CLINICAL GUIDELINE FOR MAXIMUM SURGICAL BLOOD ORDER SCHEDULE (MSBOS) Summary. Start Elective procedure identified, blood requirement listed in guideline Patient attends PAC and has a group and screen (G&S) taken G&S tested in transfusion lab Patient appropriate for electronic issue Yes No G&S taken on admission as required (detail in guideline) G&S taken several days prior to allow crossmatch (detail in guideline) Page 1 of 14 Page 1 of 14
Aim/Purpose of this Guideline 1.1. The MSBOS is a guide to help ensure that blood is available at elective surgery. 1.2. This guidance is not absolute: factors other than the type of surgery (low Hb, antiplatelet drugs, bleeding tendency, previous surgery, co-morbidities etc) should be considered with respect to both the choice of hospital site and the availability of crossmatch. Page 2 of 14 Page 2 of 14
1. The Guidance 1.1. Important Information: 1.2. There must be a valid Group and Antibody Screen (G+S) specimen in the lab to supply any blood except emergency O Rh D neg 1.3. Emergency O Rh D neg may not be suitable for patients with antibodies 1.4. A G+S specimen is valid for a maximum of 7 days (3 days if transfused or pregnant in the last three months) 1.5. The sole function of a G+S specimen taken in a pre-operative assessment clinic is to identify the presence of red cell antibodies and allow appropriate planning (ie order in antigen negative red cells which may need to come from Bristol). It does not contribute to the availability of blood at surgery for which a specimen < 7 days old must be available 1.6. If there is a risk of significant blood loss at surgery for any procedure then a valid G+S specimen should be supplied within the 7 days preceding surgery. 1.7. Electronic Issued (EI) Red Cells 1.8. Electronic issue is the supply of blood on the basis of an automated confirmed blood group and a negative antibody screen performed. Blood does not need to be crossmatched and so can be dispensed within five minutes of request. A valid sample must be available in the laboratory. 1.9. Electronic issue is only allowable where a patient s plasma does not contain (or has not been known to contain) red cell antibodies, where there is no history of a solid organ transplant, and where there has been sufficient time for a valid (<7day old) sample to be grouped and screened by analyser (two hours minimum). Where these criteria are not met, a full manual crossmatch must be performed. 1.10. If surgery proceeds and blood loss occurs before this automated check is performed then crossmatched blood should be requested and this takes 45 min. 1.11. If blood is required within 45 mins, group specific blood can be supplied within 15 mins. Telephone the lab on ext 2500 to organise this. 1.12. Antibodies 1.13. When an antibody has been identified in the pre-op assessment clinic it is the responsibility of this clinic to ensure a valid G+S specimen, and crossmatched blood if necessary, is made available for surgery. This MSBOS advises how many units should be ordered in. This should be done at least a day before surgery. 1.14. Blood availability Page 3 of 14 Page 3 of 14
1.15. In the absence of antibody it is the responsibility of the surgeon to supply a G+S specimen if considered necessary 1.16. If no antibodies are present this sample may be taken on admission 1.17. In the event of blood loss patients first on the list will require manual crossmatch 1.18. If essential emergency O neg and group specific blood is available during the interval between receipt of a G+S specimen and crossmatched or electronic issued blood becoming available 1.19. Be aware that there is a small risk that patients may have made antibodies since the PAC sample, particularly if transfused in the meantime. 1.20. For very low risk procedures a G+S specimen is not required. 1.21. Surgery at St Michaels and West Cornwall 1.21.1. The G+S specimen must be supplied to the RCH site. If there is a risk of requiring transfusion consideration should be given whether it is appropriate for surgery on that site. There may be a lower threshold for taking a G+S specimen, and it is wise to ensure this G+S specimen arrives at the laboratory before the commencement of surgery. The time required for transport will delay availability. The case mix at WCH and SMH would suggest that this delay is acceptable. 