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Original Article

Surgical blood ordering schedule for better

inventory management: An experience from a
tertiary care transfusion center

Pruthvi Raj Guduri a, Shamee Shastry b,*, Manish Raturi c, Anitha Shenoy d
a
Head (Transfusion Medicine), The Mission Hospital, Durgapur, West Bengal, India
b
Professor & Head (Immunohematology & Blood Transfusion), Kasturba Medical College, Manipal, Manipal
Academy of Higher Education, Manipal, Karnataka, India
c
Assistant Professor (Immunohematology & Blood Transfusion), Himalayan Institute of Medical Sciences, Dehradun,
Uttarakhand, India
d
Professor (Anesthesia), Kasturba Medical College, Manipal, Manipal Academy of Higher Education, Manipal,
Karnataka, India

article info abstract

Article history: Background: Overordering of blood has been a challenge faced by the blood bank staff. The
Received 16 July 2019 present study addresses the role of maximum surgical blood ordering schedule (MSBOS) in
Accepted 9 July 2020 optimizing the blood inventory management.
Available online 9 October 2020 Methods: The blood requests for elective surgical procedures from various surgical de-
partments were reviewed to constitute MSBOS. Transfusion profile was assessed using
Keywords: crossmatch to transfused units (C/T) ratio, transfusion probability (TP), and transfusion
C/T ratio index (TI). A cutoff of 0.3 and 5% value of TI and TP, respectively, was considered to decide
Transfusion probability on the type of crossmatch. The efficacy of MSBOS implementation has been determined
Transfusion index prospectively by unpaired t test using SPSS software, version 20 (IBM, USA).
MSBOS Results: A total of 2674 patients were studied. Overall red cell usage rate was 15%. The
comprehensive C/T ratio was 4.57. The C/T ratios for the various departments ranged from
1 to 8.5 (adjusted C/T ratio). Highest C/T ratio was observed for surgical procedures per-
formed in the specialties of otorhinolaryngology and urology. A C/T ratio greater than 5
was noted in 30.4% of different types of surgical procedures. Of the 176 different types of
elective surgical procedures studied, type and screen protocol was applicable for 75.5%
(133) of the procedures. After implementation of MSBOS, the number of crossmatches
reduced by 2152 and total working time saved in our laboratory is close to 75,320 man
hours.
Conclusion: MSBOS helps in identifying the common surgical procedures with low TP and is
one of the efficient tools in preventing the overordering of the blood.
© 2020 Director General, Armed Forces Medical Services. Published by Elsevier, a division of
RELX India Pvt. Ltd. All rights reserved.

* Corresponding author.
E-mail address: shameeshastry@gmail.com (S. Shastry).
https://doi.org/10.1016/j.mjafi.2020.07.004
0377-1237/© 2020 Director General, Armed Forces Medical Services. Published by Elsevier, a division of RELX India Pvt. Ltd. All rights
reserved.
284 m e d i c a l j o u r n a l a r m e d f o r c e s i n d i a 7 8 ( 2 0 2 2 ) 2 8 3 e2 9 0

