Transfusion Preparedness in the Labor and Delivery Unit: An Initiative to Improve Safety and Cost.

OBJECTIVE: To evaluate patient safety, resource utilization, and transfusion-related cost after a policy change from universal type and screen to selective type and screen on admission to labor and delivery. METHODS: Between October 2017 and September 2019, we performed a single-center implementation study focusing on risk-based type and screen instead of universal type and screen. Implementation of our policy was October 2018 and compared 1 year preimplementation with 1 year postimplementation. Patients were risk-stratified in alignment with California Maternal Quality Care Collaborative recommendations. Under the new policy, the blood bank holds a blood sample for processing (hold clot) on patients at low- and medium-risk of hemorrhage. Type and screen and crossmatch are obtained on high-risk patients or with a prior positive antibody screen. We collected patient outcomes, safety and cost data, and compliance and resource utilization metrics. Cost included direct costs of transfusion-related testing in the labor and delivery unit during the study period, from a health system perspective. RESULTS: In 1 year postimplementation, there were no differences in emergency-release transfusion events (4 vs 3, P>.99). There were fewer emergency-release red blood cell (RBC) units transfused (9 vs 24, P=.002) and O-negative RBC units transfused (8 vs 18, P=.016) postimplementation compared with preimplementation. Hysterectomies (0.05% vs 0.1%, P=.44) and intensive care unit admissions (0.45% vs 0.51%, P=.43) were not different postimplementation compared with preimplementation. Postimplementation, mean monthly type and screen-related costs (ABO typing, antibody screen, and antibody workup costs) were lower, $9,753 compared with $20,676 in the preimplementation year, P<.001. CONCLUSION: Implementation of selective type and screen policy in the labor and delivery unit was associated with projected annual savings of $181,000 in an institution with 4,000 deliveries per year, without evidence of increased maternal morbidity.

Routine group and save screening prior to emergency laparoscopic surgery.

INTRODUCTION: Two group and save (G&S) samples are routinely collected from patients undergoing diagnostic laparoscopy and/or emergency appendicectomy. We aimed to identify the necessity of this practice by looking at the perioperative transfusion rates. METHODS: Data were obtained from our electronic theatre system for all patients who underwent emergency laparoscopic surgery (specifically diagnostic laparoscopy and/or laparoscopic appendicectomy) between January 2017 and December 2018. Records were reviewed for the number of G&S samples sent and perioperative transfusion rates. RESULTS: A total of 451 patients were included in the study. The numbers of procedures performed in 2017 and 2018 were 202 (44.8%) and 249 (55.2%), respectively. The total number of samples sent was 930. Only 786 (84.5%) samples were processed and the rest were rejected for various reasons. Of the 451 patients included in the study, 308 (68.3%) had two G&S samples sent, whereas 41 patients (9.1%) had only one G&S sample sent. Fifty-six (12.4%) and 20 (4.4%) patients had three and four G&S samples sent, respectively. Only two patients required transfusion perioperatively (0.4%), and the indication in both was irrelevant to the primary operation. CONCLUSIONS: These results demonstrate a near-zero transfusion rate in this patient cohort. Omitting G&S is safe and potentially saves time and resources.

Prevalence of clinically significant antibodies in patients undergoing elective surgery in a Nigerian teaching hospital: A case for the type and screen method.