1.22. Revision THR at St. Michaels Hospital 1.23. Patients should be selected on the following basis: ASA1 and ASA2 (unless low grade ASA3) Pre-optimised with Hb > 120g/l women and > 130g/L men. This must be a FBC within 1 month of surgery and checked before surgery commences. No contra-indication to using intra-operative cell salvage No antibodies on PAC G&S 1.24. O neg blood is available as follows: WCH 2 units SMH 2 units RCHT Transfusion lab 2 units Main theatre 2 units Trauma theatre 2 units Maternity 2 units + neonatal emergency unit Duchy Hospital 2 units Page 4 of 14 Page 4 of 14
NB if Ab detected blood must be requested well in advance as it may have to come from Bristol. If there is a particular individual risk of significant blood loss (eg low Hb, clotting risk, previous surgery etc), consider triage to RCHT and err on the side of ensuring a G+S specimen is available ahead of surgery NB this pre-op clinic specimen serves as an antibody screen and does not mean that e-matched blood will be available at surgery Pre op clinic On day of surgery GENERAL SURGERY WCH / SMH RCHT If antibodies detected Abdominal-perineal resection G & S G & S 2 UNITS Cholecystectomy G & S 2 UNITS Colectomy G & S G & S Gastrectomy - Partial G & S G & S Hemicolectomy G & S G & S Laparotomy (Malignancy or Crohn s) G & S G & S 2 UNITS BREAST VASCULAR Anterior resection rectum G & S G & S 2 UNITS Pan-proctocolectomy G & S G & S 2 UNITS Splenectomy G & S G & S 4 UNITS Major reconstruction G & S 2 UNITS Mastectomy G & S 2 UNITS Aneurysm G & S G & S 4 UNITS Aorto-femoral graft G & S G & S 4 UNITS Carotid G & S G & S 2 UNITS Femoral-popliteal graft G & S G & S 2 UNITS Profundaplasty G & S G & S 2 UNITS BKA G & S G & S 2 UNITS AKA G & S G & S 2 UNITS EVAR G & S G & S 4 UNITS NB for MAJOR emergency blood loss eg for aortic aneurysm rupture a massive haemorrhage pack should be requested and consists of: Pack A: Pack B Pack C 4 units RBC + 4 units FFP 4 units RBC, 4 FFP + 1 platelets 4 units RBC, 4 FFP, 1 unit platelets and 2 pools cryo Pack C repeats until lab is stood down Page 5 of 14 Page 5 of 14
NB if Ab detected blood must be requested well in advance as it may have to come from Bristol. If there is a particular individual risk of significant blood loss (eg low Hb, clotting risk, previous surgery etc), consider triage to RCHT and err on the side of ensuring a G+S specimen is available ahead of surgery NB this pre-op clinic specimen serves as an antibody screen and does not mean that e-matched blood will be available at surgery OBSTETRICS AND GYNAECOLOGY Pre op clinic On day of surgery WCH / SMH RCHT If antibodies detected APH / PPH G & S 2 UNITS APH (significant) 2 UNITS (variable) 2 UNITS Caesarean section (LSCS) G & S G & S 2 UNITS ERPC (D+C) G & S G+S Ectopic pregnancy - if ruptured G & S 4 UNITS - laparotomy G & S 2 UNITS Hysterectomy - total abdominal G & S G & S 2 UNITS - vaginal G & S G & S 2 UNITS - laparoscopic G & S G & S 2 UNITS - radical for vaginal cancer G & S G & S 2 UNITS Laparotomy for advanced ovarian G & S G & S 2 UNITS cancer Myomectomy G & S G & S 2 UNITS Oophorectomy (cyst) - benign G & S G & S 2 UNITS Placenta praevia G & S 2 UNITS Placenta removal - manual G & S 2 UNITS Termination (TOP) G & S G & S 2 UNITS Trial of scar G & S 2 UNITS Vaginal prolapse repair G & S G & S 2 UNITS Vulval cancer radical surgery G & S G & S G & S and consists of: Pack A: Pack B Pack C 4 units RBC + 4 units FFP 4 units RBC, 4 FFP + 1 platelets 4 units RBC, 4 FFP, 1 unit platelets and 2 pools cryo Pack C repeats until lab is stood down Page 6 of 14 Page 6 of 14
