Blood and blood components are scarce therapeutic resources that require continuous quality monitoring. Inappropriate ordering, unnecessary compatibility testing and avoidable discard increase laboratory workload and cost while reducing the availability of components for patients who need them. Periodic review of transfusion practice is therefore an established approach for identifying inefficiencies and improving institutional blood-use policies.1,2

Several quantitative indices are used to evaluate blood-ordering efficiency. The crossmatch-to-transfusion ratio (C:T) compares the number of units crossmatched with the number transfused, transfusion probability (%T) describes the proportion of crossmatched patients who are ultimately transfused, and the transfusion index (TI) represents the average number of units transfused per patient crossmatched. A C:T ratio of 2.5 or less, %T of 30% or more and TI of 0.5 or more have been widely used as indicators of efficient blood utilization.2,3

Transfusion stewardship also requires monitoring of component discard. Wastage can result from expiry, inadequate collection volume, storage or handling problems, return of issued components, contamination, and mandatory infectious-disease screening. The impact is particularly important for platelets because of their short shelf life and unpredictable clinical demand. Recent Indian audits have shown considerable inter-institutional variation in discard rates, with platelets frequently emerging as the component at greatest risk of wastage.4–7

Simultaneous assessment of utilization indices, appropriateness and wastage provides a more complete picture of blood-bank performance than any single measure alone. Such an audit can identify whether resources are being crossmatched judiciously, whether components are being used for supported indications, and where preventable losses occur. These data can inform corrective actions, inventory management, clinician education and department-specific transfusion policies.1,4,5

OBJECTIVES

• To study the appropriate usage of blood and blood components.
• To assess wastage and discard of blood components and identify the principal causes of discard.
• To calculate and evaluate the crossmatch-to-transfusion ratio (C:T), transfusion probability (%T) and transfusion index (TI) as measures of blood-utilization efficiency.

This prospective observational study was conducted in the Department of Immunohematology and Blood Transfusion (Blood Bank), Government Medical College Srinagar, a 1300-bed tertiary care teaching institution serving GMC Srinagar and associated hospitals. The study period was 24 months, from January 2024 to December 2025.

All complete requests for blood and blood components received during the study period from inpatient wards, intensive care units, operation theatres, emergency services, outpatient treatment areas and associated clinical services were eligible for inclusion. Incomplete blood-request forms were excluded. Data sources included blood-bank records, transfusion issue registers, component issue registers and the Hospital Information System/electronic medical records.

For the present paper, the analysis focused on the original study objectives related to appropriateness, wastage and transfusion efficiency. The numbers of PRBC, FFP and RDP units prepared and discarded were extracted, together with blood-group-specific discard counts and documented reasons for discard. Component-specific discard rate was calculated as: discarded units / prepared units × 100. Whole-blood discard was not included because a

corresponding discard dataset was not provided in the source results.

Transfusion efficiency was assessed using the protocol-defined indices: C:T ratio = number of units crossmatched / number of units transfused; %T = number of patients transfused / number of patients crossmatched × 100; and TI = number of units transfused / number of patients crossmatched. The protocol benchmarked efficient utilization at C:T ≤2.5, %T ≥30% and TI ≥0.5, consistent with published transfusion-utilization criteria.2

Appropriateness was assessed descriptively against the component-specific transfusion criteria used in the study protocol and standard transfusion guidance.8,9 The available source data did not provide complete patient-level numerators and denominators for calculating component-specific appropriateness percentages; therefore, these findings are presented qualitatively rather than as rates.

The source dataset reports aggregate crossmatch and transfusion figures of 37,144 and 25,219 for calculation of the transfusion indices. Because 25,219 is also reported elsewhere as the number of PRBC units utilized, the %T and TI values are reproduced as source-reported results and should be independently validated against patient-level counts before final journal submission

Discard information was available for PRBC, FFP and RDP components. Across these three component categories, 63,000 units were prepared and 3,440 were discarded, giving an overall component discard rate of 5.46%. RDPs had the highest discard rate (14.44%), followed by FFP (5.36%) and PRBCs (1.66%).

Table 1. Component-specific preparation and discard rates

RDP wastage was approximately nine times the PRBC discard rate and more than twice the FFP discard rate, identifying platelets as the principal component-specific wastage problem.

Blood-group-specific discard pattern

Table 2. Blood-group-specific discard rates by component

Relative RDP discard was particularly high among Rh-negative groups, reaching 53.7% for AB-negative, 35.1% for A-negative, 32.1% for B-negative and 27.1% for O-negative units. FFP discard was also proportionally higher among Rh-negative groups than among the major Rh-positive groups. PRBC discard remained low in most groups, with the highest relative rate observed for AB-negative units (4.7%).