aforementioned departments at our tertiary care center.7 The

Introduction sources of retrospective data collection were the cross-match
requisitions, preanesthetic checkup form, Blood Bank soft-
Excessive blood requests are a common challenge faced by the ware (Blood Bank, Data Management systems, Easy Software,
transfusion services. Nearly 66% of all the blood transfusions Ahmedabad, Gujarat), laboratory reports software (Lab infor-
are performed during the perioperative period.1 Previous mation systems), and the discharge summary. The data have
studies have revealed that there is gross overordering of blood been collected for a retrospective period of 1 year.
for elective surgical procedures, in excess of actual and
anticipated needs.2 In practice, whenever blood unit is cross- Phase II: constitution of MSBOS
matched for a patient, it is rendered unavailable to others It involves 3 major steps. The first step that we have under-
for 48 h and also results in aging of the blood unit during taken was the identification of departments with frequent
reserved period.3 Considering the limited shelf life of blood elective surgeries being performed and the study protocol was
products, transfusion services may follow any one of the formulated. Step 2 involved retrospective analysis (phase 1). In
several policies that help in making an efficient use of blood step 3, we evaluated the number of blood units transfused (T)
bank inventory and consequently reducing the risk of out- and the number of blood units cross-matched (C) for each
dating the blood units. One such policy that has been proven elective surgical procedure that was performed in patients
to be successful in the practice of blood banking is the who met our inclusion criteria. The data of units requested,
maximum surgical blood ordering schedule (MSBOS).4 MSBOS cross-matched, issued, transfused were analyzed using the
is a table of elective surgical procedures listing the number of standard known indices of blood usage analysis. Crossmatch
blood units to be cross-matched routinely. A recommended to Transfusion (C/T) ratio, TP, and transfusion index (TI) for
MSBOS for common surgical procedures was published by every specified elective surgical procedure has been deter-
Freidman et al.5 However, with the constant change in the mined. The following formulae were used during the study:
surgical techniques, there is change in the utilization rate of
blood products. Hence, MSBOS needs to be reviewed and 1. The formula for C/T ratio:
updated regularly.
The MSBOS is supposed to guide and help in deciding the
ordering and transfusion of blood, but the final judgment is  No:of units cross matched
C T ratio ¼
left to the clinician.6 The main advantage with MSBOS is that No:of units transfused
1
we can identify common surgical procedures with low trans- ½Value of < 2 is considered ideal
fusion probability (TP) and minimal blood loss by analyzing
the preoperative blood orders so that the type and screen
2. The formula for TP:
(T&S) protocol can be safely applied to such procedures.7 Our
hospital is a 2032-bed tertiary care multispecialty teaching
institute with an average of one hundred surgeries (including Transfusion probability %
minor surgical procedures) performed daily with an approxi- No: of patients transfused
¼  100
mate 120 units requested for elective surgeries per day. No: of patients crossmatched
Therefore, we aimed to develop MSBOS in our setup to opti- ½Value of > 5% was considered ideal and a value < 5%
mize the existing blood ordering practices. signifies no need for crossmatch for that particular
8
surgical procedure

Materials and methods

3. The formula for TI:
Study design
Transfusion index
The study was carried out at a tertiary care center in South
No:of units transfused
India, by the department of immunohematology and blood ¼
No:of patients crossmatched
transfusion in association with the department of anesthesia. 8
½Value of < 0:3 signifies no need for cross  match
This study was an observational and bidirectional study. The
study protocol was approved by the Institutional Ethics
Committee before its commencement. Patient consent for 4. Mead's criterion:[MSBOS ¼ 1.5 x TI]9
inclusion in study was also obtained. The study consisted of
three phases: We henceforth drafted an MSBOS schedule using the
retrospective data. Elective surgical procedures were allotted
Phase I: review and data analysis to two cohorts namely “Type and Screen” and or a “Type and
The incipient phase consisted of retrospective review of the Crossmatch” category based on the transfusion indices
blood ordering requests toward the elective surgical proced- values. A T&S determines ABO blood group and Rh type and
ures from the surgical departments. We have selected only screens for clinically significant alloantibodies in case a pa-
patients belonging to the American Society of Anesthesiolo- tient needs blood. A type and cross determines the same
gists Physical status Classification System (ASA) Grade I and II information, but additionally performs a crossmatch be-
who were scheduled for elective surgical procedures in the tween the patient's sample and a unit of blood to prepare a
 m e d i c a l j o u r n a l a r m e d f o r c e s i n d i a 7 8 ( 2 0 2 2 ) 2 8 3 e2 9 0 285

