Prevention of surgical delays by pre-admission type and screen in patients with scheduled surgical procedures: improved efficiency.

Ideally, a patient’s blood samples are collected in advance of the intended transfusion to allow for the Type and Screen (T&S) test, that is, determination of the patient’s ABO group and Rh type and screening for unexpected, clinically significant allo-antibodies1. A standard T&S can be completed with 30 minutes. If the screen is negative, ABO-compatible blood from the local inventory can be cross-matched within a matter of minutes. By contrast, if the antibody screen is positive, further (sometimes extensive and time-consuming) work-up is necessary to determine the target antigen and clinical significance, and identifying antigen-negative units can be a lengthy and difficult process. So-called antibodies of “unclear clinical significance” (usually auto-antibodies with possible underlying allo-antibody) are especially problematic because these cases need to be sent to a reference laboratory, and the results may not be available for several days. At our hospital, T&S samples obtained from patients admitted on the same day as the planned surgery were traditionally sent to the Blood Bank on the morning of the surgery according to the practice of most institutions in the USA2. Indeed, in 2003 a College of American Pathologists Q-probe of 8,941 T&S tests in 108 institutions revealed that only 2,095 these cases (23% of total) were sent to the Blood Bank at least 3 days prior to the operation, allowing for adequate work-up3. This practice was recognised to result in an unwieldy amount of testing in the Blood Bank during the morning hours (when the bank is usually understaffed) and, consequently, cause delays in blood availability3–5. In many instances, the surgeon either had to take the risk of not being able to transfuse if needed or cancel and postpone surgery until the pre-transfusion testing was completed and cross-match compatible blood was obtained4,5. To address this problem, the Joint Commission has highlighted the importance of completing the pre-transfusion testing days before the operation is to be performed6. Indeed, many hospitals (especially large, academic institutions) have extended the time interval for collection of T&S samples to 30 days prior to surgery6. Monmouth Medical Center requires that T&S or type and cross-match (T&C) is done on patients who undergo operations in which significant blood loss is anticipated (the list of these operations is reviewed annually and approved by the Blood Utilisation Committee). In February 2013, we implemented a new pre-admission process that includes T&S testing for these patients at least 6, and no more than 28, days before the date of the elective surgery. Patients with a positive antibody screen are reported to the Anaesthesiology Department (an example of this report is shown in Figure 1) and surgeons are advised of the anticipated delay (if any). In this study, we examined the clinical utility of this approach based on 1 year of experience. Figure 1 Form to register the data of patients with positive antibody screen. Materials and methods The prospective study cohort comprised 2,544 patients scheduled to undergo elective surgery with required T&S (or T&C) at our Hospital between February 2013 and July 2014. Pre-admission T&S was performed 6 to 28 days before the date of the operation and then repeated on the day of the operation. A standard ABO and D (Rh) type was performed on a Galileo Echo (Immucor Capture-R Ready Screen solid phase system for detecting IgG antibodies, [Immucor, Norcross, GA, USA]). Patients with a positive antibody screen result from the Galileo Echo underwent a repeat screen using the MTS gel technique (MTS Anti-IgG Card -MicroTyping Systems, Pompano Beach, FL, USA). If the screen was again positive, the antibody was identified by the MTS gel technique using commercial red blood cell antibody identification panels phenotyped by the vendor. Samples with a non-specific Coombs’ reaction (consistent with an auto-antibody) were sent to our reference laboratory (American Red Cross) to rule out the possibility of an underlying allo-antibody. Patients with a positive screen were reported to the Anaesthesiology Department using a standardised form (Figure 1). In turn, the Anaesthesiology Department informed the patient’s physician of the findings and advised the surgeons of possible delays as appropriate. After approval by the Monmouth Medical Center Institutional Research Review Board, the positive screen forms (a total of 58 patients) were reviewed.