BACKGROUND: Provision of safe and adequate blood is challenging in our environment due to paucity of voluntary donors as well as inappropriate blood ordering and utilization. The type and screen (TS) method (typing of blood group and screening for antibodies) reduces the demand for blood reservation in hospital blood banks. AIMS: The aim of this study is to determine the safety (detection clinically significant antibodies) and cost effectiveness of the TS method compared to the conventional antiglobulin crossmatch (ACM). SETTINGS AND DESIGN AND METHODS: This was a cross-sectional prospective study carried out at the University of Port Harcourt Teaching Hospital (UPTH). 124 participants booked for elective surgeries with no history of blood transfusion or pregnancy were investigated. ACM was performed on all participants' serum against 159 donor red cells. TS was also performed blindly on the same participants' sera, antibody screening was done with three-screen-cells using the gel method. An 11-cell panel was used for antibody identification. Blood utilization was calculated using the crossmatch: transfusion ratio (CTR), probability of transfusion (%T) and transfusion index (TI). RESULTS: Out of the 159 units crossmatched for 124 study participants, only 19 were actually transfused (88.1% not utilized). The prevalence of compatible ACM was 100%, however the TS detected one antibody (0.81%) in a male participant identified as anti-M. The overall CTR, %T and TI were 8.4, 15.6% and 0.16 respectively, with N384,750 ($963.1) wastage in terms of cost. The TS method would have saved N266,000{$665.9} (N1900{4.78} per un-transfused patient). CONCLUSIONS: There was improper utilization of blood in elective surgeries. The TS method identified an antibody not detected by ACM. This would have saved N266,000 {$665.9}, and reduced the demand for blood reservation in the bank. Although The TS method was found not to be significantly different in outcome compared to the ACM, it was found to be cost effective.

Benefits of VISION Max automated cross-matching in comparison with manual cross-matching: A multidimensional analysis.

BACKGROUND: VISION Max (Ortho-Clinical Diagnostics, Raritan, NJ, USA) is a newly introduced automated blood bank system. Cross-matching (XM) is an important test confirming safety by simulating reaction between packed Red Blood Cells (RBCs) and patient blood in vitro before transfusion. We assessed the benefits of VISION Max automated XM (A-XM) in comparison with those of manual XM (M-XM) by using multidimensional analysis (cost-effectiveness and quality improvement). MATERIALS AND METHODS: In a total of 327 tests (130 patients), results from A-XM and M-XM were compared. We assessed the concordance rate, risk priority number (RPN), turnaround time, hands-on time, and the costs of both methods. We further simulated their annual effects based on 37,937 XM tests in 2018. RESULTS: The concordance rate between A-XM and M-XM was 97.9% (320/327, kappa = 0.83), and the seven discordant results were incompatible for transfusion in A-XM, while compatible for transfusion in M-XM. None of the results was incompatible for transfusion in A-XM, while compatible for transfusion in M-XM, meaning A-XM detect agglutination more sensitively and consequently provides a more safe result than M-XM. A-XM was estimated to have a 6.3-fold lower risk (229 vs. 1,435 RPN), shorter turnaround time (19.1 vs. 23.3 min, P < 0.0001), shorter hands-on time (1.1 vs. 5.3 min, P < 0.0001), and lower costs per single test than M-XM (1.44 vs. 2.70 USD). A-XM permitted annual savings of 46 million RPN, 15.1 months of daytime workers' labor, and 47,042 USD compared with M-XM. CONCLUSION: This is the first attempt to implement A-XM using VISION Max. VISION Max A-XM appears to be a safe, practical, and reliable alternative for pre-transfusion workflow with the potential to improve quality and cost-effectiveness in the blood bank.

Saving Blood and Reducing Costs: Updating Blood Transfusion Practice in Lower Limb Arthroplasty

Aim Our aim was to quantify blood transfusion rates in lower limb arthroplasty following the introduction of a multimodal enhanced recovery programme (ERP). We then sought to update the maximum surgical blood ordering schedule (MSBOS) and calculate cost savings achieved. Methods A retrospective cohort study was conducted of all patients who required blood transfusion following primary and revision total hip and knee arthroplasty in 2012 and 2015. A multimodal ERP was introduced in 2015. Cost savings were calculated following the introduction of a new MSBOS. Results During the two-year study period 1467 lower limb arthroplasty procedures were performed. The cross-match to transfusion ratio was 3.6:1 in 2012 and 9.9:1 in 2015. The updated MSBOS resulted in a 46% reduction of cross-matched blood and savings of €54,375 per annum. Conclusion Improved perioperative management in lower limb arthroplasty has reduced blood transfusion rates. Updating blood transfusion practice can result in considerable savings in blood, resources and costs.

Weak D Testing is not Required for D- Patients With C-E- Phenotype.

