Coagulation and Transfusion Medicine / VIRTUAL BLOOD BANKING
Virtual Blood Banking
A 7-Year Experience
K.F. Wong, MD, Angela M.Y. Kwan
Key Words: Virtual blood bank; Computer crossmatch; Operation theater blood transaction system; Compatible blood; Unmatched blood;
Intraoperative transfusion
DOI: 10.1309/13CUJ61YRB50B1CT
Abstract
The operating theater blood transaction system
(OTBTS) is a virtual blood banking system that allows
computer crossmatch–compatible blood ordering and
delivery in the operating theater remote from the
hospital blood bank. It was developed and implemented
in our hospital in 1997 and was expanded in 2002 to
include an unmatched blood module that allows
ordering and issuing unmatched RBCs for
intraoperative transfusion. During the past 7 years, the
system has handled 6,333 crossmatch requests for
intraoperative transfusion and issued 20,073 units of
RBCs, including 100 units of unmatched RBCs (group
O, 72 units; group-identical, 28 units). The OTBTS has
proven to be efficient (with a turnaround time for blood
ordering and issuing <30 seconds), effective (with a
reduced crossmatch/transfusion ratio and blood
wastage), and error free (no delay or error in
transfusion or postponement of operation).
Furthermore, our experience with the unmatched blood
module has attested to the safety and efficacy of
computer-controlled, online ordering and real-time, on-
site delivery of unmatched RBCs for emergency
transfusion.
124 Am J Clin Pathol 2005;124:124-128
124 DOI: 10.1309/13CUJ61YRB50B1CT
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A major challenge to blood bankers is to provide real-time,
zero-risk, and zero-wastage blood transfusion service, particu-
larly for patients with active bleeding. Such a target can be
achieved partly by the use of computer crossmatch. In comput-
er crossmatch, electronic verification of the ABO blood group
replaces the immediate-spin crossmatch for ABO incompatibil-
ity between donor RBCs and patient serum samples.1
Computer crossmatch is considered a safer and more effi-
cient system than the antiglobulin and immediate-spin cross-
match, provided that the ABO/Rh D blood group has been
determined twice and the patient has no history of clinically
significant antibodies.1-4 It has been estimated that the work-
load in the blood bank could be reduced by as much as two
thirds compared with antiglobulin crossmatch.2 Furthermore,
the computer crossmatch has drastically shortened the time
required for obtaining compatible RBCs when transfusion is
needed, thus allowing flexibility in the management of blood
inventory and also minimizing blood wastage.1-5 Other mea-
sures include a portable blood-storage refrigerator or out-of-
hospital transfusion,6,7 with the aim of bringing the blood bank
facilities nearer to the patients.
In 1997, we developed a computer software system (the
operating theater blood transaction system [OTBTS]) that pro-
vides “self-service” ordering and delivery of computer cross-
match–compatible RBCs by nonlaboratory personnel at sites
remote from the hospital blood bank.8 The system is cost-
effective, efficient, and user friendly. With the experience
gained and confidence built on the OTBTS, the system has
been developed further to provide emergency transfusion of
unmatched RBCs for patients who do not yet have a valid type
and screen (T&S) result. In this report, we review our 7-year
experience with the OTBTS and its capability to provide a
© American Society for Clinical Pathology

