How Rational Is the Crossmatching of Blood in a Pediatric Emergency Department?

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Abstract
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 cross-matched 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 cross-matched, but no blood was transfused. Children with sicklecell 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. Arch Pediatr Adolesc Med. 1996;150:1140-1144