BACKGROUND: Although testing to detect weak D antigens using the antihuman globulin reagent is not required for D- patients in many countries, it is routinely performed in Korea. However, weak D testing can be omitted in D- patients with a C-E- phenotype as this indicates complete deletion of the RHD gene, except in rare cases. We designed a new algorithm for weak D testing, which consisted of RhCE phenotyping followed by weak D testing in C+ or E+ samples, and compared it with the current algorithm with respect to time and cost-effectiveness. METHODS: In this retrospective study, 74,889 test results from January to July 2017 in a tertiary hospital in Korea were analyzed. Agreement between the current and proposed algorithms was evaluated, and total number of tests, time required for testing, and test costs were compared. With both algorithms, RHD genotyping was conducted for samples that were C+ or E+ and negative for weak D testing. RESULTS: The algorithms showed perfect agreement (agreement=100%; κ=1.00). By applying the proposed algorithm, 29.56% (115/389 tests/yr) of tests could be omitted, time required for testing could be reduced by 36% (8,672/24,084 min/yr), and the test cost could be reduced by 16.53% (536.11/3,241.08 USD/yr). CONCLUSIONS: Our algorithm omitting weak D testing in D- patients with C-E- phenotype may be a cost-effective testing strategy in Korea.

A preoperative risk score for transfusion in infrarenal endovascular aneurysm repair to avoid type and cross.

OBJECTIVE: Preoperative type and cross are often routinely ordered before elective endovascular aneurysm repair (EVAR), but the cost of this practice is high, and transfusion is rare. We therefore aimed to stratify patients by their risk of transfusion to identify a cohort in whom a type and screen would be sufficient. METHODS: We queried the targeted vascular module of the National Surgical Quality Improvement Program (NSQIP) for all elective EVARs from 2011 to 2015. We included only infrarenal aneurysms and excluded ruptured aneurysms and patients transfused within 72 hours preoperatively. Two-thirds of the cases were randomly assigned to a model derivation cohort and one third to a validation cohort. We created and subsequently validated a risk model for transfusion within the first 24 hours of surgery (including intraoperatively), using logistic regression. RESULTS: Between 2011 and 2015, there were 4875 patients who underwent elective infrarenal EVAR, only 221 (4.5%) of whom received a transfusion within 24 hours of surgery. The frequency of transfusion during the study period declined monotonously from 6.5% in 2011 to 3.2% in 2015. The factors independently associated with transfusion were preoperative hematocrit <36% (odds ratio [OR], 3.4 [95% confidence interval, 2.1-5.4]; P < .001), aortic diameter (per centimeter increase: OR, 1.2 [1.03-1.4]; P = .02), preoperative dependent functional status (OR, 2.5 [1.1-5.5]; P = .03), and chronic obstructive pulmonary disease (OR, 1.7 [1.04-2.9]; P = .04). A risk prediction model based on these criteria produced a C statistic of 0.69 in the prediction cohort and 0.76 in the validation cohort and a Hosmer-Lemeshow goodness of fit of 0.62 and 0.14, respectively. A score of <3 of 9, corresponding to a <5% probability of transfusion, would avoid preoperative type and cross in 86% of patients. Of the 4203 patients (86%) with a hematocrit >36%, only 6 (0.1%) had a risk score of >3. CONCLUSIONS: Perioperative transfusion for EVAR is becoming increasingly uncommon and is predicted well by a transfusion risk score or simply a hematocrit of <36%. Application of this risk score would avoid unnecessary type and cross in the majority of patients, leading to significant savings in both time and cost.

Transfusion Preparedness Strategies for Obstetric Hemorrhage: A Cost-Effectiveness Analysis.