safe and timely blood transfusion service and, in particular,
the value and safety of real-time ordering and delivery of
unmatched RBCs through the remote blood delivery system.
Materials and Methods
Blood Bank
The Queen Elizabeth Hospital, Hong Kong, China, is an
acute care hospital with 1,800 beds and all major medical and
surgical departments, including cardiothoracic surgery and
traumatology units. Each year, the blood bank handles about
32,000 requests for compatibility testing and issues more than
25,000 units of RBCs for transfusion. Routine serologic com-
patibility testing (T&S and immediate-spin crossmatch) was
replaced by computer crossmatch in August 1996, which led
to improvement of the crossmatch/transfusion (C/T) ratio
from around 1.7 to 1.5. The blood bank of Queen Elizabeth
Hospital is situated in a separate building some distance from
the operating theater (OT); the round trip requires 20 to 30
minutes. In view of the efficacy and safety of computer cross-
match, we implemented a computer system for self-service
blood ordering and issuing in the OT in 1997.8
Operating Theater Blood Transaction System
The software and hardware requirements have been
described in a previous report.8 Briefly, the system has built-
in logic to verify and confirm compatibility of the RBCs taken
from the blood-storage refrigerator in the OT and ensure that
only designated blood units are issued for transfusion in sero-
logically complicated cases. The numbers of crossmatch
requests and blood units issued (and transfused) through the
OTBTS in a 7-year period from June 16, 1997, to June 15,
2004, were reviewed. The turnaround time (TAT) for blood
ordering and issuing through the OTBTS, the C/T ratio, and
the expiration rate of RBCs were recorded. The frequency,
duration, and effects of computer downtime were monitored.
All clerical, computer, and transfusion errors were document-
ed and investigated.
Unmatched Blood Module
In 2002, the OTBTS was expanded to incorporate the
logic for ordering and issuing unmatched RBCs for emer-
gency transfusion ❚Figure 1❚. If the blood group of the trans-
fusion recipient is not yet known, group O RBCs will be
issued ❚Figure 2A❚. If the blood group is known (with a his-
toric record in the hospital laboratory information system) and
has been confirmed from a current blood sample, the nursing
staff will be instructed to take group-identical RBCs for trans-
fusion ❚Figure 2B❚ and group O RBCs can no longer be issued.
Once the blood bank has received and registered the patient’s
© American Society for Clinical Pathology
Coagulation and Transfusion Medicine / ORIGINAL ARTICLE
blood sample and the T&S is being performed, a real-time
indication of the expected time for completion of the T&S and
availability of computer crossmatch–compatible RBCs
(except for cases with a positive T&S result) will be given
❚Figure 3❚; the latter is estimated from the registration time of
the blood sample and the promised TAT of T&S. This infor-
mation can help decide whether one can wait for the T&S
result and computer crossmatch–compatible RBCs. A com-
puter printout (with the patient’s data and blood group if avail-
able and the blood group of the unmatched blood unit) will be
issued to the anesthesia provider for confirmation and signing.
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Similar to the release of computer crossmatch–compati-
ble RBCs through the OTBTS, there is no additional tagging
or labeling of the unmatched blood unit.8 The blood bank will
be alerted if unmatched RBCs have been issued. Unmatched
RBCs will not be issued through the OTBTS if the patient is
younger than 4 months or known to have a Rh D-negative phe-
notype, alloantibody, or ABO anomaly.
The system logic was written according to the current
practices in the blood bank and international standards.9,10 The
system was tested, validated, and fully implemented on April
10, 2002. The use and efficacy of the unmatched blood mod-
ule from April 10, 2002, to June 15, 2004, are reviewed.
Results
During the 7-year period, 20,073 units of RBCs were
issued for 6,333 patients for intraoperative transfusion through
the OTBTS. Of these, 1,099 units were returned to the blood
bank after being issued. The system rejected 62 of these units
for reissuing because they had left the blood-storage refriger-
ator for more than 30 minutes. Thus, the wastage rate for the
OTBTS was only 0.31%, and the C/T ratio was 1.06:1.
The amount of RBCs issued through the OTBTS consti-
tuted approximately 11% (20,073/181,599) of the total
amount of RBCs and whole blood transfused in the hospital
during the study period. The TAT for blood ordering and issu-
ing from the OTBTS was less than 30 seconds, even when
multiple blood units were issued. No transfusion incident
(including delay) or postponement of operation occurred, and
no transfusion error was reported in the OT during this period.
A 4-hour computer downtime was scheduled monthly
for preventive maintenance of the network and other hard-
ware components of the hospital laboratory information sys-
tem, usually at midnight or early on Sunday morning when
there were no scheduled operations. Unscheduled computer
downtime was exceedingly rare for the OTBTS, and intraop-
erative blood transfusion was never affected. A documented
manual backup system for blood ordering and issuing was in
place during computer downtime, with retrospective entry of
all transactions.
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125 DOI: 10.1309/13CUJ61YRB50B1CT 125
Wong and Kwan / VIRTUAL BLOOD BANKING

