# Cutting Costs and Carbon: Re-evaluating Routine Group and Save Testing for Appendicectomies

## TL;DR

This study finds that routine blood testing before appendectomy is unnecessary, costly, and harmful to the environment, suggesting a shift to testing only high-risk patients.

## Contribution

The study introduces a selective, risk-based approach to preoperative blood testing for appendicectomy to improve cost and environmental efficiency.

## Key findings

- No transfusions occurred in 265 appendicectomy cases, with a 0% transfusion rate.
- 15% of Group and Save samples were rejected, incurring a £7,735 cost and 190.06 kg CO₂e carbon footprint.
- Higher WCC, CRP, age, and ASA grade predicted complicated appendicitis.

## Abstract

Background: Routine preoperative Group and Save (G&S) testing is traditionally performed before appendicectomy to ensure blood availability; however, transfusion is exceedingly rare in this context. In an era of value-based and sustainable healthcare, this study re-evaluates the necessity of routine G&S testing by analyzing its clinical utility, cost, and environmental impact in a district hospital in the United Kingdom (UK).

Methods: A retrospective review of 265 appendicectomies performed between December 1, 2023, and June 30, 2024, at Pinderfields Hospital was conducted. Demographic, biochemical, and intraoperative data were collected, including ASA (American Society of Anesthesiologists) grade, white cell count (WCC), and C-reactive protein (CRP). Cases were categorized as uncomplicated or complicated based on operative findings. Independent-samples t-tests were used to compare continuous variables (age, WCC, CRP), and chi-square tests assessed associations between ASA grade and case complexity. The 95% confidence interval (CI) for the zero-transfusion rate was calculated using the Clopper-Pearson exact method. Financial and carbon estimates were derived from published UK data.

Results: Of the 265 cases, 261 (98.5%) were laparoscopic, with four conversions to open surgery. No intraoperative or immediate postoperative transfusions occurred (transfusion rate 0%; 95% CI 0-1.4%). Patients with complicated appendicitis had significantly higher mean WCC (15.2 vs 11.9 ×10⁹/L; p < 0.001), CRP (115.8 vs 57.3 mg/L; p < 0.001), and age (41.7 vs 32.6 years; p = 0.001). Higher ASA grades were also associated with increased case complexity (χ²(3) = 13.07, p = 0.004). A total of 520 G&S samples were submitted, of which 78 (15%) were rejected. The estimated testing cost was £7,735 for the study period (£14,116 annually), and the carbon footprint was 190.06 kg CO₂e.

Conclusions: Routine preoperative G&S testing for appendicectomy provides negligible clinical benefit while incurring measurable financial and environmental costs. Elevated inflammatory markers, higher ASA grades, and older age were predictive of complicated disease, supporting a selective, risk-based testing strategy. Restricting G&S to higher-risk patients could maintain safety, enhance efficiency, and contribute to National Health Service (NHS) sustainability goals.