Recycling older blood by integration into the inventory of a single large hospital blood bank: a computer simulation application

Recycling units of older blood from hospital blood banks with high outdate rates to other hospital blood banks with a high level of transfusion activity and a low outdate rate to increase the probability of utilization of the blood prior to outdating is an accepted method of inventory control. The purpose of this study was to determine with the use of a computer simulation the effects of integrating a variable number of units of ten-day-old blood into the inventory of a single large hospital blood bank. The analysis involved separate consideration of the recycling of 30, 60, 90, 120, 180, 240, 300, and 360 units of ten-day-old blood with one, three, and five deliveries per week into the modeled blood bank inventory. With one delivery per week and a 30 per cent outdate rate for blood ten days old or older at the hospital or hospitals from which the blood is recycled, the net saving achieved per week by recycling these variable quantities is 5, 4, 13, 17, 7, 0, –17, and –50 units; for a 50 per cent outdate rate, the net saving achieved is 11, 16, 31, 41, 43, 48, 43, and 22 units. Possible net saving of blood based on three and five deliveries per week and other outdate rates is also given. The frequency of blood delivery has no significant effect on the net saving of blood in the blood recycling plans evaluated. The implementation of an automatic blood recycling program, a practical and effective method for reducing blood outdating in a multi-hospital regional blood system, is discussed in detail.     

A Computer‐based Blood Inventory and Information System for Hospital Blood Banks as Part of a Regional Blood‐management Program

The feasibility of establishing computerized networks between hospital blood banks and regional blood distribution centers is being tested. A portion of this system is described which serves the individual hospital blood bank directly and eventually will feed its data into the total regional system. Information is entered via a teletypewriter by blood bank personnel. Reports can be generated that can serve as accession, reservation, and transfusion logs, reproduce the blood bank history of a patient or a unit of blood, indicate the status of the entire inventory or a single unit of blood, and highlight units about to outdate. Statistical summaries of various blood bank activities can be derived readily from the data base created. Analysis of a data base created from the blood bank records of two large metropolitan New York hospitals reveals significant differences in the amounts of blood used on the various services (medical, surgical, emergency, special) and for certain major medical conditions (gastrointestinal bleeding, renal dialysis). The probability that units requested actually will be transfused was calculated for one major medical category and a tentative age‐matching policy for the selection of bloods to be reserved was suggested. Attention is called to the necessity of considering standards of compatibility between present and future computer‐based systems for blood banks, that they can be merged into regional networks that will benefit the community, the donor, and the patient‐recipient.     

Management policies for a regional blood bank

This paper considers management strategies for the administration of a regional blood bank. The techniques of management science and mathematical inventory theory are applied to construct a model for the system, identify policy areas, and formulate management objectives. Two simulation models and data collected from both a regional and single hospital blood bank are used in the analysis. The results presented examine the interactions and savings associated with following optimal ordering, crossmatch, and issuing policies. Since each of these policies have an important effect on the number of shortages and outdates, they therefore influence optimal blood bank management. In addition, the question of centralized versus decentralized control is examined.     

The impact of adenine and inventory utilization decisions on blood inventory management

The use of citrate-phosphate-dextrose-adenine as an anticoagulant for whole blood increases the storage period permitted for whole blood and red cells from 21 to 35 days. A simulation model was used to analyze the possible consequences for outdates and shortages of the addition of adenine. The model accepts as input (1) the maximum age (21 or 35 days), (2) parameters describing the demand and supply distributions, and (3) parameters describing inventory control (crossmatch recycle period, transfusion fraction, deviation from optimal target inventory levels). These parameters were varied over wide ranges, and a full factorial design was carried out. The observed shortage and outdate rates were then related (via multiple regression) to the parameter values. The resulting shortage and outdate functions indicated the effect of parameter changes, including extending the lifetime from 21 to 35 days, and the joint effect of changing more than one parameter. Conclusions indicate that, while the contribution of an increased lifetime to reducing shortages and outdates can be substantial, this contribution can be easily dissipated by relaxing the tightness of other inventory management controls.     