Unmatched blood requested

Patient identification

If the patient is/has:

(a) <4 months old or
(b) known to be Rh D negative or
(c) a previous record of alloantibody or
(d) a previous record of ABO anomaly

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Yes No

Contact blood bank Current ABO/Rh D

Known Unknown

Historical ABO/Rh D if available

Different Same

Antibody screen result

Positive Negative Unknown/In progress

Contact blood bank Computer crossmatch Unmatched group Unmatched

compatible RBCs identical RBCs group O RBCs

❚Figure 1❚ A flowchart showing the algorithm for ordering and issuing unmatched RBCs through the operating theater blood
transaction system.

A B

❚Figure 2❚ If an emergency transfusion is required before the availability of the type and screen result, group O RBCs (A) or
group-identical RBCs (B) can be issued, depending on whether the patient’s blood group is known.

126 Am J Clin Pathol 2005;124:124-128 © American Society for Clinical Pathology

126 DOI: 10.1309/13CUJ61YRB50B1CT
 Coagulation and Transfusion Medicine / ORIGINAL ARTICLE

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❚Figure 3❚ Once the patient’s blood sample has been received, a real-time estimate of availability of the type and screen result
and, thus, computer crossmatch–compatible RBCs will be indicated (arrow).

Since the development of the unmatched blood module of
the OTBTS, 72 units of unmatched group O RBCs and 28 units
of unmatched group-identical RBCs were issued to 33 patients
for intraoperative transfusion. This represents 14.3% of all
unmatched RBCs transfused in the hospital during the study
period (100/700). Emergency transfusions using computer
crossmatch–compatible RBCs instead of unmatched RBCs
eventually were given to 2 patients with the knowledge that
T&S could be completed within a short time. The average num-
ber of units of unmatched RBCs for each request issued through
the OTBTS was 3, compared with 3.2 for the whole hospital.
Only 8 units of unmatched RBCs were returned through the
OTBTS and within 30 minutes of issue. Compared with the
past, the total number of requests for unmatched RBCs and the
total amount of unmatched RBCs transfused for the hospital
have decreased since introduction of the OTBTS, with further
In 1997, our hospital implemented a computer-based sys-
tem for remote ordering and on-site issuing of computer cross-
match–compatible RBCs in the OT.8 The system is able to
shorten markedly the time of blood delivery to the OT, reduce
the C/T ratio, and reduce the blood inventory and wastage.
The TAT for obtaining compatible RBCs for intraoperative
transfusion has decreased from more than 30 minutes to less
than 30 seconds, even when multiple units of RBCs are
ordered and issued at the same time. The quality of blood
stock can be improved, because the blood units that have left
the blood-storage refrigerator for more than 30 minutes will
be discarded, in accordance with international guidelines.12
During the past 7 years, there were no delays in transfu-
sion or postponement of surgical operations due to problems or
OTBTS
No. of Requests/Amount of RBCs

400
improvement after the implementation of the unmatched blood
350 Unmatched blood module
module ❚Figure 4❚. The return rate of issued unmatched blood 300
dropped from 21.8% to 13.6% after the implementation of the 250
unmatched blood module. No transfusion errors were observed. 200
150
100
50
Discussion 0
97/98 98/99 99/00 00/01 01/02 02/03 03/04
Although computer crossmatch was first described by
Year
Butch et al1 in 1994, it has not been practiced widely, with
only 4% of hospitals in United States using computer cross- ❚Figure 4❚ The number of requests (dotted line) for
match when no alloantibody was detected.11 The capability of unmatched blood transfusion and the total amount of
blood bank computerization, therefore, has not been realized unmatched RBCs transfused (solid line) from 1997 to 2004.
fully and its versatility not wholly explored. OTBTS, operating theater blood transaction system.