OBJECTIVE: To evaluate the cost-effectiveness of common obstetric transfusion preparedness strategies to prevent emergency-release transfusions. METHODS: A decision analytic model compared five commonly used transfusion preparedness strategies in a general obstetric population. Patients were classified as being at low, moderate, or high risk for transfusion. The most prepared strategy used a policy of universal type and screen plus crossmatch for high-risk patients. Other strategies used universal type and screen only, universal hold clot plus crossmatch for high-risk patients, selective type and screen only in high-risk patients, or no routine admission testing. Strategies were compared using transfusion-related cost and probability estimates derived from patient-level data and from the published literature. The primary outcome was incremental cost per emergency-release transfusion prevented. A strategy was considered cost-effective if the cost was less than $1,500 per emergency-release transfusion avoided as determined by expert consensus. Emergency-release transfusion included universal donor or type-specific packed red cells that are not crossmatched to the recipient. Along with the base-case analyses, we also conducted one- and two-way sensitivity analyses and probabilistic sensitivity analyses using second-order Monte Carlo simulation. Variability in the willingness-to-pay threshold was explored in a cost-effectiveness acceptability analysis. The model was conducted from a hospital perspective. RESULTS: In the base-case analysis, the strategy of universal type and screen with crossmatch for high-risk patients yielded an incremental cost of $115,541 per emergency-release transfusion prevented compared with a strategy of universal hold clot. The universal hold clot strategy yielded a cost of $2,878 per emergency-release transfusion prevented compared with a strategy of no routine admission testing. Strategies using universal type and screen were cost-effective in zero of the 10,000 simulations at a willingness-to-pay threshold of $1,500 per emergency-release transfusion prevented. Even at willingness to pay greater than $10,000 to prevent an emergency-release transfusion, universal type and screen strategies were not cost-effective. CONCLUSION: Transfusion preparedness with universal type and screen is not cost-effective in a general obstetric population across a wide range of assumptions and variable ranges.

Overuse of preoperative laboratory coagulation testing and ABO blood typing: a French national study.

Background: Following publication of guidelines on routine preoperative tests, the French Society of Anaesthesiology and Intensive Care (SFAR), in association with French national public health insurance, conducted a survey to evaluate adherence to guidelines and the economic consequences. Methods: Using the French Hospital Discharge Database and National Health Insurance Information system, tests performed during the 30 days before surgery were analysed for two situations: (1) standard laboratory coagulation tests and ABO blood typing in children able to walk and scheduled for tonsillectomy/adenoidectomy; and (2) ABO blood typing in adults before laparoscopic cholecystectomy, thyroidectomy, lumbar discectomy or breast surgery. Guidelines do not recommend any preoperative tests in these settings. Results: Between 2013 and 2015, a coagulation test was performed in 49% of the 241 017 children who underwent tonsillectomy and 39% of the 133 790 children who underwent adenoidectomy. A similar pattern was observed for ABO blood typing although re-operation rates for bleeding on the first postoperative day were very low (0.12-0.31% for tonsillectomy and 0.01-0.02% for adenoidectomy). Between 2012 and 2015, ABO blood typing was performed in 32-45% of the 1 114 082 patients who underwent one of the four selected procedures. The transfusion rate was very low (0.02-0.31%). The mean cost for the four procedures over the 4 yr period was €5 310 000 (sd €325 000). Conclusions: Standard laboratory coagulation tests and ABO blood typing are still routinely prescribed before surgery and anaesthesia despite current guidelines. This over-prescription represents a high and unnecessary cost, and should therefore be addressed.

Medical and economic implications of strategies to prevent alloimmunization in sickle cell disease.

BACKGROUND: The pathogenesis of alloimmunization is not well understood, and initiatives that aim to reduce the incidence of alloimmunization are generally expensive and either ineffective or unproven. In this review, we summarize the current medical literature regarding alloimmunization in the sickle cell disease (SCD) population, with a special focus on the financial implications of different approaches to prevent alloimmunization. STUDY DESIGN AND METHODS: A review of EMBASE and MEDLINE data from January 2006 through January 2016 was conducted to identify articles relating to complications of SCD. The search was specifically designed to capture articles that evaluated the costs of various strategies to prevent alloimmunization and its sequelae. RESULTS: Currently, there is no proven, inexpensive way to prevent alloimmunization among individuals with SCD. Serologic matching programs are not uniformly successful in preventing alloimmunization, particularly to Rh antigens, because of the high frequency of variant Rh alleles in the SCD population. A genotypic matching program could offer some cost savings compared to a serologic matching program, but the efficacy of gene matching for the prevention of alloimmunization is largely unproven, and large-scale implementation could be expensive. CONCLUSIONS: Future reductions in the costs associated with genotype matching could make a large-scale program economically feasible. Novel techniques to identify patients at highest risk for alloimmunization could improve the cost effectiveness of antigen matching programs. A clinical trial comparing the efficacy of serologic matching to genotype matching would be informative.

