Objectives.—To determine the normative distribution of time elapsed for blood bank personnel to fill nonscheduled operating room (OR) blood component orders in hospital communities throughout the United States, and to examine hospital blood bank practices associated with faster blood component delivery times.
Design.—Participants in the College of American Pathologists Q-Probes laboratory quality improvement program collected data prospectively on the times elapsed for blood bank personnel to fill nonscheduled emergent orders from hospital ORs for red blood cell (RBC) products, fresh frozen plasma (FFP), and platelets (PLTs). Participants also completed questionnaires describing their hospitals' and blood banks' laboratory and transfusion practices.
Setting and Participants.—Four hundred sixty-six public and private institutions located in 48 states in the United States (n = 444), Canada (n = 9), Australia (n = 8), the United Kingdom (n = 4), and Spain (n = 1).
Main Outcome Measures.—The median time elapsed between requests for blood components by OR personnel and the retrieval of those components by blood component transport personnel, and the median time elapsed between requests for blood components by OR personnel and the arrival of those components in ORs.
Results.—Participants submitted data on 12 647 units of RBCs, FFP, and PLTs. The median aggregate request-to-retrieval turnaround times (TATs) for RBCs, FFP, and PLTs ranged from 30 to 35 minutes, and the median aggregate request-to-arrival TATs for RBCs, FFP, and PLTs ranged from 33 to 39 minutes. Most of the TAT was consumed by events occurring prior to, rather than after release of components from blood banks. Shorter prerelease TATs were associated with having surgical schedules that listed patients' names and procedures available to blood bank personnel prior to surgeries, and having adequate clotted specimens in the blood bank and completed type-and-screen procedures performed before requests for blood components were submitted to blood banks. Among the fastest-performing 10% of participants (90th percentile and above), request-to-retrieval TATs ranged from 12 to 24 minutes for the 3 blood components, whereas among the slowest-performing 10% of participants (10th percentile and below), request-to-retrieval TATs ranged from 63 to 115 minutes for the 3 components. Median TATs ranged from 33 to 37 minutes for the 3 components. Institutions with TATs in the fastest-performing 25th percentile more frequently stored cross-matched RBCs in the OR daily, stocked PLTs for unexpected surgical use, stored PLTs in or near the OR, and had laboratory rather than nonlaboratory personnel deliver components to the OR than did those institutions with TATs in the slowest-performing 25th percentile.
Conclusions.—Hospital blood bank personnel can deliver blood components to the OR in slightly longer than 30 minutes, measured from the time that those units are requested by OR personnel. Practices aimed at saving time before components are released from blood banks will be more efficient in reducing overall TAT than those practices aimed at saving time after components are released from blood banks. Specific practices associated with shorter blood delivery TATs included providing blood bank personnel with access to the names of surgical patients potentially requiring blood components, having pretransfusion testing completed on those patients prior to surgery, having ample blood products on hand, and having laboratory personnel control blood product delivery.
Turnaround time (TAT) is a visible and common standard by which clinicians judge the quality of laboratory services.1 Physicians are likely to be especially sensitive to the timeliness with which laboratories provide blood components during those moments of surgical urgency when performance expectations run high. Although organizations that accredit blood banks and hospitals provide criteria for the effectiveness with which laboratory services, including blood bank services, meet patients' needs,2,3 no performance criteria exist for evaluating the timeliness with which blood bank personnel provide blood components to operating rooms (ORs).
Since 1989, the College of American Pathologists (CAP) Q-Probes program has conducted multi-institutional studies that have determined a broad range of performance benchmarks in both anatomic pathology and laboratory medicine. Laboratories participating in these studies worldwide, representing the entire gamut of practice styles, have been able to compare their performances with those of their peers. Previous Q-Probes studies have examined TAT performances of anatomic pathology and clinical laboratories4–16 and have examined blood component utilization of medical institutions.17–19 In this study, we expand the CAP's database of quality indicators of TAT and of blood bank performance by examining the lengths of time that it took blood bank personnel to fill emergent nonscheduled blood component orders emanating from hospital ORs. In addition, we sought to identify those blood bank and hospital practices associated with shorter TATs.
This study was designed to measure the lengths of time that it took blood bank workers to fill ad hoc blood requests, that is, nonelective intraoperative requests for blood components intended for patients whose surgery was already underway. Institutions enrolled in the CAP Q-Probes program participated in this study. The study was conducted and the data were handled similarly to previously described methods.20 On their enrollment into the Q-Probes program, participants from each institution submitted certain demographic information, including geographic location, community type (urban, suburban, rural, etc), teaching status, occupied bed size, hospital and laboratory accreditation statuses, and whether the institution maintained a pathology residency program.