product for immediate transfusion. A type and cross should 46 ± (19e68, SDd3.81) years. Gender ratio was 1.2:1 where
only be ordered if there is a high likelihood of transfusion. On majority were men, 54% (n ¼ 1445/2674). The total number of
surgical procedures with TI value of <0.3 and TP < 5% only PRBCs requested was 5422 out of which only 813 units have
T&S was performed and surgical procedures with TI value of been transfused giving us a red cell usage rate of around 15%.
>0.3 and TP > 5% type and crossmatch was performed. The The comprehensive C/T ratio was seen to be 6.67. The highest
number of units to be cross-matched for each surgery in type C/T ratio was seen for the surgical procedures belonging to the
and crossmatch was derived from Mead's criterion which otorhinolaryngology followed by the urology department.
states that the maximum number of units to be cross- Transfusion indices for different specialties are shown in
matched for a particular surgical procedure is 1.5 times the Table 1. The overall TI was less than 0.3 in all the specialties
TI.9 The adjusted C/T ratio was also calculated and was and overall TP is greater than 30% for general surgery and
defined as the C/T ratio when only cross-matched blood used orthopedics specialties.
intraoperatively was included in the calculation.2 Because we Analysis of the retrospective data of the transfusion prac-
considered only elective surgeries for this study, we have not tices revealed that of the 176 different types of elective sur-
come across any clinical wastage of PRBC; therefore, we gical procedures performed in different departments,
justify the usage of C/T ratio rather than crossmatch to issue T&S protocol is applicable for 133 types of procedures (75.5%)
ratio. in patients belonging to ASA score I and II (Table 2). Type and
crossmatch of a single unit or two units is indicated in 43 types
Phase III: implementation of MSBOS of procedures (24.4%) (Table 2). When the C/T ratio for the
The development and implementation of MSBOS was carried different types of surgical procedures was scrutinized, it was
out in accordance with the “guidelines for implementation of noticed that C/T ratio of greater than 5 was noticed in 30.45%
an MSBOS” by the British Committee for Standards in He- of surgical procedures.
matology.10 Preimplementation consensus by stakeholders The blood ordering practices have been followed up for a
such as surgeons, anesthetists, and blood bank was obtained period of six months after implementation of MSBOS. In the
to ensure ease of implementation. It was put forward to our prospective study, we analyzed 1354 patients, for whom 2226
Hospital Transfusion Committee comprising the medical units have been cross-matched of which only 417 units were
superintendent, chiefs of various surgical departments, and transfused in this phase. The comprehensive C/T ratio has
the nursing superintendent all of whom approved it before its showed a favorable reduction of 47% with a fall from 6.67 to
implementation. The department-specific MSBOS charts 3.14. It has also been noted that there has been a rise in
were circulated to the specific surgical departments, opera- T&S requests because the implementation of MSBOS (average
tion theaters (OTs), and were put up on the notice boards of number of requests received per month before and after
the wards. The OT staff and the blood bank crossmatch implementation were 115 and 523, respectively). Because the
laboratory technicians were informed about the imple- patients analyzed in the two phases of the study were
mentation of the same and they were also provided the different, unpaired t test was utilized to find out the statistical
approved charts of MSBOS. The analysis of the effectiveness significance.
has been analyzed by unpaired t test after 6 months of the
implementation. The department wise results are as follows

Obstetrics and gynecology

Results The transfusion profile was created for this specialty depicting
the various transfusion indices which revealed that elective
A total of 2674 patients were included both retrospectively and Lower Segment Cesarean Section (LSCS) with sterilization had
prospectively in this study. Patients were split into groups the highest C/T ratio. The greatest TP has been found for
based on the specialty and were further grouped based on the elective LSCS with myomectomy. Adjusted C/T ratio value
type of surgery. The mean age of the population was was 3.05 comprehensively for this department. The reduction

Table 1 e Transfusion indices of the surgical departments of our hospital.

