days, with certain criteria being met; ie no transfusion during this time, no pregnancy, and negative anitbody screen. If any one or combination of these criteria are not met then the patient would have to have a specimen drawn the date of surgery; this policy would be understood and implimented by the out-patient surgical staff such that the surgery would be delayed until compatible units were assigned.

The other policy/practice is MSBOS (I do not remember what this acrynim stands for), but this essentially is a minimum numbers of blood products needed for a specific surgical procedure and is established by your hospital surgeons and the blood bank medical director. This system is to ensure that a minimum number of blood products are ready for an in-patient surgical procedure.

Both of these practices help to maintain blood bank inventory. I hope this helps a little.

MSBOS = Maximum Surgical Blood Order Schedule

[Eoin]

Thanks for post Mabel.

I knew Joint Commission was going to get us to measure this as a KPI, so can start now. We have a very well used pre-op clinic and we keep plasma for 30 days (with the usual provisos - no pregnancy, Tx in last three months or between pre-op draw and surgery). Despite this we get elective patients turning up late & need Group, Screen & Hold or X-match. As soon as we see this, we send a letter (copy kept) to the anaesthetist in theatre warning that there may be no blood ready, especially if we encounter an antibody - etc, etc and the responsibility to proceed lies with them. We ask for a signed reply (but rarely get it mind you), but we feel that is the best we can manage.

Cheers

Eoin

[jfdrn]

hi

here is an article i found in my coolection that might help.

Ensuring timely Completion of Type and Screen Testing and the verification of ABO/Rh status for elective surgical patients. by Sunita Saxena, janice Nelson, Melanie Osby, et al.. Arch Pathol Lab Med vol 131 April 2007 576-581

[rravkin@aol.com]

Why do they call it "Maximum?" It sounds as though this is all the blood that would be available for the procedure and this is not true.

MSBOS = Maximum Surgical Blood Order Schedule

- - - Updated - - -

[Malcolm Needs ☆]

Why do they call it "Maximum?" It sounds as though this is all the blood that would be available for the procedure and this is not true.

- - - Updated - - -

HI Ronald,

The word "maximum" comes from the whole raft of learned papers that came out when the idea was first aired. What it actually means is that, if a physician/nurse/whomsoever orders more units than would normally be expected for a particular surgical procedure in a particular hospital (the MSBOS being unique to each procedure and to each hospital, based on historical usage), the laboratory were entitled to contact the person making the request and ask why more blood than normal was being ordered. If there was a good reason, I don't know, maybe the patient was high risk of haemorrhage for some reason, then fine, the extra units would be cross-matched and made available. If, on the other hand, there was no good reason, then the person making the request could be "pursuaded" to think again, unless they would like to contact the Consultant-in-Charge of the Blood Bank and talk to them!

The word "maximum" is, I tend to agree, not quite the mot juste, and may be seen as an anacronism, but that was where it first arose - and it has stuck.

[swede]

We call ours OSBOS (optimal surgical blood order schedule). We didn't like the word maximum either!

Why do they call it "Maximum?" It sounds as though this is all the blood that would be available for the procedure and this is not true.

- - - Updated - - -

[rravkin@aol.com]

So here "Maximum" is the number of presurgical blood products the blood bank will assign for a particular procedure at a particular hospital based on their own particular statistics of usage for this procedure in light of an inconsistancy amongst surgeon and/or physician orders in order to manage inventory. I guess in this light the term "Maximum" is applicable. Thank you Malcolm.

HI Ronald,

The word "maximum" comes from the whole raft of learned papers that came out when the idea was first aired. What it actually means is that, if a physician/nurse/whomsoever orders more units than would normally be expected for a particular surgical procedure in a particular hospital (the MSBOS being unique to each procedure and to each hospital, based on historical usage), the laboratory were entitled to contact the person making the request and ask why more blood than normal was being ordered. If there was a good reason, I don't know, maybe the patient was high risk of haemorrhage for some reason, then fine, the extra units would be cross-matched and made available. If, on the other hand, there was no good reason, then the person making the request could be "pursuaded" to think again, unless they would like to contact the Consultant-in-Charge of the Blood Bank and talk to them!

The word "maximum" is, I tend to agree, not quite the mot juste, and may be seen as an anacronism, but that was where it first arose - and it has stuck.