Blood bank workers were instructed to record data prospectively on up to 30 ad hoc OR requests for red blood cells (RBCs), fresh frozen plasma (FFP), and platelets (PLTs) for a period of 3 months or less. Included in this study were only those unplanned requests for RBCs and whole RBC units (including and/or in addition to any units cross-matched prior to surgery), FFP requiring thawing of units, PLT concentrates, and apheresis PLTs that were not communicated to blood bank staffs prior to surgery. Specifically excluded from this study were requests for blood components that had been communicated to blood bank staffs prior to patients' surgeries and/or for which any processing had been performed prior to and in preparation for patients' surgeries.
For each request, blood bank technologists recorded the times that blood components were requested by OR personnel, were procured (or arrived in the blood bank, if applicable), were ready for release, were retrieved by health care workers for delivery to the ORs, and arrived in the ORs. For each blood request, blood bank technologists also recorded the categories and numbers of blood components requested, the extent of compatibility testing performed, whether a clotted specimen was already available in the laboratory prior to the request, whether compatibility testing revealed the presence of unexpected antibodies, and whether the patient's surgery was an emergency or an elective case.
From the aggregate data, we calculated the following 2 TAT quality indicators for all 3 blood components (RBCs, PLTs, FFP): the intervals spanning the moments that these blood components were requested by OR personnel to the moments that these blood components were released from laboratories to ORs (ie, retrieved by blood component couriers) and the intervals spanning the moments that these blood components were requested by OR personnel to the moments that these blood components arrived in ORs. For each component, we also calculated the intervals for 4 segments of blood bank service, including the intervals spanning the moments that blood components were requested by OR personnel to the moments that blood components were procured by blood bank personnel, the moments that blood components were procured by blood bank personnel to the moments that blood components were released for distribution to ORs, the moments that blood components were released for distribution to the ORs to the moments that blood components were retrieved by couriers for delivery to ORs, and the moments that blood components were retrieved by couriers for delivery to ORs to the moments that blood components arrived in ORs.
The median institutional TATs for both quality indicators were also calculated for each participating institution. We then organized the median institutional TATs for all participating institutions into percentile ranks. This percentile ranking was used to compare TAT performance among participants.
By making tick marks on a detailed questionnaire, participants answered questions concerning their institutions' practice characteristics, including the following:
the numbers of units of RBCs, FFP, and PLTs transfused at their institutions during the calendar year prior to participating in this study;
whether cardiac surgery and/or liver transplants were performed at their hospital;
whether RBCs were released without serologic cross-matches and/or with abbreviated compatibility testing in extreme situations;
whether laboratory policy specified a maximum TAT for delivery of blood products to the OR for ad hoc requests;
details of blood bank workers' access to surgical schedules;
details of blood bank workers' pretransfusion communications with surgeons and OR personnel regarding requirements for blood components;
details of blood bank inventory management;
details of how blood orders are communicated to the blood bank;
details of blood bank staffing;
details of blood bank procedures for thawing plasma, including use of quick-thawing procedures, and/or processing platelet concentrates;
the types of blood components maintained and stored daily in the blood bank and in the OR;
the types of health care workers that routinely transport blood components from the blood bank to the OR;
the routine timing of pretransfusion testing for patients undergoing “same day” surgeries;
the routine timing between specimen collection and compatibility testing prior to surgical procedures;
the relative locations of the blood bank and the OR;
the presence of satellite laboratories; and
the availability of emergency and trauma services.
We evaluated the effects of institutional demographics and practice characteristics on the institutional request-to-retrieval TAT quality indicator. If a participant failed to answer a question for any of the demographic or practice characteristics listed, that participant's data were excluded from the database for that question only. We compared the incidence of these variables present in the fastest- and in the slowest-performing 25th percentiles of institutional median TATs, and then tested for differences between the groups using the χ2 test. We considered a P value of .01 or less to be statistically significant. We also compared each of the 4 median segmental turnaround intervals between those institutions in which the various practice characteristics were and were not present. Again, if a participant failed to answer a question for any of the demographics or practice characteristics, that participant's data were excluded from the database for that question only. We tested for differences between groups using nonparametric Kruskal-Wallis and Wilcoxon tests. We considered a P value of .05 or less to be statistically significant.