Sl. No. Description Sur Neuro OBG Ortho ENT Uro
1 Number of patients cross-matched 469 228 594 781 144 368
2 Number of units cross-matched 986 526 1156 1540 252 584
3 Number of patients transfused 98 61 79 295 8 15
4 Number of units transfused 147 79 118 343 12 29
5 Crossmatch/transfusion 6.70 6.65 9.79 4.48 21.5 20.13
6 Adjusted crossmatch/transfusiona 4.76 5.8 3.05 6.5 1.5 2.85
7 Transfusion index 0.31 0.34 0.19 0.43 0.08 0.07
8 Transfusion probability 31.3% 26.7% 13.3% 37.7% 5.5% 4.0%

Note: Sur (general surgery), Neuro (neurosurgery), OBG (obstetrics and gynecology), Ortho (orthopedics), ENT (otorhinolaryngology), Uro
(urology).
a
Adjusted C/T ratio is calculated only in cases were transfusions are performed.
 286
Table 2 e MSBOS chart.
Department Type and screen indications Indications for crossmatch of single Indications for
unit crossmatch of two units
Obstetrics and 1. Vaginal polypectomy 16. Cervical biopsy 31. Elective lower segment Caesarean Nil
gynecology (33 2. Cervical dilatation under 17. Diagnostic laparoscopy with chromotubation section with myomectomy
Procedures) ultrasound guidance 18. Diagnostic hysteroscopy 32. Total abdominal hysterectomy and
3. Cervical polypectomy 19. Cystectomy bilateral salpingo-oopherectomy
4. Colpofixation 20. Elective LSCS 33. Vaginal hysterectomy
5. D&C 21. Endometrial and cervical curettage
6. Elective LSCS with sterilization 22. Exploratory laparotomy
7. Excision of scar endometriosis 23. Laparoscopy
8. Hysteroscopy 24. Laparoscopy assisted vaginal hysterectomy and

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9. Laparotomy bilateral salpingo-oopherectomy
10. Loop Electro Surgical Excision 25. Mirena insertion
11. Manual removal of placenta 26. Minilap sterilization - modified Pomeroy's
12. Modified Pomeroy's technique technique
13. Medical termination of 27. Myomectomy
pregnancy 28. Manual vacuum aspiration
14. Subtotal hysterectomy with 30. Bilateral labia major growth excision
bilateral salpingo-oopherectomy
15. Postpartum sterilization
Urology (20 1. BMG urethroplasty 11. Incision and drainage 19. Radical nephrectomy Nil
procedures) 2. End-to-end anastomotic 12. Transuretheral resection of prostate 20. Transuretheral Resection of Bladder
urethroplasty 13. Laparoscopic simple nephrectomy Tumors
3. Donor nephrectomy 14. Ureterolitotomy
4. Double-J stent removal Partial nephrectomy
5. Laparoscopic partial 15. Urethroscopic lithotripsy with double-J stenting
nephrectomy 16. Urethral dilation with cystoscopy
6. Pyelolithotomy 17. Visual internal urethrotomy
7. Inguinal orchidectomy 18. Partial nephrectomy
8. Ureteric reimplantation
9. Cystoscopy
10. Percutaneous nephrolithotomy
with double-J stenting
Otorhinolaryngology 1. Adenoidectomy 14. DNE cauterization 26. Total laryngectomy 29. Hemimandibulectomy
(29 Procedures) 2. Endoscopic adenoidectomy 15. Cochlear implant 27. Total thyroidectomy
3. FESS 16. Excision of cyst 28. Wide excision
4. Hemithyroidectomy 17. Hypopharyngoscopy
5. Incision and drainage 18. Laser-assisted tongue excision
6. Lipoma excision 19. Maxillary sinusotomy
7. Micro laryngoscopy 20. Myringoplasty
8. Septoplasty 21. Sistrunk operation
9. Septoturbinoplasty 22. Preauricular sinus excision
10. Nasal mass excision 23. Superficial parotidectomy
11. Submandibular gland excision 24. Young's operation
12. Tonsillectomy 25. Tracheostomy
13. Tympanoplasty
General Surgery (40 1. Amputation of Toe 13. Ascitic tap 25. Abdominoplasty 37. Abdomino-perineal resection
Procedures) 2. Arthrotomy 14. Cholecystectomy 26. Above-knee amputation 38. Explorative laparotomy
3. Breast conservation surgery 15. Bilateral orchidectomy 27. Below-knee amputation 39. Hemicolectomy
4. Colonoscopy 16. Cyst excision 28. Hemorroidectomy 40. Total gastrectomy
5. Complete thyroidectomy 17. Diagnostic laparoscopy 29. Hepatico-jejunostomy
6. Endoscopic variceal ligation and 18. Great toe amputation 30. Incisional hernioplasty
banding 19. Forefoot amputation 31. Ileal resection anastomosis
7. Hemithyroidectomy 20. Incision and drainage 32. Modified radical mastectomy
8. Flap reconstruction 21. Laparoscopic hernioplasty 33. Open cholecystectomy
9. Laparoscopic cholecystectomy 22. Transhiatal esophagectomy 34. Open incisional hernia repair
10. Laparotomy and Hydatid cyst 23. Sigmoid colectomy 35. Wide local excision
excision 24. Wound debridement 36. Debridement
11. Simple mastectomy

