A Complete Loop Quality Improvement Project into the need, safety and cost of routine Group and Save samples in patients undergoing Elective Transurethral Resection of Bladder Tumour
BAUS ePoster online library. Parker S. Jun 26, 2018; 217790
Sidney Parker
Sidney Parker
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Abstract
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Introduction
Routine Group and Save samples have historically been taken for patients undergoing transurethral resection of bladder tumours (TURBT) due to previous studies quoting transfusion rates as high as 13% (Dick, Barnes et al. 1980). There is little guidance on the need for Group and Save in these patients nationally and most policies are decided locally.
A retrospective analysis of patients undergoing TURBT and TURP in one centre suggested that Group and Save are not required pre-operatively (Smith, Falconer et al. 2018). We know that post-operative transfusion rate for TURBT to be lower than for transurethral resection of prostate (TURP). The post-operative transfusion rate is less than 2.5% for patients post-TURBT when compared to 2% to 9.3% of patients undergoing TURP (Nieder, Meinbach et al. 2005, Pu, Wang et al. 2008, Xishuang, Deyong et al. 2010). The improvement in transfusion rates exist due to better equipment and technology including resectoscopes, optics, displays and also a better understanding of transfusion indications and target ranges (Milkins, Berryman et al. 2013, United Kingdom Blood Services 2013).
Aims
To assess the need for routine Group and Save samples pre-operatively in patients undergoing elective TURBT and to assess the safety and cost effectiveness in stopping this as routine practice.
To retrospectively analyse patients in one centre undergoing elective TURBT to assess our current practice in pre-operative Group and Saves, and post-operative transfusion rates and the urgency of transfusion.
To stop routine Group and Saves as a cost effectiveness measure, presuming the retrospective analysis suggests it is safe to do so, and to implement a continuous prospective analysis of patients undergoing elective TURBT to assess rate of transfusion and patient safety.
Measures
The measures used to to assess the current practice, safety and cost of pre-operative Group and Save samples included:
1) The number of pre-operative Group and Save samples taken and whether there were two valid samples required to issue a blood transfusion sample.
2) The number of patients that received a blood transfusion and the clinical urgency of transfusion according to the operative, case notes, observations and blood tests.
3) Analysis of the cost of Group and Save samples within each audit cycle.
Changes
To stop routine Group and Saves in elective patient undergoing TURBT after 1st August 2017.
Method
We retrospectively searched coding for all patient undergoing transurethral resection of bladder lesion, tumour, cancer, malignancy, TUR, TURBT during 1st January 2016 - 1st January 2017. Electronic patient records were analysed for operation notes and discharge summaries to exclude emergency TURBT and to include elective TURBT patients only.

The number of Group and Saves samples were recorded for each patient undergoing elective TURBT. These patients were then cross referenced with the blood transfusion laboratory records for all urology patients who received a blood transfusion to identify which patients received a transfusion as demonstrated in Figure 1.

The case notes were requested for individual patients who received a blood transfusion to assess the urgency of transfusion by reviewing the operation and case notes, blood tests and observations at that time.
Results
1) The number of pre-operative Group and Save samples taken and whether there were two valid samples required to issue a blood transfusion sample.
There were 295 patients in the retrospective analysis of patients undergoing elective TURBT in the entirety of 2016. Figure 2 demonstrates that 'No Group and Save samples were taken' in 17% (n=51) of patients and 'One Group and Save sample was taken' in 73% (n=216) of patients. Therefore, 90% (n=267) did not have a sufficient Group and Save sample to process a Group specific blood transfusion without requiring a repeat sample.
Interestingly, the number of patients with one or more Group and Save samples taken was still 83% (n=244). A total of 272 samples were therefore processed in the laboratory despite only 10% (n=28) of patients having two valid samples to issue a transfusion without repeating a Group and Save post-operatively.
2) The number of patients who received a blood transfusion and the clinical urgency of transfusion according to the case notes and blood tests.
