title: Variation in the use of type and crossmatch blood ordering among patients undergoing hepatic and pancreatic resections.
abstract: BACKGROUND
  The use of preoperative blood orders involved in major gastrointestinal surgery has been poorly studied. The objective of the current study was to analyze compliance with guidelines and factors associated with crossmatch and blood ordering among patients who underwent a hepatic or pancreatic resection.
  
  
  METHODS
  All patients who underwent a hepatic or pancreatic resection between 2010 and 2013 at Johns Hopkins Hospital were identified. Crossmatch to transfusion (C/T) ratios were calculated based on transfusion rates and total units used. A C/T ratio of >2.0 was considered excessive.
  
  
  RESULTS
  Among the 2,629 patients, 11,574 units of packed red blood cells (PRBCs) were crossmatched (mean number of PRBC units crossmatched: 5.9 ± 7.3). Of the 2,629 patients, 34.1% of patients received ≥ 1 PRBCs and 3,611 total units of PRBC were transfused, resulting in an institutional C/T ratio of 2.17 based on the proportion of patients transfused and 3.21 based on the overall number of PRBC units transfused. Using our criterion of excessive C/T ratio of >2.0, we found that 411 patients (45.9%) were "excessively" crossmatched among transfused patients. Among nontransfused patients, 41.0% (n = 711) of patients were crossmatched for >2 units PRBC. Factors associated with receipt of "excess" crossmatch included the presence of multiple comorbidities and an estimated blood loss >450 mL (both P < .05). Provider-level variation among surgeons (C/T ratio range 1.22-3.81) also was associated strongly with "excess" crossmatching ratios (odds ratio 2.56, 95% confidence interval 2.09-3.13; P < .001).
  
  
  CONCLUSIONS
  More than 1 in 4 patients received crossmatch orders that exceeded institutional and national guidelines. Provider variation both among surgeons and anesthesiologists was an important factor associated with crossmatch variation and excessive ordering of blood for crossmatch in patients undergoing pancreatic and hepatic surgery.
authors.affiliation: Department of Surgery, University of Illinois Hospital and Health Sciences System, Chicago, IL.
authors.forename: Aslam
authors.initials: A
authors.lastname: Ejaz
authors.affiliation: Department of Anesthesiology/Critical Care Medicine, Interdisciplinary Blood Management Program, The Johns Hopkins Hospital, Baltimore, MD.
authors.forename: Steven M
authors.initials: SM
authors.lastname: Frank
authors.affiliation: Department of Surgery, The Johns Hopkins Hospital, Baltimore, MD.
authors.forename: Gaya
authors.initials: G
authors.lastname: Spolverato
authors.affiliation: Department of Surgery, The Johns Hopkins Hospital, Baltimore, MD.
authors.forename: Michael
authors.initials: M
authors.lastname: Mavros
authors.affiliation: Department of Surgery, The Johns Hopkins Hospital, Baltimore, MD.
authors.forename: Yuhree
authors.initials: Y
authors.lastname: Kim
authors.affiliation: Department of Surgery, The Johns Hopkins Hospital, Baltimore, MD. Electronic address: tpawlik1@jhmi.edu.
authors.forename: Timothy M
authors.initials: TM
authors.lastname: Pawlik
mesh_terms: D000368:Aged; D000704:Analysis of Variance; D001788:Blood Grouping and Crossmatching / Q000706:statistics & numerical data*; D016063:Blood Loss, Surgical / Q000517:prevention & control; D001803:Blood Transfusion / Q000379:methods / Q000706:statistics & numerical data*; D016208:Databases, Factual; D005260:Female; D005500:Follow-Up Studies; D006498:Hepatectomy / Q000379:methods* / Q000401:mortality; D006801:Humans; D007430:Intraoperative Care / Q000379:methods; D016015:Logistic Models; D008297:Male; D008875:Middle Aged; D015999:Multivariate Analysis; D010180:Pancreatectomy / Q000379:methods* / Q000401:mortality; D011183:Postoperative Complications / Q000401:mortality / Q000503:physiopathology; D011300:Preoperative Care / Q000379:methods; D012189:Retrospective Studies; D018570:Risk Assessment; D018709:Statistics, Nonparametric; D016019:Survival Analysis