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12. Umbilical hernia repair
Neurosurgery (18 1. Abscess drainage 8. Laminectomy 14. Craniotomy 18. Occipital cervical fusion
Procedures) 2. Burr hole evacuation 9. Cranioplasty 15. Foramen magnum decompression
3. Disectomy 10. Frontal burr hole 16. Odontoid screw fixation
4. Endoscopic third 11. External Ventriclar drainage 17. Subdural hemorrhage evacuation
ventriculostomy 12. Microdisectomy
5. Mini craniotomy 13. VP shunt
6. Syringo pleural shunt
7. Thecoperitoneal shunt
Orthopedics (36 1. Antibiotic bead removal 13. Abdominal flap 24. Below-the-knee amputation 35. Above-knee amputation
Procedures) 2. Abscess drainage 14. Anterior cervical discectomy 25. Bipolar Hemireplacement 36. Dynamic hip screw fixation
3. Spinal stabilization and fusion 15. Antibiotic bead removal 26. Arthroplasty
4. Arthroscopic debridement 16. Cervical discectomy and fusion 27. Bone grafting
5. Bead application 17. Laminectomy 28. Cephalomedullary Nailing
6. Corticotomy 18. Decompression 29. Closed reduction þ screw fixation
7. Saucerization 19. Sequestrectomy 30. External fixator
8. Curettage and saucerization 20. Wound debridement 31. Intra Medullary nailing of femur
9. Discectomy 21. DHS removal 32. Foot amputation
10. External fixator removal 22. Intra medullary nail removal 33. Hemireplacement arthroplasty
11. Open reduction and internal 23. Total knee replacement 34. Total hip replacement (THR)
fixation
12. Implant removal
Total: 176 133 35 8

287
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Table 3 e Comparison of crossmatch to transfusion ratio.

S. No. Department Pre-MSBOS adjusted C/T ratio Post-MSBOS adjusted C/T ratio P value by unpaired t testa
1. Urology 2.85 1.83 <0.05
2. Otorhinolaryngology 1.50 1.47 0.10
3. Neurosurgery 5.80 3.13 <0.05
4. Orthopedics 6.50 4.27 0.10
5. General surgery 4.70 2.64 <0.05
6. Obstetrics and gynecology 3.05 2.01 <0.05

*p value of <0.05 is considered as significant.

surgical procedures that showed us favorable reduction in C/T

ratio were myringoplasty, septoturbinoplasty, and Sistrunk
operation with a percentage reduction of 69%, 63%, and 62%,
respectively.

