78th Annual PostGraduate Assembly in Anesthesiology (PGA78) 2024

Purpose

The necessity of an active type and screen for a scheduled surgical procedure may not always be agreed upon by all members of the peri-operative staff. Current institution guidelines can be subject to interpretation based on the perceived relative risk of the procedure. The lack of an immediately available type and screen in the perioperative period where blood product transfusion is indicated can result in an increase in the utilization of emergency uncrossmatchedproducts, posing certain risks to the patients and resource burdens to the blood bank that could be avoided in scheduled surgical procedures.

Study Aims:

- Investigate the incidence of emergency blood transfusions

- Evaluate the result time of Type and Screens and barriers to meeting the institutional standard of result time within 90 minutes

- Increase the % of T&S resulted prior to case start in OR

Investigation Methods

Emergency Blood Orders Chart Review Jan 2021- Aug 2023
Classified by service
Filtered as ED admit vs outpatient admit
Type and Screen Orders Oct 2023- Dec 2023
Classified by service
T&S result times of 45 min, 90 min, 100 min, 120 min
Chart review of NSGY cases where emergency blood was transfused; when T&S resulted after case end

Blood Order Results

	T&S + ABO Confirmation Order Count	Yes	No
Specimen Received Before Case Start?	2771	93.08%	6.92%
T&S Resulted before Case Start?	2458	82.57%	17.43%
T&S Resulted before Case End?	2836	95.26%	4.74%
T&S Resulted within 45min of Specimen Received?	539	18.11%	81.89%
T&S Resulted within 1hr of Specimen Received?	1255	42.16%	57.84%
T&S Resulted within 90min of Specimen Received?	2407	80.85%	19.15%
T&S Resulted within 100min of Specimen Received?	2543	85.42%	14.58%
T&S Resulted within 120min of Specimen Received?	2729	91.67%	8.33%

Figure 1: Current T&S Perioperative Guidelines

LOW RISK SURGERY (e.g. Breast biopsy, similar minor and superficial procedures, cataracts, screening endoscopy, diagnostic angiogram, vein stripping) --> Regardless of patient co-morbidities: Routine screening labs are NOT recommended or required

NTERMEDIATE RISK SURGERY (e.g. Intraabdominal, intrathoracic, intracranial non-vascular, carotid, vascular infra- inguinal, head and neck, orthopedic, or prostate surgery)

T&S recommended if significant blood loss possible, if patient has a bleeding history

HIGH-RISK SURGERY (e.g. Open Aortic, Major vascular, Major thoracic, Intracranial vascular, Intracranial Re-do Procedure)

T&S always recommended

Figure 2: Infographic on Proper Type and Screen Collection

We have found that truncated labels and inadequately filled tubes account for the majority of delays that result in use of emergency uncrossmatched blood, increasing the rate of complications. We are hoping to decrease these delays with all of your help utilizing the following few steps:

1. Sufficient Quantity

Adults: Draw 2-6mL of blood in the collection tubes (always prefer a larger volume)

Peds: Draw 1 mL per tube

2. ENSURE the label has the full name and MRN of the patient.

3. ENSURE label has Collection Date and Time .

3. IF the machine doesn't print the full MRN and name of the patient, use the patient sticker and label it with the collection time/date AND your initials.

Proposed Solutions

Safety Events Dashboard for Blood Bank
Keep records of any safety incidents reported regarding type and screen
Categorize common reasons for T&S results delays
Examples) Identify percentage of specimen tubes truncated, percentage of tubes not adequately filled, length of time taken for specimen to be delivered to the blood bank since being drawn from the patient
Clarify Department Specific Guidelines on T&S Ordering
Educate specific surgical departments regarding bleeding risks associated with their procedure and need for pre-op T&S to be ordered
Examples) Craniotomies in NSGY, Uterine myomectomies in GYN Surgery
Perioperative Staff Education (Figure 2)
In-service education and infographics for perioperative nursing and patient assistant staff regarding proper labeling of T&S tubes

Future Directions

Evaluate the percentage of perioperative type and screens that took longer than 90 minutes to result after 3 months of intervention, categorized into delay reason
Develop institutional perioperative guideline handbook to delineate the need for type and screen for each surgical department and surgical procedure based on historic needs for transfusion

Abbreviations: T&S: type and screen, NSGY: neurosurgery, GYN: gynecology

78th Annual PostGraduate Assembly in Anesthesiology (PGA78) 2024

Improving Type and Screen Result Time

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