Blood and blood-component transfusions have become part and parcel of the modern complex surgical practice due to blood loss during surgical procedures. According to the World Health Organization Blood Transfusion Safety Report, blood usage in operating rooms accounts for between 23 to 40 percent of all blood transfusions in developed countries.
In the United States, pre-transfusion testing of potential recipients is required before any routine transfusion and is an essential step in maximizing safe and effective transfusion outcomes for recipients.
The Mayo Clinic Hospital – Rochester Pre-Surgical Sample (PSS) Program allows patients who are scheduled for elective surgery, with no history of a pregnancy or blood transfusion in the preceding three months, to have their samples collected for pre-transfusion testing up to 56 days in advance of their scheduled surgery. This advanced testing allows ample time to investigate and resolve any serologic problems due to unexpected red-cell-directed antibodies. The efforts and processes implemented by the PSS Program were recently highlighted in the journal Transfusion.
According to Karafa Badjie, Mayo Clinic Transfusion Service Manager and first author on the paper, “Pre-surgical testing offers many benefits, including improved patient safety and efficiency in the process, reduced costs, and increased patient satisfactions, as potential surgical delays due to unexpected clinically significant red cell-directed antibodies can be mitigated.”
Upon assessing the PSS Program, Mayo Clinic discovered that the type-and-screen (TS) test completion rate in eligible patients before the morning of surgery was only 83 percent. This means that, on average, 17 percent of eligible patients did not have a TS completed by the day of surgery in contrast to the national median average of nine percent, according to a College of American Pathologists Q-TRACKS 2005 Survey. TS is one of the required pre-transfusion tests which determines the ABO and D blood grouping of the recipient and screening for unexpected clinically significant antibodies in the patient serum or plasma so that compatible blood components can be selected for transfusion.
In 2011, a team was charged to develop a standardized process, along with other process improvements, while ensuring no increase in transfusion-related events.
“The project to develop a standardized process was important, as our TS completion rate prior to surgery was inferior to national standards,” says Badjie. “However, the most important step in the process was about patient safety. This particular procedure was fraught with permutations that were inimical to patient safety. Too many patients, on average 35 patients a day, needed a pre-surgical sample drawn for compatibility testing on the morning of surgery.”
The team followed the DMAIC (define, measure, analyze, improve, and control) framework in appraising the effectiveness and efficiency of the “current state” process, including baseline data collection such as PSS TS completion rate, number of eligible patients needing a PSS TS on the day of surgery, benchmarking, standard surgical blood order (SSBO) utilization, and “future state” mapping.
The improved practice has improved the ordering process, reduced the risk for potential surgical delays, and has averted hundreds of thousands of dollars in waste and non-added-value costs to both Mayo Clinic and patients.
“Many patients were subjected to blood draws for type-and-screen tests for procedures that had zero chance of needing a blood transfusion. The corrective actions implemented resulted in averting those unnecessary and non-added-value services in the form of blood draws and testing to both patients and Mayo Clinic in employee time and materials or consumables,” adds Badjie.
Another startling result from the study was the amount of blood product inventory loss due to duplicate ordering and cross-matches that never get issued from the Mayo Clinic Blood Bank to operating rooms. Cross-matching refers to the testing that is performed prior to a blood transfusion in order to determine if the donor's blood is compatible with the blood of an intended recipient. Not issuing these cross-matches caused patients thousands of dollars in non-added-value cost in cross-match charges.
In relation to Mayo Clinic’s practice of working differently and always putting the needs of the patient’s first, this project has had a significant impact.
“This process improvement demonstrates how working differently can improve patient safety and enhance efficiencies by reducing cost and waste to impact desired goals and cost benefits of any practice guideline or procedure, which overall makes us competitive and affordable to attracting more patients,” says Badjie.
By using a quality-focused and data-driven approach to redesign and implement process enhancements and standards, Mayo’s new procedure improves the TS completion rate, blood product ordering, and utilization.
“Our new process propels transfusion in operating rooms toward evidence-based practice, improving efficiency and safety of our patients,” says Badjie.
In the first year after implementation of the new procedure 53 percent fewer patients needed blood drawn on the day of surgery, 24 percent fewer blood draws were needed, and 47 percent less blood product was wasted, saving substantial costs.