General surgery
A total of 40 elective surgical procedures were included from
this specialty. Maximum number of blood products have been
cross-matched for exploratory laparotomy and debridement
procedures. The TP of abdomino-perineal resection, hepatico-
jejunostomy, abdominoplasty, total gastrectomy, and hemi-
colectomy procedures is found to be greater than 30%. Surgi-
cal procedures with high C/T ratio were open cholecystectomy
Fig. 1 e Comparison of the number of type and screen tests (adjusted C/T ratiod3.8) and open incisional hernia repair
performed before and after implementation of MSBOS. (adjusted C/T ratiod3.4). The most favorable reduction in the
C/T ratio after MSBOS was identified in hemithyroidectomy,
total thyroidectomy, and cholecystectomy with reduction
percentage values of 87%, 86%, and 82%, respectively.
in adjusted C/T ratio was found to be statistically significant
after implementation of MSBOS (Table 3). Neurosurgery
Most units cross-matched in this specialty were for crani-
Urology otomy, laminectomy, and discectomy. Very high C/T ratio was
The top three surgical procedures with high C/T ratio values found in discectomy and laminectomy followed by cranio-
were percutaneous nephrolithotomy with double-J (DJ) plasty. A significant fall of 42% was noted in C/T ratio after
stenting, TURP, and ureteroscopic lithotripsy with DJ stenting implementation of MSBOS. The highest percentage reduction
(URS þ DJ stenting). Highest percentage of TP was observed is observed in abscess drainage, discectomy, and micro-
among the less commonly performed surgeries such as discectomy with values of 71%, 67%, and 53%, respectively.
radical nephrectomy, partial nephrectomy, and transur-
etheral resection of bladder tumors. The mean adjusted C/T Orthopedics
ratio of this department before the implementation of MSBOS The specific surgeries in orthopedics with very high C/T
was 2.85 which scaled down to 1.83 because of the interven- ratio were total knee replacement, discectomy, and bead
tion. The highest percentage reduction in C/T ratio was application. The probability of transfusion was seen to be
observed in DJ stent removal procedure (60%). highest for above-knee amputation (70.3%). The greatest
percentage reduction in C/T ratio was detected in the sur-
ENT gical procedures of abscess drainage, bead application, and
The highest percentage reduction in C/T was observed in total hip replacement with values of 78.75%, 75%, and
preauricular sinus excision procedure (84%). The other 64.44%, respectively.

Table 4 e Transfusion indices in various other studies.

SL.No Study Year Sample Red cell usage C/T TP TI
8
1 Frank et al. 2013 53,526 32.6% NA NA 1.8
2. Aryal et al.6 2016 122 22.5% 4.44 9.83% 0.27
3. Yazdi et al.3 2016 398 26.9% 3.71 16.83% 0.31
4. Subramanian et al.15 2015 1109 39.7% 3.61 47.8% 0.39
5. Hall et al.2 2013 541 46.9% 2.6 34.5% 1.53
6. Bhutia et al.16 1997 680 40.23% 2.48 38.4% 1.6
7 Present study 2017 2674 15% 4.57 26.6% 0.3
 m e d i c a l j o u r n a l a r m e d f o r c e s i n d i a 7 8 ( 2 0 2 2 ) 2 8 3 e2 9 0 289

