CLINICAL GUIDELINE FOR MAXIMUM SURGICAL BLOOD

ORDER SCHEDULE (MSBOS)

Summary.
Start

Elective procedure identified, blood

requirement listed in guideline

Patient attends PAC and has a

group and screen (G&S) taken

G&S tested in transfusion lab

Patient appropriate
for electronic issue

Yes No

G&S taken on admission as required G&S taken several days prior to

(detail in guideline) allow crossmatch (detail in guideline)

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Aim/Purpose of this Guideline
1.1. The MSBOS is a guide to help ensure that blood is available at elective surgery.

1.2. This guidance is not absolute: factors other than the type of surgery (low Hb,
antiplatelet drugs, bleeding tendency, previous surgery, co-morbidities etc) should be
considered with respect to both the choice of hospital site and the availability of cross-
match.

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1. The Guidance
1.1. Important Information:

1.2. There must be a valid Group and Antibody Screen (G+S) specimen in the
lab to supply any blood except emergency O Rh D neg

1.3. Emergency O Rh D neg may not be suitable for patients with antibodies

1.4. A G+S specimen is valid for a maximum of 7 days (3 days if transfused or

pregnant in the last three months)

1.5. The sole function of a G+S specimen taken in a pre-operative assessment

clinic is to identify the presence of red cell antibodies and allow appropriate
planning (ie order in antigen negative red cells which may need to come from
Bristol). It does not contribute to the availability of blood at surgery for which a
specimen < 7 days old must be available

1.6. If there is a risk of significant blood loss at surgery for any procedure then
a valid G+S specimen should be supplied within the 7 days preceding surgery.

1.7. Electronic Issued (EI) Red Cells

1.8. Electronic issue is the supply of blood on the basis of an automated

confirmed blood group and a negative antibody screen performed. Blood does not
need to be crossmatched and so can be dispensed within five minutes of request. A
valid sample must be available in the laboratory.

1.9. Electronic issue is only allowable where a patient’s plasma does not
contain (or has not been known to contain) red cell antibodies, where there is no
history of a solid organ transplant, and where there has been sufficient time for a
valid (<7day old) sample to be grouped and screened by analyser (two hours
minimum). Where these criteria are not met, a full manual crossmatch must be
performed.

1.10. If surgery proceeds and blood loss occurs before this automated check is
performed then crossmatched blood should be requested and this takes 45 min.

1.11. If blood is required within 45 mins, group specific blood can be supplied
within 15 mins. Telephone the lab on ext 2500 to organise this.

1.12. Antibodies

1.13. When an antibody has been identified in the pre-op assessment clinic it is
the responsibility of this clinic to ensure a valid G+S specimen, and crossmatched
blood if necessary, is made available for surgery. This MSBOS advises how many
units should be ordered in. This should be done at least a day before surgery.

1.14. Blood availability

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 1.15. In the absence of antibody it is the responsibility of the surgeon to supply a
G+S specimen if considered necessary

1.16. If no antibodies are present this sample may be taken on admission

1.17. In the event of blood loss patients first on the list will require manual cross-
match

1.18. If essential emergency O neg† and group specific blood is available during
the interval between receipt of a G+S specimen and crossmatched or electronic
issued blood becoming available

1.19. Be aware that there is a small risk that patients may have made antibodies
since the PAC sample, particularly if transfused in the meantime.

1.20. For very low risk procedures a G+S specimen is not required.

1.21. Surgery at St Michaels and West Cornwall

1.21.1. The G+S specimen must be supplied to the RCH site. If there is a risk of
requiring transfusion consideration should be given whether it is appropriate for
surgery on that site. There may be a lower threshold for taking a G+S specimen,
and it is wise to ensure this G+S specimen arrives at the laboratory before the
commencement of surgery. The time required for transport will delay availability.
The case mix at WCH and SMH would suggest that this delay is acceptable.

1.22. Revision THR at St. Michaels Hospital

1.23. Patients should be selected on the following basis:

 ASA1 and ASA2 (unless low grade ASA3)

 Pre-optimised with Hb > 120g/l women and > 130g/L men. This must be a FBC
within 1 month of surgery and checked before surgery commences.