A total of 466 institutions representing 48 states in the United States (n = 444, 95.3%), Canada (n = 9, 1.9%), Australia (n = 8, 1.7%), the United Kingdom (n = 4, 0.9%), and Spain (n = 1, 0.2%) submitted TAT data on requests for 7204 units of RBCs, 2909 units of FFP, and 2534 units of PLTs. Most (92.1%) participants represented private institutions, and the remainder (7.9%) of participants represented governmental and other types of institutions. Most (94.4%) hospitals were accredited by the Joint Commission on Accreditation of Healthcare Organizations, most (79.9%) laboratories were accredited by the CAP, and most (71.0%) blood banks were accredited by the American Association of Blood Banks. Nearly all (98.9%) of the participating institutions maintained emergency departments, and about one third (33.8%) were designated major trauma centers. Most (79.6%) of the participating hospitals contained 350 or fewer beds, and the remainder (20.4%) of hospitals contained more than 350 beds. About one fifth (20.4%) of participating hospitals maintained residency training programs.
Table 1 shows the median aggregate TATs for all components of RBCs, FFP, and PLTs monitored in this study. The table is organized into 2 sections. The first section consists of 2 columns, in which the TATs for the quality indicators are listed (request for blood components by OR personnel to retrieval of blood components by transport personnel, and request for blood components by OR personnel to arrival of blood components in OR). For instance, participants submitted TAT data on 7204 unscheduled orders for units of RBCs that were filled in response to emergent OR requests. Measured from the times that blood components were requested from ORs, the median time elapsed for couriers to retrieve blood components from blood banks was 30 minutes and the median time for blood components to reach ORs was 34 minutes.
The second section consists of the next 4 columns, in which the TATs for several segments of blood component delivery are listed. Of the 4 segments of service, the longest intervals were those spanning the request for blood components to the procurement of blood components, and those spanning the procurement of blood components to the release of blood components for dispatch to ORs. For instance, of the 2909 orders of FFP filled for which participants supplied information on time intervals, the median request-to-procurement interval was 27 minutes and the median procurement-to-release interval was 25 minutes. The median release-to-retrieval and retrieval-to-OR arrival intervals were shorter (8 and 3 minutes, respectively). The TAT patterns for RBC and PLT requests were similar to that for FFP. The longest median request-to-procurement interval (39 minutes) and the shortest median procurement-to-release interval (10 minutes) were recorded for PLTs. Blood component retrieval and transit intervals were similar for all components. Each quality indicator TAT and segmental TAT was computed separately from data submitted by participants who chose to submit data for that particular interval. Therefore, the TATs are not additive, and a segmental TAT may actually exceed the total TAT (eg, request to procurement TAT = 39 minutes).
Table 2 shows the percentile distribution of median institutional TATs for retrieval of blood components from blood banks by blood transporting personnel, measured from the times that those components were requested by OR personnel. For instance, among the fastest-performing 10% of the 418 participants that supplied information concerning RBC TATs, the median interval between requests for RBCs and retrieval of those units for delivery to ORs was 14 minutes or shorter. Among the slowest-performing 10% of participants, the median request-to-retrieval interval was 79 minutes or longer. In the median-performing institution, RBC units were retrieved within 35 minutes, measured from the times that those units were requested by OR personnel.
Table 3 shows the influence of participants' demographic characteristics on the percentages of participants whose median institutional TAT performances were in the fastest and slowest 25th percentiles of request-to-retrieval TATs for blood components monitored in this study. For instance, among those participants whose median TATs were in the fastest 25th percentile, 29 (or slightly more than half [52.7%]) indicated that their institutions maintained residency programs, compared to those participants whose median TATs were among the slowest 25th percentile, 10 (23.8%) of whom likewise indicated that their institutions maintained residency programs. Similarly, faster median request-to-retrieval FFP TATs were associated with institutions containing more than 350 beds and institutions designated as major trauma centers. Faster median request-to-retrieval PLT TATs were associated with institutions that performed open-heart surgery, performed liver transplants, and were designated as major trauma centers. Red blood cell TAT was not associated with any of the participants' demographic characteristics about which we chose to inquire.
Table 4 shows the influence of various blood banks' practices on the percentages of participants whose performances fell within the fastest and slowest 25th percentile request-to-retrieval TATs for blood components monitored in this study. The table is organized in a format similar to that described for Table 3. For instance, among those participants whose median TATs were in the fastest 25th percentile, 52 (94.6%) indicated that they routinely stocked PLTs during weekdays for unexpected use in surgery, compared to those participants whose median TATs were among the slowest 25th percentile, 6 (19.1%) of whom likewise indicated that their institutions stocked PLTs for unexpected surgical use. Similarly, faster median request-to-retrieval RBC TATs were associated with routinely storing RBCs in ORs, faster median request-to-retrieval FFP TATs were associated with having laboratory rather than nonlaboratory personnel courier the blood to the OR, and faster median request-to-retrieval PLT TATs were associated with routinely storing PLTs in or near the OR and not having policies that guaranteed maximum OR blood delivery TATs. The other hospital demographics, blood bank practices, and hospital practices about which we inquired did not significantly influence institutional request-to-release TAT performance.