NB if Ab detected blood must be requested well in advance as it may have to come from Bristol. If there is a particular individual risk of significant blood loss (eg low Hb, clotting risk, previous surgery etc), consider triage to RCHT and err on the side of ensuring a G+S specimen is available ahead of surgery NB this pre-op clinic specimen serves as an antibody screen and does not mean that e-matched blood will be available at surgery Pre op clinic On day of surgery Orthopaedics WCH / SMH RCHT If antibodies detected Urological Surgery Osteotomy (tib / fib) G & S G&S 2 UNITS THR G & S 2 UNITS THR revision G & S G & S G & S 4 UNITS TKR G & S 2 UNITS # NOF G & S on admission G & S 2 UNITS Nephrectomy G & S G & S 2 UNITS Prostatectomy TUR and RRP G & S 2 UNITS TUR of bladder tumour G & S 2 UNITS ENT PCNL G & S G & S 2 UNITS Adrenalectomy G & S G & S 2 UNITS Pyeloplasty G & S G & S 2 UNITS Block dissection of neck G & S G & S 2 UNITS Laryngectomy G & S G & S 2 UNITS Bariatric Gastric Band G & S G & S 2 UNITS Gastric Bypass G & S G & S 2 UNITS NB for MAJOR emergency blood loss eg for aortic aneurysm rupture a massive haemorrhage pack should be requested and consists of: Pack A: Pack B Pack C 4 units RBC + 4 units FFP 4 units RBC, 4 FFP + 1 platelets 4 units RBC, 4 FFP, 1 unit platelets and 2 pools cryo Pack C repeats until lab is stood down Page 7 of 14 Page 7 of 14
2. Monitoring compliance and effectiveness Element to be monitored Lead Tool Frequency Reporting arrangements Acting on recommendations and Lead(s) Change in practice and lessons to be shared Appropriate availability of blood for elective surgery Dr Kathy Clarke / Stephen Bassey Audit and incident monitoring Daily monitoring by BMS staff during provision of blood Non-compliance will be raised as an incident on QPulse and reviewed by the Hospital Transfusion Team (HTT) The HTT will take executive action if urgent action is required. HTT will report to the Hospital Transfusion Committee (HTC) (sits 3 x / year) The HTC will identify appropriate action and is structured to communicate with the clinical workforce and ensure corrective action is undertaken. The HTC will determine whether any alterations to this (MSBOS) policy are necessary 3. Equality and Diversity 3.1. This document complies with the Royal Cornwall Hospitals NHS Trust service Equality and Diversity statement which can be found in the 'Equality, Diversity & Human Rights Policy' or the Equality and Diversity website. 3.2. Equality Impact Assessment The Initial Equality Impact Assessment Screening Form is at Appendix 2. Page 8 of 14 Page 8 of 14
Appendix 1. Governance Information Document Title Date Issued/Approved: November 2017 Maximum Surgical Blood Order Schedule (MSBOS) Date Valid From: November 2017 Date Valid To: November 2019 Directorate / Department responsible (author/owner): Nicki Jannaway, Lead Transfusion Practitioner Contact details: 01872 253093 Brief summary of contents Provides indication for appropriate blood ordering Suggested Keywords: Transfusion; Blood ordering; Red cells; MSBOS ; MBOS; haemorrhage; preassessment; PAC; Target Audience Executive Director responsible for Policy: RCHT PCH CFT KCCG Medical Director Date revised: 03/11/17 This document replaces (exact title of previous version): Approval route (names of committees)/consultation: Divisional Manager confirming approval processes Maximum Surgical Blood Order Schedule (MSBOS) V4 Hospital Transfusion Team, Hospital Transfusion Committee, CSCS Divisional Governance Board Name and Post Title of additional signatories Name and Signature of Divisional/Directorate Governance Lead confirming approval by specialty and divisional management meetings Kevin Wright, Governance Lead CSCS {Original Copy Signed} Name: Page 9 of 14 Page 9 of 14
Signature of Executive Director giving approval Publication Location (refer to Policy on Policies Approvals and Ratification): Document Library Folder/Sub Folder Links to key external standards Related Documents: Training Need Identified? {Original Copy Signed} Internet & Intranet Clinical / Haematology Intranet Only Guidelines for the Clinical Use of Red Cell Transfusions (BCH) Patient Blood Management (NHSBT) Better Blood Transfusion 3 (DOH) Transfusion Policy No ongoing training given in transfusion mandatory sessions across the Trust Version Control Table Date Version Changes Made by Summary of Changes No (Name and Job Title) June 2007 V1.0 New Document Stephen Bassey, Transfusion Laboratory Manager July 2009 V2.0 Minor changes Stephen Bassey April 2011 V3.0 Revision