Age of blood as a limitation for transfusion: potential impact on blood inventory and availability

BACKGROUND: Evolving concerns about storage lesions for red blood cells (RBCs) have led to ongoing trials evaluating the benefits of transfusing fresher blood to acutely ill patients. STUDY DESIGN AND METHODS: We evaluated several RBC maximum shelf lives (MSLs) and their impact on RBC availability and outdate rate. First, we determined the mean age of the RBC units in our inventory by analyzing the data set of 18,987 nonirradiated RBC units transfused at our institution from April 2008 to March 2009. Second, we determined the feasibility of issuing RBC units of a designated age to patients using the same data set. We defined six scenarios where RBC units have different MSLs: Scenarios 1, 2, 3, 4, and 5 used a MSL of 7, 14, 21, 28, and 35 days, respectively. Scenario 6 used a combination of different MSLs depending on the category of patients. RESULTS: RBC units spent on average 8.6 days on the shelf with a mean age of 10.2 days at delivery and 18.8 days at issue for transfusion. Using the original 18,987 data points, we observed a shortfall in the availability of RBC units, decreased by 51, 20, 10, 4, 1, and 0% and an increase in the outdate rate to 3.2, 2.2, 1.0, 0.6, 0.4, and 4.5% for Scenarios 1, 2, 3, 4, 5, and 6, respectively, compared to baseline. CONCLUSION: Changing the MSL for RBC units would require novel approaches to RBC inventory management to meet hospital demands with acceptable outdate rates.     

Evaluating the inventory impact of utilizing low titer platelets in regional hospitals

Background

As a result of constrained supply, it is sometimes necessary to provide patients with ABO-mismatched platelets. Such practices increase the risk of acute hemolytic transfusion reaction (AHTR). Providing patients with platelets suspended in O plasma having low-titer Anti-A and Anti-B antibodies (LtABO) could reduce the incidence of AHTR. However, natural scarcity limits the number of such units that can be produced. In this paper we present a study to evaluate strategies for deploying LtABO at regional hospitals in Canada.

Study Design and Methods

Regional hospitals often experience demand for platelets on an irregular basis. They are, however, required to stock some number of platelets (typically one A-unit and one O-unit) for emergencies; outdates are common, with discard rates sometimes >>50%. A simulation study was completed to determine the impact of replacing a (1A, 1O) inventory with 2 or 3 units of LtABO at regional hospitals.

Results

A significant decreases in wastage and shortage can be expected by replacing a (1A, 1O) inventory policy with 2 units of LtABO. In tested cases, a 2-unit LtABO dominated a (1A, 1O) policy, resulting in statistically fewer outdates and instances of shortage. Holding 3 units of LtABO, increases product availability, but results in an increase in outdates when compared to a (1A, 1O) policy.

Conclusion

Providing LtABO platelets to smaller, regional hospitals will lower wastage rates and improve patient access to care, when compared to existing (1A, 1O) inventory policies.     

Target inventory levels for a hospital blood bank or a decentralized regional blood banking system

For any blood type, there is a complex interaction among the optimal inventory level, daily demand level, the transfusion to crossmatch ratio, the crossmatch release period and the age of arriving units that determine the shortage and outdate rate. The blood bank administrator should establish optimal target inventory levels based on a simple equation (decision rule) relating these factors. Evaluation of this rule indicates that its implementation can lead to a very low shortage rate and a reasonable low outdate rate if the blood bank administrator makes efforts to control the crossmatch release period and the average transfusion to crossmatch ratio.     

Inventory management in Sydney Public Hospital Blood Banks

SUMMARY. Monitoring the outdating of donated units is one way of assessing the efficiency of blood usage. Inventory management in public hospital blood banks in Sydney was reviewed with the aim of determining factors which lead to the outdating of donor blood. Factors which correlated significantly with increased outdating in hospitals included absence of an effective hospital transfusion committee; high ratio of average inventory: units transfused; fewer than three routine deliveries from the BTS per day; increased time taken for delivery of urgent products; CT values greater than 2: 1; premature performance of the crossmatch and prolonged crossmatching holding time. Hospitals were informed of the initial audit results and were alerted to the factors contributing to excessive outdating. They received monthly feedback of individual outdating results compared with overall outdating. After 6 months there was a significant reduction in overall outdating from 5.0 to 0.9% ( P < 0.05), which has been maintained for a further 12 months. Changes in inventory management associated with an improvement in overall outdating included: changes in crossmatching practice which increase the effective shelf-life of blood, knowledge of when blood was due to outdate and effective stock rotation.     

