A recent study in obstetric patients examined the effects of a policy change at an institution that moved from universal type and screen to selective type and screen based on risk stratification. According to this study, which of the following events MOST likely increased after instituting selective type and screen for only high-risk obstetric patients and not low- and medium-risk patients?
- □ (A) Emergency-release blood units requested
- □ (B) Transfusion-related costs
- □ (C) Intensive care unit (ICU) admissions
Postpartum hemorrhage is the leading cause of obstetric deaths worldwide. It accounted for 27% of maternal deaths worldwide in 2013 and 11.5% of maternal deaths in the United States between 2011 and 2014. The rise in the number of cesarean deliveries from approximately one-quarter of births in 1996 to approximately one-third in 2011 likely contributes to the rate of hemorrhage because cesarean delivery increases the risk of placenta previa and accreta. However, uterine atony remains the primary cause of postpartum hemorrhage. Hemorrhage is mostly a preventable cause of maternal death. Most hospitals in the U.S. obtain a type and screen for every obstetric patient in preparation for a blood transfusion event. Because only 1% to 2% of obstetric patients actually require blood transfusion, this is a costly approach to a relatively uncommon occurrence.
A process-improvement implementation study was undertaken recently to assess the cost-saving benefit and possible risks associated with implementing a policy for selective type and screen and crossmatch based on patient risk for hemorrhage, instead of universal type and screen. According to the new selective policy, patients who were at high risk of obstetric hemorrhage or had a known positive antibody would have a type and screen and crossmatch. (Additionally, patients with laboratory values from an outside hospital had type and screen and crossmatch performed.) Patients who were low or medium risk had their blood sample held in the laboratory, but a crossmatch request was sent only if the need arose for transfusion. The study evaluated the cost savings and safety outcomes, in a before-after fashion, under the new policy from its implementation in October 2018 until September 2019 (the postimplementation period) and compared them to those of the old policy of universal type and screen for the pre-implementation period of October 2017 through September 2018. The policy was reviewed by a multidisciplinary group of physicians representing maternal-fetal medicine, transfusion medicine, and obstetric anesthesiology, as well as labor and delivery nurses and nursing educators. Patients were assigned a risk category based on the California Maternal Quality Care Collaborative criteria; criteria for the high-risk category included placenta previa, low-lying placenta, suspected placenta accreta, hematocrit less than 30, platelets less than 100,000, active bleeding, and known coagulopathy. The risk category was assigned on admission and reassessed every 12 hours, or when a change in clinical status occurred. Patients who were high risk or who had a need for blood transfusion had a blood crossmatch performed.
The study assessed safety outcomes, including emergency-release red blood cell (RBC) transfusion events and units transfused, rate of postpartum hemorrhage (estimated blood loss >1,000 mL), number of ICU admissions, and rate of hysterectomy. Emergency-release, uncrossmatched RBC transfusion can increase risk of patient complications and use valuable hospital resources. The study used a comprehensive cost-analysis tool to estimate the cost of transfusion preparation, including holding blood samples in the laboratory, ABO typing, antibody screening, crossmatching, and transfused products. In the hospital where the study took place, there were 4,111 deliveries in the pre-implementation period and 4,400 deliveries in the postimplementation period. The authors found differences in safety outcomes. The number of events necessitating emergency-release transfusion before and after policy implementation were similar (three vs. four, respectively). The number of units transfused, including emergency-release RBCs, emergency release of any blood products, and O-negative RBCs, were lower after the policy change compared with before. This finding, however, was likely less related to the type and screen process change as it was to the implementation of clinical decision support for RBC transfusion made in April 2019. The rate of postpartum hemorrhage increased post implementation (7.65% post implementation vs. 5.95% preimplementation). Despite this, the number of hysterectomies (four vs. two) and ICU admissions (21 vs. 20) were similar before and after the policy change. Although the number of requests for emergency-release RBCs increased after the policy change, most units were returned, and there was not an increase in transfusion rates. The authors found that the mean monthly cost of transfusion preparation after the policy change was lower compared with before the policy change ($25,090 ± $8,506 vs. $39,211 ± $7,576, respectively). The mean monthly cost related to type and screen after the new policy was also lower compared with before ($9,753 ± $2,927 vs. $20,676 ± $3,666, respectively).
There were some limitations to this study. The study evaluated two years of data at a single hospital during which time very few emergency-release transfusion events occurred. In addition, the study site was a tertiary care facility with significant blood bank resources.
Transfusion in obstetric patients is infrequent, yet the emergent need for transfusion can be life-threatening. Predicting which patients will need transfusion is a difficult task, and obtaining a type and screen on every patient is costly. This study found that obtaining a type and screen for only high-risk patients and holding a blood sample for all other patients was not associated with an increase in emergency-release transfusion events. Although the number of emergency-release RBC units transfused did not increase, the number of requests for emergency-release RBCs did increase after the policy change. The policy change to selectively type and screen only high-risk obstetric patients resulted in a reduction in transfusion-related costs with no apparent adverse safety outcomes.