Reasons for component discard

Table 3. Reason-wise distribution of discarded blood components

For PRBCs, inadequate volume was the leading cause of discard (187/430; 43.5%), followed by hemolysis (129/430; 30.0%). For FFP, low volume accounted for almost half of all discarded units (681/1,382; 49.3%), while returned units and breakage during storage together contributed another 29.8%. RDP wastage was dominated by overdating, which accounted for 1,421 of 1,628 discarded units (87.3%).

Transfusion-utilization indices

Table 4. Source-reported transfusion-utilization indices

The source-reported C:T ratio, transfusion probability and transfusion index all fell within the protocol-defined efficiency thresholds. However, patient-level counts required to independently verify %T and TI were not separately available in the aggregate source dataset, and the value 25,219 is also used elsewhere as the PRBC-unit utilization count. These two indices therefore require validation before external submission.

Assessment of transfusion appropriateness

Table 5. Descriptive findings from the appropriateness audit

Quantitative numerator/denominator data for appropriate versus inappropriate transfusions were not provided in the aggregate source results; consequently, no overall appropriateness percentage was calculated.

The present study demonstrates that blood-component wastage was not evenly distributed across products. RDPs were the most vulnerable component, with a discard rate of 14.4%, followed by FFP at 5.4%, whereas PRBC discard was comparatively low at 1.7%. This pattern is consistent with the operational challenges of platelet inventory, where short shelf life and fluctuating demand make overdating a recurrent problem. Recent Indian quality audits have similarly identified platelets as a major source of component-specific wastage.5,7

The RDP discard rate of 14.4% in the present study was close to the 17.0% platelet discard reported in the Telangana audit by Rai et al., while the same study reported higher discard for FFP (16.9%) and PRCs (7.9%) than observed here.7 Priya et al. also identified platelets as the component with the highest wastage in their tertiary-care quality-indicator analysis.5 Although direct comparisons should be made cautiously because

denominators, inventory practices and reporting systems differ, these studies reinforce the need for platelet-specific stock management.

Overdating accounted for 87.3% of RDP discards, making expiry the single most important preventable source of platelet wastage. In contrast, PRBC and FFP wastage was dominated by collection and handling factors. Inadequate volume and hemolysis together accounted for nearly three-quarters of PRBC discards, while low volume, return of issued units and storage breakage accounted for most FFP wastage. These findings indicate that wastage-reduction strategies should be component specific: demand forecasting and rapid stock rotation for platelets, improved collection quality for PRBCs, and careful preparation, storage and return policies for plasma.5,7

Blood-group analysis showed disproportionately high RDP discard rates among Rh-negative groups, especially AB-negative. Maintaining emergency availability of uncommon groups while avoiding expiry is inherently difficult when component shelf life is short. This finding supports tighter demand-based preparation, inter-facility redistribution where feasible, and close monitoring of near-expiry platelet stocks rather than uniform inventory targets across all blood groups.

The source-reported transfusion efficiency indices were favorable: C:T ratio 1.5:1, transfusion probability 68% and transfusion index 0.7. These values meet the study protocol benchmarks derived from established utilization criteria.2 Kaur et al. reported a C:T ratio of 1.88, transfusion probability of 53.8% and TI of 0.68 in a tertiary-care PRBC audit.4 Lahare et al. reported an overall C:T ratio of 1.53, transfusion probability of 88% and TI of 1.15, with all departments within accepted thresholds.6 Kalra et al. demonstrated much wider specialty-level variation in elective surgery, with C:T ratios ranging from 1.37 to 7.38 and transfusion indices from 0 to 2.03.8 Together, these studies show why aggregate institutional efficiency can coexist with department-specific over-ordering and why regular service-level audits remain important.

The appropriateness review in the present study suggested that most component use followed the transfusion criteria used in the institutional protocol. Nevertheless, prophylactic FFP use without laboratory confirmation and incomplete documentation of haemoglobin or platelet counts were identified as areas of concern. Appropriate component selection and documentation are core elements of transfusion practice, and technical guidance emphasizes matching component therapy to a documented clinical or laboratory indication.9,10

An important methodological caution concerns the aggregate transfusion-index dataset. The source report uses 25,219 in the calculations of C:T, %T and TI, and the same number is also reported as total PRBC units utilized elsewhere in the results. Because %T requires numbers of patients crossmatched and transfused, and TI requires units transfused divided by patients crossmatched, the patient-level denominators should be checked against the original master records before publication. The C:T ratio can be interpreted more confidently if 37,144 and 25,219 indeed represent units crossmatched and transfused, but the reported %T and TI should be regarded as provisional until validated.