and reformatting throughout Dr Richard Noble, Haematology Consultant July 2014 V4.0 Minor changes to tables, reformatting throughout to meet RCHT Documents Library criteria Dr Richard Noble, Haematology Consultant November 2017 V6.0 Reformatting tables, addition of G&S for #NOF, removal of G&S for mastectomy, change of Nicki Jannaway, Lead emergency O neg locations, addition of Transfusion Practitioner parameters for surgery at SMH All or part of this document can be released under the Freedom of Information Act 2000 This document is to be retained for 10 years from the date of expiry. This document is only valid on the day of printing Controlled Document This document has been created following the Royal Cornwall Hospitals NHS Trust Page 10 of 14 Page 10 of 14
Policy on Document Production. It should not be altered in any way without the express permission of the author or their Line Manager. Page 11 of 14 Page 11 of 14
Appendix 2. Initial Equality Impact Assessment Form This assessment will need to be completed in stages to allow for adequate consultation with the relevant groups. Name of Name of the strategy / policy /proposal / service function to be assessed Maximum Surgical Blood Order Schedule (MSBOS) Directorate and service area: Is this a new or existing Policy? Clinical Haematology, CSCS Division Existing Name of individual completing assessment: Telephone: Nicki Jannaway 1. Policy Aim* Provides indication for appropriate blood ordering Who is the strategy / policy / proposal / service function aimed at? 2. Policy Objectives* To ensure adherence to national guidelines on provision of blood during surgical interventions 3. Policy intended Outcomes* To support medical and laboratory staff in decision making process 4. *How will you measure the outcome? 5. Who is intended to benefit from the policy? 6a Who did you consult with b). Please identify the groups who have been consulted about this procedure. What was the outcome of the consultation? Daily monitoring by BMS staff during course of provision of blood Laboratory and medical staff, patients Workforce Patients Local groups External organisations Other Please record specific names of groups Consultant Anaesthetists and Consultant Surgeons Hospital Transfusion Team Document approved Page 12 of 14 Page 12 of 14
7. The Impact Please complete the following table. If you are unsure/don t know if there is a negative impact you need to repeat the consultation step. Are there concerns that the policy could have differential impact on: Equality Strands: Yes No Unsure Rationale for Assessment / Existing Evidence Age Sex (male, female, trans-gender / gender reassignment) Race / Ethnic communities /groups Disability - Learning disability, physical impairment, sensory impairment, mental health conditions and some long term health conditions. Religion / other beliefs Marriage and Civil partnership Pregnancy and maternity Sexual Orientation, Bisexual, Gay, heterosexual, Lesbian You will need to continue to a full Equality Impact Assessment if the following have been highlighted: You have ticked Yes in any column above and No consultation or evidence of there being consultation- this excludes any policies which have been identified as not requiring consultation. or Major this relates to service redesign or development 8. Please indicate if a full equality analysis is recommended. Yes No 9. If you are not recommending a Full Impact assessment please explain why. Not required as no impact Page 13 of 14 Page 13 of 14
Signature of policy developer / lead manager / director Nicki Jannaway Names and signatures of members carrying out the Screening Assessment 1. Nicki Jannaway 2. Human Rights, Equality & Inclusion Lead Date of completion and submission 3/11/17 Keep one copy and send a copy to the Human Rights, Equality and Inclusion Lead c/o Royal Cornwall Hospitals NHS Trust, Human Resources Department, Knowledge Spa, Truro, Cornwall, TR1 3HD This EIA will not be uploaded to the Trust website without the signature of the Human Rights, Equality & Inclusion Lead. A summary of the results will be published on the Trust s web site. Signed Date Page 14 of 14 Page 14 of 14