[Josephine Merka]

hi all,

where i work, that's how we pattern our policy for pre-op testing, though there are always "surprises", surgeon is ready to incise, and calling blood bank for available blood producst.. and we dont even have a blood type on that patient. emergency uncross is ready for action. yeah!! let the fun begins...

[Josephine Merka]

Very interesting!!! Love you PEOPLE.. BUNCH OF GENIUSES!!

[pstruik]

Yes, a better name (well, for British readers who will appreciate the reference) would be Accepted Standard Blood Ordering Schedule - ASBOS : which I wish i had thought of years ago.

[jeanne.wall]

Thanks for your replies. We have had several instances this week where the physician has written an order to do the type and screen day of surgery. This just seems like we are asking for a disaster, but the OR director thinks lab is over reacting so I wanted to give her some data on the importance of having the type and screen done before the patient goes to surgery.

jerriemc -

It has been a while since I was running an active transfusion service but we offered physicians the 'oportunity' to order a pre-op antibody screen with the patient's other PAT work. Our approach was that if the antibody screen was negative we'd have some appropriate blood for the patient and the physician could have more confidence accepting 'uncrossmatche' blood if it was necessary. If the antibody screen was positive, we had the opportunity to work through what was going on and discuss issues with the physician. We didn't convert all the physicians but if someone did get 'caught' it didn't happen again.

Jeanne

[Brenda K Hutson]

Correction, both of those practices help "when/if" the Surgeons use them! And therein lies the problem faced by most Hospitals to some degree. We know what Best Practice is; however, the Physicians don't always follow that. I have had my Medical Directo at 2 different Institutions send letters out to ALL Physicians stating our Policy for specimen acceptance (i.e. how many days prior to surgery they can be drawn); and that if we do not receive a specimen until the day of surgery, we cannot guarantee we will have blood for their patient (thus putting the patient at risk). Then when I would receive one on the day of surgery and the patient had an antibody, I would write it up as a Hospital Quality Report to get my message across. And yet, there were still the Physicians that sent them on the day of surgery; then called every 2 minutes to "crank up the stress level a little" by telling you that if their patient dies, it is your fault! I say HA!!!!! Learn your lesson! :mad:

But that does not answer the initial question; and no, I have no such data.

Brenda Hutson, CLS(ASCP)SBB

I do not know of such data however I do have practicle knowledge of two policies/ practices, PAT and MSBOS. The PAT practice is established to ensure out-patient blood bank needs are met prior to thier surgery. It consists of an established time frame from which the specimen to be used for crossmatching is drawn until date of the surgery; in practice I've seen thirty days and twenty days, with certain criteria being met; ie no transfusion during this time, no pregnancy, and negative anitbody screen. If any one or combination of these criteria are not met then the patient would have to have a specimen drawn the date of surgery; this policy would be understood and implimented by the out-patient surgical staff such that the surgery would be delayed until compatible units were assigned.

The other policy/practice is MSBOS (I do not remember what this acrynim stands for), but this essentially is a minimum numbers of blood products needed for a specific surgical procedure and is established by your hospital surgeons and the blood bank medical director. This system is to ensure that a minimum number of blood products are ready for an in-patient surgical procedure.

Both of these practices help to maintain blood bank inventory. I hope this helps a little.

[AMcCord]

I have a well defined PAT policy that was once used quite effectively. Several years ago, the surgeons who were using the PAT visit decided it was an imposition and inconvenience for their patients...even if that patient was already going to be in house for a visit with Radiology or getting other lab work drawn. Even if an out-of-town patient was in town for a pre-surgical visit with the surgeon. We now see 99.98% of our surgical patients with Blood Bank orders less than 90 minutes (sometimes a lot less) before they are scheduled to be rolled back into the OR, and that's only if they show up in admitting at the time they have been told to show up.

Every time we have an antibody, we call the OR and document same. Every time there are issues related to the antibody - calls from the OR asking for blood, delay or cancellation of surgery, etc - I write a hospital occurrence report for the Quality folks to read. One orthopedist gets caught this way time after time after time. His comment is that "it's not his problem". I will welcome Joint Commission interest in this area with open arms. However, being the cynic that I am, I suspect that rather than seeing this as a physician order problem, it will be viewed here as a lab problem. Specifically, "Why does it take you guys so long to get a silly little crossmatch with 2 alloantibodies done. We read in one of our interesting little books that you should be able to do a crossmatch in ____ minutes (inserting whatever number they come up with)." Heavy Sigh!!! Thankfully we have always been able to pull the rabbit out of the hat, presto chango, here's some blood or the patient does OK through surgery and is transfused later.