In the present study, we considered only ASA I and II pa-

Discussion tients for the development of MSBOS; hence, it is also appli-
cable only in patients who come under ASA score I and II.
In this study, we have analyzed 5422 blood requests (3196 Another limitation of this concept is that the MSBOS system
retrospective and 2226 prospective) in 2674 patients, which is does not incorporate the individual differences in transfusion
the largest sample evaluated to create MSBOS for an individ- requirements among patients undergoing the same proced-
ual hospital in India till date. This is a study that involved ure. Patient-oriented factors sucha as patient weight and he-
evaluation of blood requisitions from all surgical departments matocrit which can influence the requirement of transfusion
in our hospital. Thereby, we studied the blood requests have not been considered in the study.
received for 176 different types of elective surgical procedures
in six different surgical departments.
The strength of this study is that we selected only pa- Conclusion
tients belonging to ASA Grade I and II who were scheduled
for elective surgical procedures in the aforementioned de- The practice of MSBOS made a significant reduction in the C/T
partments at our tertiary care center to alleviate the con- ratio and the change implemented has in total miniaturized
founding effect of comorbidities present in the patients.7 the crossmatches by approximately 2152 at our center. The
The blood ordering patterns of the elective surgical pro- average crossmatch time in our department is close to 35 min
cedures performed in various departments at our center in view of which the total working time saved in our labora-
showed that there is overordering of blood units. Before tory is close to 75,320 man hours. The implementation of
implementation of MSBOS, in our hospital, the comprehen- MSBOS downsized the blood products being caught up in the
sive C/T ratio, TI, and TP were 4.57, 0.3, and 26.6%, respec- crossmatch-decross-crossmatch cycle which leads to aging of
tively. There has been overall increment in the monthly T&S the units and their unavailability. The number of free
tests performed after implementation of MSBOS (Fig. 1). Our uncrossmatched bags marked up which contributed in the
TIs were high when compared with the study by Aryal et al, better inventory management by the blood bank staff.
wherein their indices C/T ratio, T%, and TI were 4.44, 9.83%,
and 0.27, which included multiple surgical departments6
(Table 4). We formulated MSBOS based on the TP and TI. Disclosure of competing interest.
This method was adopted from the study by Mead et al on
chemotherapy in elective surgery.9 The authors have none to declare.
Total patients included in our study were 2674 with male
preponderance (54%) in comparison with the study by Kulkarni
that had a total number of 804 patients with female prepon- Research involving human participants and/or
derance (71.6%) in the study group with an age range from 15 animals
to 65 years.11
We noted the overordering of blood for most of the lapa- This research involves human participants.
roscopic surgeries. Charvadeh et al. made similar observation
in their study on laparoscopic surgeries.12 Thabah et al., in
2013 conducted a study that revealed the different factors that Informed consent
affect the C/T ratio.13 First, their study has acknowledged that
the distance of blood bank from their respective operating As per the hospital transfusion policy an informed consent
theater and the effectiveness of the blood bank affect the was obtained from all individual participants included in the
confidence of the surgeons and the anesthesiologists. Second, study.
the patient's preoperative condition also influences the blood
units requested; more blood units were ordered in patients
who looked anemic.14 Similarly many factors that are hospi- Ethical approval
tal-specific such as the transfusion practices, surgeons,
anesthetists, blood-sparing techniques followed influence the All procedures performed in studies involving human partic-
MSBOS and differ from center to center. Hence, it is quite ipants were in accordance with the ethical standards of the
essential that each center develop their individual center- institutional ethics committee and with the 1964 Helsinki
specific MSBOS. Declaration and its later amendments or comparable ethical
The implementation of this system of MSBOS has led to a standards. The study was approved before its commencement
significant abatement in the adjusted C/T ratio values of four by the Institutional Ethics Committee (IEC) with the reference
surgical departments, that is, urology, neurosurgery, general number IEC 507/2015.
surgery, obstetrics and gyneacology, which are the major
consumers. The general notion prevailing amidst clinicians
that PRBC crossmatch is mandatory for every surgery be- Acknowledgments
forehand has to be ousted by our study which is mirrored by
the increasing T&S requests that the blood bank received after The authors gratefully acknowledge the support of data entry
the implementation of MSBOS (Fig. 1). staff for their help in data compilation during the study.
290 m e d i c a l j o u r n a l a r m e d f o r c e s i n d i a 7 8 ( 2 0 2 2 ) 2 8 3 e2 9 0

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