 No contra-indication to using intra-operative cell salvage

 No antibodies on PAC G&S

1.24. †O neg blood is available as follows:

WCH 2 units
SMH 2 units
RCHT Transfusion lab 2 units
Main theatre 2 units
Trauma theatre 2 units
Maternity 2 units + neonatal emergency unit
Duchy Hospital 2 units

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If there is a particular individual risk of significant blood loss (eg low Hb, clotting risk, previous
surgery etc),
consider triage to RCHT and err on the side of ensuring a G+S specimen is available ahead of
surgery

NB if Ab detected blood must be requested well in advance

NB this pre-op clinic specimen serves as an antibody screen and does not mean that e-matched
blood will be available at surgery
▼

as it may have to come from Bristol.

Pre op clinic On day of surgery
GENERAL SURGERY WCH / SMH RCHT If antibodies detected ◄

Abdominal-perineal resection G&S G&S 2 UNITS

Cholecystectomy G&S 2 UNITS
Colectomy G&S G&S
Gastrectomy - Partial G&S G&S
Hemicolectomy G&S G&S
Laparotomy (Malignancy or Crohn’s) G&S G&S 2 UNITS
Anterior resection rectum G&S G&S 2 UNITS
Pan-proctocolectomy G&S G&S 2 UNITS
Splenectomy G&S G&S 4 UNITS
BREAST
Major reconstruction G&S 2 UNITS
Mastectomy G&S 2 UNITS
VASCULAR
Aneurysm G&S G&S 4 UNITS
Aorto-femoral graft G&S G&S 4 UNITS
Carotid G&S G&S 2 UNITS
Femoral-popliteal graft G&S G&S 2 UNITS
Profundaplasty G&S G&S 2 UNITS
BKA G&S G&S 2 UNITS
AKA G&S G&S 2 UNITS
EVAR G&S G&S 4 UNITS
NB for MAJOR emergency blood loss eg for aortic aneurysm rupture a massive haemorrhage pack
should be requested
and consists of:

Pack A: 4 units RBC + 4 units FFP

Pack B 4 units RBC, 4 FFP + 1 platelets
Pack C 4 units RBC, 4 FFP, 1 unit platelets and 2 pools
cryo

Pack C repeats until lab is stood down

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If there is a particular individual risk of significant blood loss (eg low Hb, clotting risk, previous
surgery etc),

NB if Ab detected blood must be requested well in advance as it may have to come from Bristol.
consider triage to RCHT and err on the side of ensuring a G+S specimen is available ahead of
surgery

NB this pre-op clinic specimen serves as an antibody screen and does not mean that e-matched blood
will be available at surgery
▼
Pre op clinic On day of surgery
OBSTETRICS AND WCH / SMH RCHT If antibodies detected
◄
GYNAECOLOGY
APH / PPH G&S 2 UNITS
APH (significant) 2 UNITS (variable) 2 UNITS
Caesarean section (LSCS) G&S G&S 2 UNITS
ERPC (D+C) G&S G+S
Ectopic pregnancy - if ruptured G&S 4 UNITS
- laparotomy G&S 2 UNITS
Hysterectomy - total abdominal G&S G&S 2 UNITS
- vaginal G&S G&S 2 UNITS
- laparoscopic G&S G&S 2 UNITS
- radical for vaginal cancer G&S G&S 2 UNITS
Laparotomy for advanced ovarian G&S G&S 2 UNITS
cancer
Myomectomy G&S G&S 2 UNITS
Oophorectomy (cyst) - benign G&S G&S 2 UNITS
Placenta praevia G&S 2 UNITS
Placenta removal - manual G&S 2 UNITS
Termination (TOP) G&S G&S 2 UNITS
Trial of scar G&S 2 UNITS
Vaginal prolapse repair G&S G&S 2 UNITS
Vulval cancer radical surgery G&S G&S G&S
and consists of:

Pack A: 4 units RBC + 4 units FFP

Pack B 4 units RBC, 4 FFP + 1 platelets
Pack C 4 units RBC, 4 FFP, 1 unit platelets and 2 pools
cryo

Pack C repeats until lab is stood down

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 If there is a particular individual risk of significant blood loss (eg low Hb, clotting risk,
previous surgery etc),
consider triage to RCHT and err on the side of ensuring a G+S specimen is available ahead