The introduction of 7-day platelets: a university hospital experience

INTRODUCTION: Recently, the FDA approved the Post Approval Surveillance Study of Platelet Outcomes, Release Tested protocol which allows participating institutions to utilize 7 day platelets following guidelines. As one of the first hospitals to implement a 7-day protocol, we reviewed our hospital experience with 7-day Gambro apheresis platelets to determine the impact on inventory. METHODS: A review of apheresis platelet transfusions and outdate records was performed. Data were collected prospectively from March to August 2006. This data were compared with a retrospective review for the same time period in 2005. RESULTS: For the 1,503 platelets transfused from March-August 2005, the mean day of issue was 3.44 (SD = 1.060). During the same time period of 2006, 1,688 platelets were transfused with a mean day of issue of 4.02 (SD = 1.083). This difference was statistically significant (P < 0.001). The outdate rate dropped from 2.9% (44/1,547) to 1.3% (22/1,710, P < 0.001). During the study period, approximately 59.7% of the platelets were 7-day platelets. DISCUSSION: Over the 6-month period, we noted a decrease in outdates from 2.9% to 1.3%. There was a shift toward older platelets (from a mean of day 3.4 to day 4). During the study period, 139 platelets were transfused on days 6 or 7 of storage. Overall, the implementation of 7-day platelets in a university hospital setting was easily accomplished and has resulted in benefits to our institution by decreasing our outdate rate and to our patients by providing an additional 139 days 6 and 7 apheresis platelets with a potential cost savings of $78,952 (over the 6-month study).     

Distribution of Fresher Blood in a Statewide Blood Program

A change in distribution policy by a central blood bank resulted in greater than three days of additional shelf life of blood at hospitals. This change in distribution policy was temporally associated with a decrease in statewide outdating from 11.9 to 9.2 per cent. The magnitude of the decrease in outdating is similar to that predicted by theoretical studies of the effect of longer shelf life of blood. It is suggested that the prolonged shelf life of blood at hospitals was causal to reduced outdating. This experience, taken with the theoretical studies, indicates that a central blood bank can make a major, beneficial impact on hospital outdating by distributing blood on a date closer to its date of collection.     

Regional variation in child mortality at hospitals lacking a pediatric intensive care unit

OBJECTIVE: To investigate statewide variation in failure to utilize existing regional pediatric intensive care units (PICUs). METHODS: Deaths of children in hospitals lacking specialized units (non-PICU hospitals) were postulated to represent possible PICU utilization failures. A survey study was performed on hospital inpatient discharges and deaths in 1997, using data obtained from the New York Statewide Planning and Research Cooperative System (SPARCS). Children 0-14 yrs old were studied, excluding neonatal Diagnosis-Related Groups and emergency department deaths. Hospitals were considered to have a PICU if they had a board-certified pediatric intensivist on staff, and either New York State designation as a PICU or a separate dedicated unit for children. Non-PICU hospital pediatric death rates were compared for health service areas to determine whether regional variation occurred. RESULTS: Statewide, 157 of 584 (27%) pediatric hospital inpatient deaths occurred in non-PICU hospitals. Significant variation was seen among eight regions in pediatric death rates in non-PICU hospitals (p < .05). The 114 of 328 (35%) New York City inpatient deaths occurring in non-PICU hospitals significantly exceeded the 43 of 256 (17%) throughout the remainder of the state (p < .05). New York City non-PICU hospital death rates also were higher than in the rest of the state, when expressed per 100,000 pediatric population (8.04 vs. 2.00), and per 1,000 non-PICU hospital discharges (2.25 vs. 1.18), respectively (p < .05). Forty percent of New York City non-PICU hospitals experienced a pediatric inpatient death compared with only 13% in the rest of the state (p < .05). CONCLUSIONS: Although the death of some children in hospitals lacking a PICU is expected, the significant regional variation in these deaths suggests that local obstacles, perhaps unique to metropolitan areas, may interfere with access to existing pediatric critical care resources.     

The blood inventory control system--helping blood bank management through computerized inventory control

This article describes a computerized inventory control system for controlling blood distribution between the blood bank and its client hospitals. The system has been operative since October 1964, and has excelled the blood utilization efficiency of previous procedures. Significantly, appropriately processed information of daily blood status by a centralized computer has led to a 60 per cent reduction in outdating together with an inventory reduction at the blood bank averaging 30 per cent. Incorporation of the new system into current hospital and blood bank management is evaluated in terms of psychological, labor, and economic implications.     