Serological weak D phenotypes: a review and guidance for interpreting the RhD blood type using the RHD genotype.

Approximately 0·2-1% of routine RhD blood typings result in a "serological weak D phenotype." For more than 50 years, serological weak D phenotypes have been managed by policies to protect RhD-negative women of child-bearing potential from exposure to weak D antigens. Typically, blood donors with a serological weak D phenotype have been managed as RhD-positive, in contrast to transfusion recipients and pregnant women, who have been managed as RhD-negative. Most serological weak D phenotypes in Caucasians express molecularly defined weak D types 1, 2 or 3 and can be managed safely as RhD-positive, eliminating unnecessary injections of Rh immune globulin and conserving limited supplies of RhD-negative RBCs. If laboratories in the UK, Ireland and other European countries validated the use of potent anti-D reagents to result in weak D types 1, 2 and 3 typing initially as RhD-positive, such laboratory results would not require further testing. When serological weak D phenotypes are detected, laboratories should complete RhD testing by determining RHD genotypes (internally or by referral). Individuals with a serological weak D phenotype should be managed as RhD-positive or RhD-negative, according to their RHD genotype.

Development of a risk prediction model for transfusion in carotid endarterectomy and demonstration of cost-saving potential by avoidance of "type and screen".

OBJECTIVE: Preoperative testing for carotid endarterectomy (CEA) often includes blood typing and antibody screen (T&S). In our institutional experience, however, transfusion for CEA is rare. We assessed transfusion rate and risk factors in a national clinical database to identify a cohort of patients in whom T&S can safely be avoided with the potential for substantial cost savings. METHODS: With use of the National Surgical Quality Improvement Program database, transfusion events and timing were established for all elective CEAs in 2012-2013. Comorbidities and other characteristics were compared for patients receiving intraoperative or postoperative transfusion and those who did not. After random assignment of the total data to either a training or validation set, a prediction model for transfusion risk was created and subsequently validated. RESULTS: Of 16,043 patients undergoing CEA in 2012-2013, 276 received at least one transfusion before discharge (1.7%); 42% of transfusions occurred on the day of surgery. Preoperative hematocrit <30% (odds ratio [OR], 57.4; 95% confidence interval [CI], 29.6-111.1), history of congestive heart failure (OR, 2.8; 95% CI, 1.1-7.1), dependent functional status (OR, 2.7; 95% CI, 1.5-5.1), coagulopathy (OR, 2.5; 95% CI, 1.7-3.6), creatinine concentration ≥1.2 mg/dL (OR, 2.3; 95% CI, 1.6-3.3), preoperative dyspnea (OR, 2.0; 95% CI, 1.4-3.1), and female gender (OR, 1.6; 95% CI, 1.1-2.3) predicted transfusion. A risk prediction model based on these data produced a C statistic of 0.85; application of this model to the validation set demonstrated a C statistic of 0.81. In the validation set, 93% of patients received a score of 6 or less, corresponding to an individual predicted transfusion risk of 5% or less. Omitting a T&S in these patients would generate a substantial annual cost saving for National Surgical Quality Improvement Program hospitals. CONCLUSIONS: Whereas T&S are commonly performed for patients undergoing CEA, transfusion after CEA is rare and well predicted by a transfusion risk score. Avoidance of T&S in this low-risk population provides a substantial cost-saving opportunity without compromise of patient care.

Rapid and inexpensive blood typing on thermoplastic chips.