NB if Ab detected blood must be requested well in advance as it may have to come from Bristol.
of surgery

NB this pre-op clinic specimen serves as an antibody screen and does not mean that e-matched
blood will be available at surgery
▼
Pre op clinic On day of surgery
Orthopaedics WCH / SMH RCHT If antibodies detected ◄

Osteotomy (tib / fib) G&S G&S 2 UNITS

THR G&S 2 UNITS
THR revision G&S G&S G&S 4 UNITS
TKR G&S 2 UNITS
# NOF G & S on G&S 2 UNITS
admission
Urological Surgery
Nephrectomy G&S G&S 2 UNITS
Prostatectomy TUR and RRP G&S 2 UNITS
TUR of bladder tumour G&S 2 UNITS
PCNL G&S G&S 2 UNITS
Adrenalectomy G&S G&S 2 UNITS
Pyeloplasty G&S G&S 2 UNITS
ENT
Block dissection of neck G&S G&S 2 UNITS
Laryngectomy G&S G&S 2 UNITS

Bariatric
Gastric Band G&S G&S 2 UNITS
Gastric Bypass G&S G&S 2 UNITS
NB for MAJOR emergency blood loss eg for aortic aneurysm rupture a massive haemorrhage pack
should be requested
and consists of:

Pack A: 4 units RBC + 4 units FFP

Pack B 4 units RBC, 4 FFP + 1 platelets
Pack C 4 units RBC, 4 FFP, 1 unit platelets and 2 pools
cryo

Pack C repeats until lab is stood down

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2. Monitoring compliance and effectiveness

Element to be Appropriate availability of blood for elective surgery

monitored
Lead Dr Kathy Clarke / Stephen Bassey

Tool Audit and incident monitoring

Frequency Daily monitoring by BMS staff during provision of blood
Reporting Non-compliance will be raised as an incident on QPulse and
arrangements reviewed by the Hospital Transfusion Team (HTT)

Acting on The HTT will take executive action if urgent action is required. HTT
recommendations will report to the Hospital Transfusion Committee (HTC) (sits 3 x /
and Lead(s) year)

Change in The HTC will identify appropriate action and is structured to

practice and communicate with the clinical workforce and ensure corrective
lessons to be action is undertaken.
shared The HTC will determine whether any alterations to this (MSBOS)
policy are necessary

3. Equality and Diversity

3.1. This document complies with the Royal Cornwall Hospitals NHS Trust
service Equality and Diversity statement which can be found in the 'Equality,
Diversity & Human Rights Policy' or the Equality and Diversity website.

3.2. Equality Impact Assessment

The Initial Equality Impact Assessment Screening Form is at Appendix 2.

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Appendix 1. Governance Information
Maximum Surgical Blood Order Schedule
Document Title
(MSBOS)

Date Issued/Approved: November 2017

Date Valid From: November 2017

Date Valid To: November 2019

Directorate / Department responsible Nicki Jannaway, Lead Transfusion

(author/owner): Practitioner

Contact details: 01872 253093

Provides indication for appropriate blood

Brief summary of contents ordering

Transfusion; Blood ordering; Red cells;

MSBOS ; MBOS; haemorrhage; pre-
Suggested Keywords:
assessment; PAC;

RCHT PCH CFT KCCG

Target Audience

Executive Director responsible for
Medical Director
Policy:
Date revised: 03/11/17
Maximum Surgical Blood Order Schedule
This document replaces (exact title of
(MSBOS) V4
previous version):
Hospital Transfusion Team, Hospital
Approval route (names of
Transfusion Committee, CSCS Divisional
committees)/consultation:
Governance Board
Divisional Manager confirming
approval processes
Name and Post Title of additional
Kevin Wright, Governance Lead CSCS
signatories

Name and Signature of {Original Copy Signed}

Divisional/Directorate Governance
Lead confirming approval by specialty
and divisional management meetings Name:

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 Signature of Executive Director giving
{Original Copy Signed}
approval
Publication Location (refer to Policy
on Policies – Approvals and Internet & Intranet  Intranet Only
Ratification):
Clinical / Haematology
Document Library Folder/Sub Folder
Guidelines for the Clinical Use of Red Cell
Transfusions (BCH)
Links to key external standards Patient Blood Management (NHSBT)
Better Blood Transfusion 3 (DOH)

