Reducing routine group and save testing in emergency laparoscopic appendicectomy surgery: a quality improvement project assessing the triple bottom line
Introduction There is compelling evidence supporting the omission of routine group and save (G&S) testing pre-operatively in emergency laparoscopy where appendicitis is suspected. Most studies are retrospective; however, one study prospectively demonstrated safe application in laparoscopic c...
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BMJ Publishing Group
2025-05-01
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| Series: | BMJ Open Quality |
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| author | Dominic Furniss Cyra Mackintosh Emanuele Gammeri Vrettos Ierodiakonou |
| author_facet | Dominic Furniss Cyra Mackintosh Emanuele Gammeri Vrettos Ierodiakonou |
| author_sort | Dominic Furniss |
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| description | Introduction There is compelling evidence supporting the omission of routine group and save (G&S) testing pre-operatively in emergency laparoscopy where appendicitis is suspected. Most studies are retrospective; however, one study prospectively demonstrated safe application in laparoscopic cholecystectomies only. We sought to assess safety, cost, and environmental and social savings—the triple bottom line—of omitting routine G&S testing in laparoscopic appendicectomies, by undertaking a quality improvement project at a busy district general hospital.Methods All patients who underwent an emergency laparoscopy +/− appendicectomy, between 1 November 2020 and 31 October 2021, were retrospectively reviewed, and cross-referenced to haematological testing and blood product dispensation data. A cost of £15 was applied to processed G&S samples and £1.89 to rejected samples. A carbon cost of 1,066 g CO2 emissions (CO2e) was applied to all samples. We then prospectively undertook a 6-month pilot intervention to omit routine G&S testing in these cases. Patients from either cohort who required blood transfusions underwent a deep dive to identify risk factors.Results Pre-intervention, 281/392 (71.7%) of patients had valid G&S samples prior to their procedure and no patient required blood products during their episode. Post-intervention, 56/189 (29.1%) patients had valid G&S samples. One patient with chronic anaemia required a preoperative blood transfusion. Pre-intervention, G&S testing cost £22.24 and 1.7 kg CO2e per laparoscopy. Post-intervention, the cost reduced to £9.78 and 0.7 kg CO2e per laparoscopy. The intervention saved £5,021 and 353 kg CO2e, and our institution has adopted a selective approach, based on clinical risk, for these cases indefinitely.Conclusion Routine G&S testing in emergency laparoscopy +/− appendicectomy is unnecessary, costing money and time and producing carbon emissions. With effective communication of risk-mitigating factors, practice can shift from high to low rates of preoperative testing. There are further savings accessible by applying this method to other surgical procedures using a risk-based approach. |
| format | Article |
| id | doaj-art-99bb9efed8e348d8a8329e7b760759c9 |
| institution | Kabale University |
| issn | 2399-6641 |
| language | English |
| publishDate | 2025-05-01 |
| publisher | BMJ Publishing Group |
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| series | BMJ Open Quality |
| spelling | doaj-art-99bb9efed8e348d8a8329e7b760759c92025-08-20T03:49:37ZengBMJ Publishing GroupBMJ Open Quality2399-66412025-05-0114210.1136/bmjoq-2024-003120Reducing routine group and save testing in emergency laparoscopic appendicectomy surgery: a quality improvement project assessing the triple bottom lineDominic Furniss0Cyra Mackintosh1Emanuele Gammeri2Vrettos Ierodiakonou3University of Oxford Nuffield Department of Orthopaedics Rheumatology and Musculoskeletal Sciences, Oxford, Oxfordshire, UKOxford University Hospitals NHS Trust, Oxford, UKUniversity Hospitals Coventry and Warwickshire NHS Trust, Coventry, West Midlands, UKBuckinghamshire Healthcare NHS Trust, Aylesbury, Buckinghamshire, UKIntroduction There is compelling evidence supporting the omission of routine group and save (G&S) testing pre-operatively in emergency laparoscopy where appendicitis is suspected. Most studies are retrospective; however, one study prospectively demonstrated safe application in laparoscopic cholecystectomies only. We sought to assess safety, cost, and environmental and social savings—the triple bottom line—of omitting routine G&S testing in laparoscopic appendicectomies, by undertaking a quality improvement project at a busy district general hospital.Methods All patients who underwent an emergency laparoscopy +/− appendicectomy, between 1 November 2020 and 31 October 2021, were retrospectively reviewed, and cross-referenced to haematological testing and blood product dispensation data. A cost of £15 was applied to processed G&S samples and £1.89 to rejected samples. A carbon cost of 1,066 g CO2 emissions (CO2e) was applied to all samples. We then prospectively undertook a 6-month pilot intervention to omit routine G&S testing in these cases. Patients from either cohort who required blood transfusions underwent a deep dive to identify risk factors.Results Pre-intervention, 281/392 (71.7%) of patients had valid G&S samples prior to their procedure and no patient required blood products during their episode. Post-intervention, 56/189 (29.1%) patients had valid G&S samples. One patient with chronic anaemia required a preoperative blood transfusion. Pre-intervention, G&S testing cost £22.24 and 1.7 kg CO2e per laparoscopy. Post-intervention, the cost reduced to £9.78 and 0.7 kg CO2e per laparoscopy. The intervention saved £5,021 and 353 kg CO2e, and our institution has adopted a selective approach, based on clinical risk, for these cases indefinitely.Conclusion Routine G&S testing in emergency laparoscopy +/− appendicectomy is unnecessary, costing money and time and producing carbon emissions. With effective communication of risk-mitigating factors, practice can shift from high to low rates of preoperative testing. There are further savings accessible by applying this method to other surgical procedures using a risk-based approach.https://bmjopenquality.bmj.com/content/14/2/e003120.full |
| spellingShingle | Dominic Furniss Cyra Mackintosh Emanuele Gammeri Vrettos Ierodiakonou Reducing routine group and save testing in emergency laparoscopic appendicectomy surgery: a quality improvement project assessing the triple bottom line BMJ Open Quality |
| title | Reducing routine group and save testing in emergency laparoscopic appendicectomy surgery: a quality improvement project assessing the triple bottom line |
| title_full | Reducing routine group and save testing in emergency laparoscopic appendicectomy surgery: a quality improvement project assessing the triple bottom line |
| title_fullStr | Reducing routine group and save testing in emergency laparoscopic appendicectomy surgery: a quality improvement project assessing the triple bottom line |
| title_full_unstemmed | Reducing routine group and save testing in emergency laparoscopic appendicectomy surgery: a quality improvement project assessing the triple bottom line |
| title_short | Reducing routine group and save testing in emergency laparoscopic appendicectomy surgery: a quality improvement project assessing the triple bottom line |
| title_sort | reducing routine group and save testing in emergency laparoscopic appendicectomy surgery a quality improvement project assessing the triple bottom line |
| url | https://bmjopenquality.bmj.com/content/14/2/e003120.full |
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