The findings have practical implications for transfusion stewardship. A targeted quality-improvement programme should prioritize reduction of platelet overdating, prevention of low-volume collections, handling and storage safeguards for plasma, clear return policies, and mandatory documentation of laboratory values supporting component requests. Regular feedback of wastage and utilization indicators to high-volume clinical services may further reduce avoidable use and improve inventory turnover.

LIMITATIONS

The study was observational and relied on blood-bank and hospital records. Incomplete request forms and missing laboratory documentation limited detailed evaluation of appropriateness in some cases. Patient outcomes following transfusion were outside the scope of the study. The source results did not provide patient-level numerators and denominators for all utilization indices or for calculation of an overall appropriateness rate. In addition, the source document contains two internal inconsistencies relevant to this manuscript: the methods define the study period as January 2024 to December 2025 whereas the transfusion-index section labels it 2023–2025, and the aggregate value 25,219 is used both as a PRBC-unit count and in patient-based index formulas. These issues should be reconciled against the original master records before submission to a journal.

Blood-component wastage in this tertiary-care transfusion service was concentrated in platelets, with RDPs showing a discard rate of 14.4% and overdating responsible for the large majority of platelet losses. FFP wastage was driven chiefly by low volume, returned units and storage breakage, whereas PRBC discard was relatively low and was mainly related to inadequate volume and hemolysis. These patterns identify clear targets for component-specific quality improvement.

The source-reported C:T ratio of 1.5:1, transfusion probability of 68% and transfusion index of 0.7 suggest generally efficient blood ordering by the protocol benchmarks, while the appropriateness audit indicated broadly supported component use with residual gaps in documentation and prophylactic plasma use. Regular transfusion audits, improved inventory forecasting, stricter documentation and targeted reduction of platelet expiry and preventable technical losses should form the core of ongoing transfusion-stewardship efforts. Patient-level verification of %T and TI is required before final publication.

1. Silberstein LE, Kruskall MS, Stehling LC, Johnston MF, Rutman RC, Samia CT, Ramsey G, Eisenstaedt RS. Strategies for the review of transfusion practices. JAMA. 1989 Oct 13;262(14):1993-7.
2. Belayneh T, Messele G, Abdissa Z, Tegene B. Blood requisition and utilization practice in surgical patients at University of Gondar Hospital, Northwest Ethiopia. J Blood Transfus. 2013;2013:758910. doi:10.1155/2013/758910.
3. Friedman BA, Oberman HA, Chadwick AR, Kingdon KI. The maximum surgical blood order schedule and surgical blood use in the United States. Transfusion. 1976;16(4):380-387.
4. Kaur A, Patale D, Lokhande T. Analyzing RBC transfusion practices using quality indicators: a retrospective transfusion audit. Cureus. 2024;16(9):e69550. doi:10.7759/cureus.69550.
5. Priya S, Srinivasan S, Karthikeyan V. A retrospective analysis of utilization patterns and the National Accreditation Board for Hospitals and Healthcare Providers (NABH)-mandated blood bank quality indicators at a tertiary care hospital in South India. Cureus. 2025;17(5):e84876. doi:10.7759/cureus.84876.
6. Lahare S, Kumar R, Das B, Singh N. Blood utilization review using transfusion indices in a tertiary care center: a retrospective observational study. Cureus. 2025;17(7):e88344. doi:10.7759/cureus.88344.
7. Rai J, Behera NK, Gupta MK, Vemuri P, Kendre BD, Dixit H, et al. Blood component utilization and discard patterns in Telangana, India: a three-year retrospective study. Cureus. 2025;17(12):e99846. doi:10.7759/cureus.99846.
8. Kalra T, Gupta S, Gupta A, Bansal N, Kaur Y, Kajal S. Estimation of blood utilization in elective surgeries to formulate maximum surgical blood ordering schedule for a tertiary care center in North India. Int J Appl Basic Med Res. 2025;15(3):163-170. doi:10.4103/ijabmr.ijabmr_89_25.
9. Saran RK, India Directorate General of Health Services, World Health Organization. Transfusion Medicine: Technical Manual. New Delhi: Directorate General of Health Services, Ministry of Health and Family Welfare, Government of India; 2003.

Liumbruno G, Bennardello F, Lattanzio A, Piccoli P, Rossetti G; Italian Society of Transfusion Medicine and Immunohaematology (SIMTI) Work Group. Recommendations for the transfusion of plasma and platelets. Blood Transfus. 2009;7(2):132-150