Related Documents: Transfusion Policy

No – ongoing training given in transfusion
Training Need Identified?
mandatory sessions across the Trust

Version Control Table

Version Changes Made by

Date Summary of Changes
No (Name and Job Title)
June 2007 V1.0 New Document Stephen Bassey,
Transfusion Laboratory
Manager
July 2009 V2.0 Minor changes Stephen Bassey

April 2011 V3.0 Revision and reformatting throughout Dr Richard Noble,

Haematology Consultant

July 2014 V4.0 Minor changes to tables, reformatting Dr Richard Noble,

throughout to meet RCHT Documents Library Haematology Consultant
criteria

Reformatting tables, addition of G&S for #NOF,

November removal of G&S for mastectomy, change of Nicki Jannaway, Lead
V6.0
2017 emergency O neg locations, addition of Transfusion Practitioner
parameters for surgery at SMH

All or part of this document can be released under the Freedom of Information
Act 2000

This document is to be retained for 10 years from the date of expiry.

This document is only valid on the day of printing

Controlled Document
This document has been created following the Royal Cornwall Hospitals NHS Trust
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 Policy on Document Production. It should not be altered in any way without the
express permission of the author or their Line Manager.

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Appendix 2. Initial Equality Impact Assessment Form
This assessment will need to be completed in stages to allow for
adequate consultation with the relevant groups.

Name of Name of the strategy / policy /proposal / service function to be assessed

Maximum Surgical Blood Order Schedule (MSBOS)
Directorate and service area: Is this a new or existing Policy?
Clinical Haematology, CSCS Division Existing
Name of individual completing assessment: Telephone:
Nicki Jannaway
1. Policy Aim* Provides indication for appropriate blood ordering

Who is the strategy /

policy / proposal /
service function aimed
at?
2. Policy Objectives* To ensure adherence to national guidelines on provision of blood
during surgical interventions

3. Policy – intended To support medical and laboratory staff in decision making process
Outcomes*

4. *How will you Daily monitoring by BMS staff during course of provision of blood
measure the
outcome?

5. Who is intended to Laboratory and medical staff, patients

benefit from the
policy?
6a Who did you Workforce Patients Local External Other
consult with groups organisations
√
Please record specific names of groups
b). Please identify the
Consultant Anaesthetists and Consultant Surgeons Hospital
groups who have
Transfusion Team
been consulted about
this procedure.
What was the Document approved
outcome of the
consultation?

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7. The Impact
Please complete the following table. If you are unsure/don’t know if there is a negative
impact you need to repeat the consultation step.

Are there concerns that the policy could have differential impact on:
Equality Strands: Yes No Unsure Rationale for Assessment / Existing Evidence
Age √

Sex (male, √
female, trans-gender /
gender reassignment)

Race / Ethnic √
communities
/groups

Disability - √
Learning disability,
physical
impairment, sensory
impairment, mental
health conditions and
some long term health
conditions.
Religion / √
other beliefs
Marriage and √
Civil partnership

Pregnancy and √
maternity
Sexual √
Orientation,
Bisexual, Gay,
heterosexual, Lesbian
You will need to continue to a full Equality Impact Assessment if the following have
been highlighted:
 You have ticked “Yes” in any column above and

 No consultation or evidence of there being consultation- this excludes any policies which have
been identified as not requiring consultation. or

 Major this relates to service redesign or development

8. Please indicate if a full equality analysis is recommended. Yes No √

9. If you are not recommending a Full Impact assessment please explain why.

Not required as no impact

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Signature of policy developer / lead manager / director Date of completion and submission
3/11/17
Nicki Jannaway
Names and signatures of 1. Nicki Jannaway
members carrying out the 2. Human Rights, Equality & Inclusion Lead
Screening Assessment

Keep one copy and send a copy to the Human Rights, Equality and Inclusion Lead
c/o Royal Cornwall Hospitals NHS Trust, Human Resources Department, Knowledge Spa,
Truro, Cornwall, TR1 3HD

This EIA will not be uploaded to the Trust website without the signature of the
Human Rights, Equality & Inclusion Lead.

A summary of the results will be published on the Trust’s web site.

Signed __ _____________

Date ________________

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