Of the 295 patients undergoing elective TURBT in 2016, only 1% (n=3) required a transfusion as shown in Figure 3.
None of the three patients that received a transfusion were seen as clinically urgent. All of which had time for Group and Save samples to be taken and processed prior to their administration.
3) Analysis of the cost of Group and Saves
In 2016, 295 patients underwent an elective TURBT in one centre alone. Each of these patient should have had two valid Group and Save samples. Our transfusion laboratory estimated the cost of a single Group and Save sample to be £3.20, rising to £14 per sample when considering additional costs of equipment, machinery, repairs and labour. Other studies have quoted £23.52 per sample (Smith, Falconer et al. 2018). Therefore, if all elective TURBT patients had two valid Group and Saves samples taken as per the requirements of the British Committee for Standard in Haematology prior to transfusion then the estimated cost was between £8,260 to £13,876 per year (Milkins, Berryman et al. 2013).
In the 2016 cohort 83% (n=244) of patients had one or more Group and Save samples taken. There were a total of 272 Group and Save samples taken in 2016, at a cost of between £3,808 and £6,397.
Action
Routine pre-operative Group and Saves were stopped for patients undergoing elective TURBT from 1st August 2017 and a continuous prospective audit was implemented until the time of publication, 9th February 2018. Group and Save samples can still be requested pre-operatively by the operative surgeon or anaesthetist according to risk factors.
This information was provided in the form on an email circulating between the urology directorate and the pre-assessment clinic. The audit was presented at the Urology directorate audit meeting and included in the induction of urology doctors.
Re-assessment
1) The number of pre-operative Group and Save samples taken and whether there were two valid samples required to issue a blood transfusion sample.
There were 162 patients that underwent an elective TURBT from 1st August 2017. Figure 4 demonstrates that 'No Group and Save samples were taken' in 82% (n=132) of patients in the prospective audit compared to 17% in the first cycle. Only 'One Group and Save sample was taken' in 15% (n=25) of patients in the second cycle compared to 73% in the first cycle. Only 3% (n=5) of patients required two valid Group and Saves and only 35 Group and Save samples were collected throughout the duration of the prospective audit.
2) The number of patients who received a blood transfusion and the clinical urgency of transfusion according to the case notes and blood tests.
None of the 162 patients required a post-operative transfusion following a planned elective TURBT. The only patient that received a blood transfusion of one unit was a patient originally listed for a suprapubic catheter and not an elective TURBT. He was subsequently found to have a large necrotic bladder tumour and therefore underwent a TURBT. It was the anesthetists request to transfuse the patient with a pre-transfusion haemoglobin of 84g/l due to numerous co-morbidites prior to the operation with symptomatic intent.
3) Analysis of the cost of Group and Saves
There were only 35 Group and Save samples taken during the entirety of the prospective cohort at a cost of between £490 and £812 over a six-month period. Anticipating an annual cost of between £980 an £1,624 which is 8.5 times cheaper than if all patients were to receive two samples.
Summary
This complete loop cycle with prospective analysis has proven that it is safe to stop routine pre-operative Group and Saves in elective TURBT patients. Only 0.7% of all the patients undergoing a planned elective TURBT in this study required a transfusion which is much lower than other literature and may be a reflection of the low transfusion rate of elective cases (Nieder, Meinbach et al. 2005, Xishuang, Deyong et al. 2010, Smith, Falconer et al. 2018). None of the patients required an urgent transfusion. We propose that it is safe to stop routine Group and Saves unless the operative surgeon or anesthetist request for pre-operative samples due to consideration of high risk patients. In our centre we propose a cost saving of an estimated £8,260 to £13,876 per year by stopping routine Group and Save samples for elective TURBT patients.
We are now extending this project to audit the need for pre-operative Group and Saves in patients undergoing elective TURP. This may further reduce cost by stopping routine Group and Saves prior to elective transurethral resections, especially with the uptake of Holmium Laser Enucleation of the Prostate (HOLEP) which we do not currently pre-operatively Group and Save for the larger prostates in our centre.
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