Analysis of the aggregate data revealed several conditions relating to individual specimens and specimen requests; although these conditions were not associated with overall request-to-retrieval TATs (ie, the quality indicator), they were associated with shorter or longer segmental TAT intervals. Specifically, shorter RBC, FFP, and/or PLT request-to-procurement, and procurement-to-release intervals were associated with the presence of patients' names and procedures listed on surgical schedules available to blood bank workers, the presence of adequate clotted blood specimens in blood banks at times of requests for blood components, and the completion of type-and-screen procedures prior to requests for blood components compared to when those conditions were not present. Longer procurement-to-release intervals were also associated with the presence of unexpected antibodies in patients' specimens and with higher numbers of component units requested (P < .05, data not shown). The extent of compatibility testing performed and the type of surgical case scheduled (ie, emergency or elective) did not influence the quality indicator or the segmental TATs.
Analysis of the institutional data revealed several conditions relating to blood bank and hospital practices, which again were not associated with quality indicator performance, but were associated with shorter or longer segmental TAT intervals. Specifically, longer RBC procurement-to-release intervals were associated with verbal transmission of blood component orders compared to written transmission of blood component orders. Longer PLT procurement-to-release intervals were associated with routinely pooling PLT units before release rather than dispatching the units individually. Longer RBC, FFP, and/or PLT release-to-retrieval and retrieval-to-arrival intervals were associated with OR personnel rather than non-OR personnel delivering blood components from the laboratory to the OR. Finally, longer RBC and FFP release-to-retrieval and retrieval-to-arrival intervals were associated with blood banks and ORs being located in different buildings and/or different levels of the hospital (P < .05, data not shown).
This Q-Probes study attempted to determine the normative distribution of TATs for the delivery of blood components to hospital ORs, and to examine blood bank practices that might influence those TATs. To make these intervals comparable and to allow us to compare performance among participating institutions, we chose to investigate TATs only for those nonelective blood component requests that were intended for patients whose surgeries were already underway. From the perspectives of blood bankers, we assumed that these orders were spontaneous and unplanned. Therefore, no participant would have a head start on the process through prior knowledge of a request.
Q-Probes studies differ from most published investigations in that rather than describe the experiences of individual institutions, many of which are academic and/or presumably have homogeneous practice environments, they reflect the daily experiences of a large heterogeneous group of hospitals that serve diverse community populations and that vary widely in their practice characteristics. In short, Q-Probes studies are designed to provide a snapshot of laboratory practice in the United States. Beyond presenting these results, this study was not intended to validate the legitimacy of these measurements as reasonable indicators of quality transfusion practices; to evaluate the consequences of TAT on patient care, blood bank efficiency, or laboratory finances; or to explain why certain associations of TAT with practice characteristics did or did not occur. By having the normative rates of selected parameters of quality available to them, participants in Q-Probes studies are able to derive benchmarks of quality that they believe are appropriate to apply in their own communities.
More than 450 health care institutions representing all practice environments in the United States provided information concerning the TATs of 12 647 units of RBCs, FFP, and PLTs. On average, it took participants ½ hour or slightly longer to ready these units for retrieval by blood couriers, and slightly longer than ½ hour to deliver these units to ORs; both times were measured from the time that blood component orders were received in blood banks. Most of this time elapsed during the prerelease phase of service, specifically, procuring requested units. The longest procurement intervals recorded were for those acquiring PLTs. Once obtained, the PLT procurement-to-release intervals were the shortest of all 3 intervals. The longest median procurement-to-release interval recorded was for FFP, presumably due to the necessity of thawing these units.
Once processed, the shortest intervals for all units were those of the postrelease phases of delivery, that is, release-to-retrieval (<10 minutes) and retrieval-to-arrival in OR (<5 minutes). Thus, if overall blood delivery time is to be shortened, it appears that reducing the prerelease intervals would be the most efficient places for OR and blood bank personnel to concentrate their efforts. Making a list of surgical patients' names and procedures available to blood bank personnel prior to surgery, having adequate clotted surgical patient specimens present in the blood bank before receiving requests for blood components, and having surgical patients' type-and-screen procedures completed before receiving requests for blood components were all associated with shorter prerelease intervals. We would expect these practices to mollify delays associated with the presence of unexpected antibodies in patients' specimens and with requests for large numbers of components, both of which were associated with longer prerelease intervals.
