How rational is the crossmatching of blood in a pediatric emergency department?
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.


METHODS
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.


METHODS
An inner-city, tertiary care, pediatric trauma center ED.


METHODS
A consecutive sample of ED patients who had a T&C ordered from October 1, 1993, through January 31, 1994.


METHODS
None.


METHODS
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.
Division of Pediatric Emergency Medicine, Children's Memorial Hospital, Northwestern University Medical School, Chicago, IL, USA.
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Grupp-Phelan
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Tanz
D000293:Adolescent; D000328:Adult; D001788:Blood Grouping and Crossmatching / Q000706:statistics & numerical data*; D001803:Blood Transfusion / Q000191:economics* / Q000706:statistics & numerical data; D002641:Chicago; D002648:Child; D002675:Child, Preschool; D003362:Cost-Benefit Analysis; D004636:Emergency Service, Hospital / Q000191:economics* / Q000592:standards; D006744:Hospital Bed Capacity, 100 to 299; D006776:Hospitals, Pediatric; D006801:Humans; D007223:Infant; D007231:Infant, Newborn; D010818:Practice Patterns, Physicians' / Q000191:economics / Q000706:statistics & numerical data*; D012189:Retrospective Studies