A portable and cost-effective colorimetric diagnostic device was fabricated for rapid ABO and Rh blood typing. Using microfluidic construction on a thermoplastic chip, blood antibodies were preloaded into a reaction channel and exposed to blood samples to initiate a haemagglutination reaction. Downstream high-aspect ratio filters, composed of 2 µm high microslits, block agglutinated red blood cells (RBCs) to turn the reaction channel red, indicating the presence of the corresponding blood antigen. Users manually actuate the blood sample using a simple screw pump that drives the solution through serpentine reaction channels and chaotic micromixers for maximum interaction of the preloaded antibodies with the blood sample antigens. Mismatched RBCs and antibodies elute from the channel into an outlet reservoir based on the rheological properties of RBCs with no colorimetric change. As a result, unambiguous blood typing tests can be distinguished by the naked eye in as little as 1 min. Blood disorders, such as thalassemia, can also be distinguished using the device. The required blood volume for the test is just 1 µL, which can be obtained by the less invasive finger pricking method. The low reagent consumption, manual driving force, low-cost of parts, high yield, and robust fabrication process make this device sensitive, accurate, and simple enough to use without specialized training in resource constrained settings.

Blood grouping based on PCR methods and agarose gel electrophoresis.

The study of erythrocyte antigens continues to be an intense field of research, particularly after the development of molecular testing methods. More than 300 specificities have been described by the International Society for Blood Transfusion as belonging to 33 blood group systems. The polymerase chain reaction (PCR) is a central tool for red blood cells (RBC) genotyping. PCR and agarose gel electrophoresis are low cost, easy, and versatile in vitro methods for amplifying defined target DNA (RBC polymorphic region). Multiplex-PCR, AS-PCR (Specific Allele Polymerase Chain Reaction), and RFLP-PCR (Restriction Fragment Length Polymorphism-Polymerase Chain Reaction) techniques are usually to identify RBC polymorphisms. Furthermore, it is an easy methodology to implement. This chapter describes the PCR methodology and agarose gel electrophoresis to identify the polymorphisms of the Kell, Duffy, Kidd, and MNS blood group systems.

Is a preoperative group and save necessary for enhanced recovery joint replacement patients?

AIM: To consider the financial benefit to the authors' trust of omitting a preoperative group and save in enhanced recovery arthroplasty patients, and to estimate the scope for national savings. Patient safety was considered to determine acceptability for routine practice. METHODS: A total of 121 patients receiving a total knee replacement or total hip replacement on the authors' enhanced recovery protocol were selected. Pre- and postoperative haemoglobin levels were obtained. The transfusion team were contacted when the postoperative haemoglobin level was ≤8 g/dl to determine whether blood products had been issued. Costs for group and save were obtained from the pathology department. RESULTS: Mean postoperative reduction in haemoglobin level was 2.6 g/dl (P≤0.001) and 2.1 g/dl (P≤0.001) for total hip replacement and total knee replacement respectively. No patients were transfused. One group and save costs £12.00, and omission of this test in these patients would have saved £1452.00. Potentially, £1 605 408 could have been saved in the 133 784 patients undergoing NHS arthroplasty in 2012. Group and save omission would not affect management of intraoperative haemorrhage where O negative blood would be available. If a transfusion is required postoperatively it would take 100 minutes to issue crossmatched blood - a time delay unlikely to compromise patient safety. CONCLUSIONS: These results suggest that a preoperative group and save could be omitted in arthroplasty patients on this enhanced recovery programme to prevent needless expenditure, but more long-term follow up is required to ensure patients are not put at risk.

Monoclonal antibodies and the transformation of blood typing.

Today, when monoclonal antibodies (mAbs) have become one of the most important classes of therapeutic drugs, it is easy to forget how much they have transformed our healthcare in other ways. One of the first clinical areas, as this paper shows, where mAbs made their mark was in the field of blood typing. The adoption of mAbs for this purpose was done with little public fanfare or funding. Nonetheless, it radically transformed the accuracy and cost of blood typing and shifted the procedure away from a dependence on reagents made from human blood donated by volunteers. This paper argues that the development of mAbs as reagents for blood typing laid the foundation for the first large-scale production of mAbs thereby paving the way to the advent of mAb diagnostics and therapeutics.

Rationalising cross-match requests in vascular surgery is safe and cost effective.

This study describes how a vascular centre rationalised their blood transfusion policy. A multidisciplinary panel reviewed data for blood transfusion protocols and implemented improvements that were analysed. The number of units cross-matched fell from 272 to 183 over a six month period. Unused blood reduced from 80% to 61%. The study concluded that rationalisation of cross matching policies is safe and provides cost and resource benefits.