Turnaround time performance varied considerably among participants. On average, the lengths of time it took blood bank workers to ready blood component orders for courier retrieval measured from the times that OR personnel requested those components was slightly greater than ½ hour. Among the swiftest-performing 10% of participants (90th percentile and above), half the RBC and PLT orders were available for retrieval within 15 minutes of their requests. Among the slowest-performing 10% of participants (10th percentile and below), half the RBC and PLT orders took more than an hour to complete. The fastest-performing 10% of participants readied half their FFP orders in less than ½ hour and the slowest-performing 10% readied half their FFP orders in greater than 1 hour.
We attempted to determine specific institutional demographics associated with faster institutional blood component request-to-retrieval TATs. Faster median TATs for various components were associated with hospitals containing greater than 350 hospital beds, maintaining pathology residency programs, being designated major trauma centers, providing open-heart surgery, and providing liver transplant programs. Previous Q-Probes studies have shown that markers of institutional complexity, such as greater bed sizes and the presence of teaching programs, are associated with longer laboratory testing TATs compared to hospitals containing fewer beds and having no teaching programs.6,8 We did not investigate whether specific blood bank or hospital procedures designed to meet the stringent demands of these complex services were established in institutions participating in this study.
We also attempted to determine specific blood bank and hospital practices associated with faster institutional blood component request-to-retrieval TATs. The practices of routinely delivering and storing RBCs in the OR daily, routinely stocking specific volumes of PLTs in the laboratory, and storing PLTs in or near the OR were associated with shorter RBC and PLT TATs. Although relatively few institutions used laboratory personnel rather than nonlaboratory personnel to deliver blood components to ORs, FFP request-to-retrieval TATs were longer in those institutions in which nonlaboratory personnel delivered blood products. Presumably, laboratory personnel, unlike nonlaboratory personnel, are on-hand and do not have to be summoned from elsewhere. Previous Q-Probes studies have shown specimen transport times to be lower when laboratory personnel, rather than nonlaboratory personnel were responsible for transporting specimens.10,16 Because postrelease blood component delivery intervals were the shortest of the 4 intervals measured, we would expect this practice to save significant amounts of time only for those institutions in which postrelease delivery intervals are inordinately long.
Institutions that embraced policies guaranteeing maximum TATs tended to have longer request-to-retrieval PLT TATs than did institutions that did not have such policies. One previous Q-Probes study showed that setting test result reporting deadlines was not associated with laboratories' abilities to meet those deadlines.14 Perhaps such guarantees of TAT targets are necessary in precisely those institutions in which blood bank personnel have been consistently unable to meet the TAT expectations of their medical staffs.
Routinely pooling PLTs prior to their release and routinely requesting blood components verbally rather than by written orders were associated with prolonged blood component prerelease intervals, but were not associated with overall TATs. We did not investigate what other practices might have been employed to compensate for the time that these practices consumed. Postrelease blood delivery intervals were prolonged when blood banks were located on floors or in buildings other than the ones on or in which ORs were located. Again, we did not investigate how hospital personnel managed to overcome these characteristics, which would be presumed to delay delivery of blood products. The presence of satellite blood banks in or adjacent to ORs was not associated with shorter blood delivery TATs. A previous Q-Probes study showed that satellite laboratories located in emergency rooms were not associated with shorter emergency room stat test TATs.13
Other hospital and blood bank practices about which we inquired, including the specifics of inventory management and staffing, FFP thawing procedures, timing of specimen collection and pretransfusion testing, and the use of abbreviated RBC compatibility testing did not influence blood delivery TAT. This is not to say that altering some of these practices would not improve performance in certain institutions. We have no way of knowing whether personnel in faster-performing institutions lacking these practices compensated for their lack by using other practices about which we neglected to inquire, or whether in slower-performing institutions in which personnel did employ these practices there were other operational flaws about which we also neglected to inquire. Certainly, hospitals with prolonged TATs, especially those performing at or below the slowest 10th percentiles, might do well to investigate the possibility that any of the practices enumerated in this study might improve performance in their own institutions.
The authors thank Kimberly M. O'Donnell for her editorial contributions.
Reprints: David A. Novis, MD, Department of Pathology, Wentworth-Douglass Hospital, Dover, NH 03820 (email@example.com)