(P-TS-98) Why Two When One Will Do: A Review of the Appropriateness of Uncrossmatched Emergency Release Units at a Level II Trauma Center

Background/Case Studies: Early transfusion of patients with severe bleeding can be lifesaving and Red Blood Cells (RBCs) sometimes must be emergently issued prior to obtaining a valid type and screen (T&S). This practice is not without risk. Transfusion of crossmatch incompatible RBCs can lead to serious transfusion reactions and death. Unnecessary transfusion of uncrossmatched (RBCs) strain the inventory of group O units. Despite good adherence to a policy for single unit transfusions for routine requests, most emergency requests were for two units. We evaluated this practice to determine whether two units were more appropriate than one unit for emergency released units.

Study

Design/Methods: From January 1, 2021, to December 31, 2021, all emergency release requests from our Emergency Department (ED) were assessed retrospectively. Efficiency of turnaround time was evaluated via the following parameters: ED triage time, CBC and T&S sample draw times, T&S result time, number of uncrossmatched units requested, unit dispense time from the blood bank, transfusion start times for each unit, pre- and post- hemoglobin values, time of crossmatch result, patient ABO, ABO of uncrossmatched units, and patient outcome (discharge, inpatient admission, or death).

Results/Findings: 20 patient encounters resulted in transfusion of uncrossmatched RBCs from January 1, 2021, to December 21, 2021, yielding 31 total uncrossmatched releases. 4 encounters (6 units) of O- RBCs and 7 encounters (10 units) of O+ RBCs were transfused to patients of a different ABO blood group. Two units of O- RBCs were not transfused and ultimately wasted. 4 encounters resulted in initiation of a Massive Transfusion Protocol and 4 patients expired in the same encounter. Evaluation of CBC turnaround times identified encounters where point of care hemoglobin assessments were being underutilized. Data was presented to the ED staff and education provided to decrease the number of uncrossmatched unit requests. Investigation of subsequent 2 unit emergency release order despite a physician note documenting an intention to order one unit led to the discovery that a certain order set defaulted to a request of 2 emergency release units. This order set is being changed to default to one unit.

Conclusions: Our review of practices associated with uncrossmatched emergency release units in a level II trauma center identified multiple areas for improvement - earlier T&S draws after triage, improved lab result turnaround times, release of a single uncrossmatched unit followed by one crossmatched unit for patients requiring multiple units, as well as identifying a fault in a computer order file. Close retrospective review of all emergency release requests will continue as part of this initiative.

Importance of research: Unnecessary uncrossmatched transfusions can be detrimental to a patient’s care and put on unnecessary strain on group O blood inventories. Mitigating that risk is paramount. We demonstrate that a careful retrospective review of all emergency released units can yield several areas for patient care improvement, and not only better adherence to the PBM paradigm of “Why two when one will do”.