[Brenda K Hutson]

Actually, should that Orthopedic Surgeon end up with a critically bleeding patient during one of his surgeries where he sent the specimen at the last minute, and the patient has antibodies, it absolutely will be his problem! And NO, I cannot imagine any regulatory agency faulting the Blood Bank for the "normal" amount of time it takes to perform an antibody identification. Now, if you take a lot longer than is reasonable, you may have to answer for that; but even then, Best Practice is that the patients have their Blood Bank Lab work performed before the day of surgery; period. With all of the regulatory agencies we have breathing down "our" necks, it is easy to become cynical and feel like everything is made out to be our fault. But those agencies are very much aware of what the Regulations are; what the Standard of Practice is; what Best Practice is; and what is a reasonable expectation.

Brenda Hutson

I have a well defined PAT policy that was once used quite effectively. Several years ago, the surgeons who were using the PAT visit decided it was an imposition and inconvenience for their patients...even if that patient was already going to be in house for a visit with Radiology or getting other lab work drawn. Even if an out-of-town patient was in town for a pre-surgical visit with the surgeon. We now see 99.98% of our surgical patients with Blood Bank orders less than 90 minutes (sometimes a lot less) before they are scheduled to be rolled back into the OR, and that's only if they show up in admitting at the time they have been told to show up.

Every time we have an antibody, we call the OR and document same. Every time there are issues related to the antibody - calls from the OR asking for blood, delay or cancellation of surgery, etc - I write a hospital occurrence report for the Quality folks to read. One orthopedist gets caught this way time after time after time. His comment is that "it's not his problem". I will welcome Joint Commission interest in this area with open arms. However, being the cynic that I am, I suspect that rather than seeing this as a physician order problem, it will be viewed here as a lab problem. Specifically, "Why does it take you guys so long to get a silly little crossmatch with 2 alloantibodies done. We read in one of our interesting little books that you should be able to do a crossmatch in ____ minutes (inserting whatever number they come up with)." Heavy Sigh!!! Thankfully we have always been able to pull the rabbit out of the hat, presto chango, here's some blood or the patient does OK through surgery and is transfused later.

[tbostock]

How timely. Just had one today; they had the patient "skip PST" where they would have automatically ordered a Type and Screen for a bowel resection. So this patient shows up today with 4 known alloantibodies (we caught it when we previewed the OR schedule yesterday afternoon). We sounded the alarm for OR to send us the specimen immediately when the patient arrived today, and they still questioned our "delay" in getting compatible units ready. I was waiting for them to say..."then just give us O Neg then". {{{{heavy sigh}}}}

[AMcCord]

Thanks for your reply Brenda. I guess I wasn't clear in my comment. Yes, absolutely the surgeon is responsible for his patient. Yes, absolutely the regulatory agencies know how things should work and will correctly identify where the problems lie. I know that we are doing the best we can do with the process in place.

The people I was referring to that will make it "Blood Banks fault" are OR managers and surgeons. They tend to look at a problem and decide what the solution is only from one viewpoint, their own. The processes are then set up accordingly and everyone else has to figure out how to work within those restrictions. Involving everyone who has a part in the entire process seems like such a logical thing to do, but it never seems to work that way. I guess it's human nature to be unable to see beyond the ends of our own noses.

Actually, should that Orthopedic Surgeon end up with a critically bleeding patient during one of his surgeries where he sent the specimen at the last minute, and the patient has antibodies, it absolutely will be his problem! And NO, I cannot imagine any regulatory agency faulting the Blood Bank for the "normal" amount of time it takes to perform an antibody identification. Now, if you take a lot longer than is reasonable, you may have to answer for that; but even then, Best Practice is that the patients have their Blood Bank Lab work performed before the day of surgery; period. With all of the regulatory agencies we have breathing down "our" necks, it is easy to become cynical and feel like everything is made out to be our fault. But those agencies are very much aware of what the Regulations are; what the Standard of Practice is; what Best Practice is; and what is a reasonable expectation.

Brenda Hutson