© American Society for Clinical Pathology Am J Clin Pathol 2005;124:124-128 127

127 DOI: 10.1309/13CUJ61YRB50B1CT 127
Wong and Kwan / VIRTUAL BLOOD BANKING
downtime of the OTBTS. Several known problems associated with
satellite blood banks and remote blood-storage facilities have
been described, such as blood for multiple patients stored in the
same refrigerator and inadequate stock on hand during an emer-
gency, resulting in using blood for other patients. The OTBTS can
solve these problems by taking full advantage of computer cross-
match, ie, immediate availability of compatible RBCs without the
need for previous allocation of blood units to designated patients,
allowing the controlled use of any group-identical RBCs, real-
time inventory monitoring, and early stock replenishment.
In 2002, we implemented a novel module for remote online
ordering and immediate on-site delivery of group O or group-
identical unmatched RBCs. The interval between prescribing the
emergency transfusion and delivery of the unmatched RBCs to
the OT is less than 1 minute. The requesting clinician (usually
the anesthesia provider) does not need to call the blood bank or
complete a request form ordering unmatched RBCs. Keeping
the clinician informed of the progress of the T&S facilitates deci-
sion making in emergency intraoperative transfusions and
reduces the need for unmatched blood transfusion. Thus, the
OTBTS can ensure timely, safe, and appropriate blood transfu-
sion during an emergency and allow documentation and trace-
ability of the unmatched RBCs ordered and issued.
Our results also show that approximately 1.1% (100 of 8,820
units issued through OTBTS) of intraoperative transfusions
required unmatched blood and about 3 units of RBCs are given
for each episode of unmatched blood transfusion. Of interest, after
implementation of the unmatched blood module, the number of
requests for unmatched RBCs and the number of unmatched
blood units transfused or returned have dropped. This observation
confirms that increased autonomy of clinicians and enhanced
accessibility of blood products will not lead to increased blood
use,8 but rather to more rational requests and use because an
“unlimited” supply can practically be instantly assured.
The OTBTS can be viewed as an extension of the comput-
er crossmatch and blood bank porter service, with the use of non-
laboratory personnel for blood ordering and issuing in the OT.
Immediate availability of computer crossmatch–compatible and
controlled release of unmatched RBCs are made possible by the
system. The hardware and software (such as database licensing)
costs are not substantial. The system is considered easily main-
tainable by the informatics team. At least 1 full-time equivalent
for transportation of blood units could be saved with this system
even before the addition of the unmatched blood module.8 There
potentially can be more savings if several satellite OTs are served
by the same blood bank. The nursing and blood bank staff are
free to perform other duties because the burden of transportation
and phone inquiry is removed. Other benefits include reduction
in stress experienced by OT and blood bank staff, particularly at
times of emergency intraoperative transfusion.
There is no clear detriment to transfusion safety with the
OTBTS compared with conventional paper-based and
128 Am J Clin Pathol 2005;124:124-128
128 DOI: 10.1309/13CUJ61YRB50B1CT
porter-dependent systems. Nevertheless, about 3% to 4% of
patients (mostly with a positive T&S) cannot receive the full
benefit of the system because designated blood units have to be
issued from the blood bank (Figure 1). Because the OT is a rel-
atively restricted area with designated staff and controlled
access, significant barriers such as security precautions, staff
training, and inventory management need to be overcome
before the full potential of the remote blood delivery system
can be exploited in other clinical settings.
To conclude, the OTBTS has proven to be safe, efficient,
and cost-effective. The success of the OTBTS is, however,
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dependent upon designated and dedicated staff with appropri-
ate training, on-site bar-code data entry and checking, and
“real-time” response, feedback, and monitoring.
From the Department of Pathology, Queen Elizabeth Hospital,
Hong Kong, China.
Address reprint requests to Dr Wong: Dept of Pathology,
Queen Elizabeth Hospital, 30 Gascoigne Rd, Kowloon, Hong
Kong SAR, China.
Acknowledgment: We thank the ECPath LIS Project Team,
Hospital Authority, Hong Kong, for developing and testing the OTBTS.
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