Feature Story

Blood pressure: New Q-Probe looks at types and screens for scheduled surgeries

September 2002
Karen Southwick

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."

AABB impact

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 months.

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 is clear."

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."

Flexible procedures

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 in October.

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 their seriousness.

"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.