How rational is the crossmatching of blood in a pediatric emergency department?
J. Grupp-Phelan and R. R. Tanz
Division of Pediatric Emergency Medicine, Children's Memorial Hospital, Northwestern University Medical School, Chicago, IL, USA.
OBJECTIVE: To determine if typed and crossmatched blood ordered in a
pediatric emergency department (ED) is actually used for transfusion and if
some ordering patterns are not cost-effective. DESIGN: Retrospective
medical record review. Emergency department records and blood bank logs
were reviewed daily to identify patients who had a type and crossmatch
(T&C) ordered; inpatient records were then reviewed. A priori
diagnostic and patient care categories were determined. Physicians and
nurses providing care were unaware of the study. SETTING: An inner-city,
tertiary care, pediatric trauma center ED. PATIENTS: A consecutive sample
of ED patients who had a T&C ordered from October 1, 1993, through
January 31, 1994. INTERVENTIONS: None. MAIN OUTCOME MEASURES: Outcome
measures included age, general category of diagnosis, number of units of
blood crossmatched and transfused within 7 days, hemoglobin concentration
in the ED, surgical procedures in the operating room, and hospital charges
for typed and crossmatched blood. For trauma patients, the Pediatric Trauma
Score was recorded. The crossmatch-to-transfusion (C/T) ratio was
calculated for each diagnostic category (the typical C/T ratio for US
hospitals is 2). We calculated a new ratio, the patient-to-transfusion
(P/T) ratio, to correct for the transfusion of numerous units of blood in a
few patients. RESULTS: Two hundred eighty-two patients had 468 U of blood
typed and crossmatched. Fifty-six patients received a total of 110 U of
blood. The mean hemoglobin concentration was 81 g/L for patients who
received a transfusion and 117 g/L for patients who did not receive a
transfusion (P < .001). The C/T ratio for all patients was 4.3. The P/T
ratio for all patients was 5.3. Sixty-four surgery patients had 78 U of
blood typed and crossmatched; 1 U of blood was transfused to 1 patient,
yielding a C/T ratio of 78 and a P/T ratio of 64. Ninety-one units of blood
were typed and crossmatched for 38 major trauma patients; 20 U of blood
were transfused to 2 patients, 19 U were transfused to 1 patient with a
Pediatric Trauma Score of 4, and 1 U was transfused to a patient with a
Pediatric Trauma Score of 7. The C/T ratio for major trauma patients was
4.6, and the P/T ratio was 19. Forty-five children with
ventriculoperitoneal shunt problems had 51 U of blood typed and
crossmatched, but no blood was transfused. Children with sickle-cell
disease had a C/T ratio of 2.2 and a P/T ratio of 3.3; those with cancer
diagnoses had a C/T ratio of 1.6 and a P/T ratio of 1.3. During the 4-month
study period, the hospital charged $84,726 for these T&Cs. The charge
for T&Cs never used for transfusion was $65,643 (77.5%). CONCLUSIONS:
Most typed and crossmatched units of blood ordered in our pediatric ED were
never used for transfusion. The C/T and P/T ratios were high for many
diagnostic categories, suggesting inefficient blood ordering and patient
management. Transfusions were uncommon in children with the following
problems: ventriculoperitoneal shunt malfunction, virtually all surgical
diagnoses, cancer with a hemoglobin concentration greater than 105 g/L, and
trauma patients with a Pediatric Trauma Score of greater than 7.