Factors affecting the frequency of red blood cell outdates: an approach to establish benchmarking targets

BACKGROUND: Benchmarking is a useful tool to identify best practices and to compare an organization's performance with that of similar peers, allowing for continuous quality improvement. In this study, a provincial database of red blood cell (RBC) product inventory/disposition in hospitals was analyzed to identify factors that affected RBC outdates and to systematically establish optimal target levels for RBC outdates.
STUDY DESIGN AND METHODS: RBC inventory/disposition data for a 21-month period from 156 hospitals were analyzed using logistic regression techniques to identify factors that affected RBC outdating (month of the year, distance from the blood supplier, monthly transfusion activity, hospital type, and provincial region). The results were used to categorize hospitals into groupings that accounted for the factors affecting wastage. Within each grouping, the lower quartile was selected as the optimal target threshold.
RESULTS: Three factors were identified as significantly affecting RBC outdating: distance from the blood supplier, mean monthly transfusion activity, and month of the year. Accounting for these variables, three hospital groupings were identified and benchmarking targets were established for mean monthly RBC outdating: There were 73 hospitals in Group 1 and their target level was 0.4 percent, 59 hospitals in Group 2 with a target of 1.1 percent, and 24 hospitals in Group 3 with a target of 20.3 percent.
CONCLUSION: A method is described for establishing evidence-based benchmarking targets for RBC outdating that allows for hospitals to be grouped with similar peers taking into account logistic factors that impact on product outdating.     

Electronic remote blood issue: a combination of remote blood issue with a system for end-to-end electronic control of transfusion to provide a "total solution" for a safe and timely hospital blood transfusion service

BACKGROUND: The rapid provision of red cell (RBC) units to patients needing blood urgently is an issue of major importance in transfusion medicine. The development of electronic issue (sometimes termed "electronic crossmatch") has facilitated rapid provision of RBC units by avoidance of the serologic crossmatch in eligible patients. A further development is the issue of blood under electronic control at blood refrigerator remote from the blood bank. STUDY DESIGN AND METHODS: This study evaluated a system for electronic remote blood issue (ERBI) developed as an enhancement of a system for end-to-end electronic control of hospital transfusion. Practice was evaluated before and after its introduction in cardiac surgery. RESULTS: Before the implementation of ERBI, the median time to deliver urgently required RBC units to the patient was 24 minutes. After its implementation, RBC units were obtained from the nearby blood refrigerator in a median time of 59 seconds (range, 30 sec to 2 min). The study also found that unused requests were reduced significantly from 42 to 20 percent, the number of RBC units issued reduced by 52 percent, the number of issued units that were transfused increased from 40 to 62 percent, and there was a significant reduction in the workload of both blood bank and clinical staff. CONCLUSIONS: This study evaluated a combination of remote blood issue with an end-to-end electronically controlled hospital transfusion process, ERBI. ERBI reduced the time to make blood available for surgical patients and improved the efficiency of hospital transfusion.     

区域化消毒供应中心建设与管理

目的:提高基层医院物品消毒灭菌的质量.方法:建立区域化消毒供应中心,配备工作人员,完善工作流程和质量控制,将23家医院需要消毒灭菌的物品进行统一集中管理.结果:实行消毒供应中心区域化管理,能够确保物品的清洗、消毒及灭菌的质量,节约资源、降低成本、提高管理效率,有效控制医院感染发生,确保医疗质量和医疗安全.结论:建立区域...     

Disproportionate outdating of group A blood

The authors studied the factors responsible for the disproportionate outdating of group A blood compared with group O blood over a 6-month interval. Distribution, transfusion, and outdate data for 99,251 units of blood were collected from representative hospitals within the region served by the Atlanta Regional Red Cross Blood Center. Factors evaluated included: neonatal transfusion of type O blood to type A recipients; use of type O blood in emergencies or due to group-specific shortages; demographic donor and recipient differences; and blood importing practices. Of 43,757 group O units (44.1% of total) available for distribution, 2050 (4.7%) were outdated, compared with 3908 (10.7%) of 36,501 group A units (36.8% of total). One thousand two hundred and seventy-nine units of type O blood were transfused to recipients who were not type O, including 842 group A neonatal patients. A larger inner-city hospital, where 46.8 percent of recipients were group O and 29.2 percent were group A, accounted for 180 more group O and 509 fewer group A transfusions than would be expected if donor-recipient ABO distributions were the same. Three hundred and seventy-four more group A units were imported than were needed. ABO-mismatched transfusions due to shortage or emergency were insignificant. It was concluded that increased use of group O blood for neonatal transfusions, donor-recipient differences in blood group frequencies, and blood importing practices are the major factors that increase the rate of group A outdating.     

Bottlenecks of blood processing in Uganda

Aim: To identify where and why delays occur in Uganda blood banks. Background: The timely provision and supply of safe and efficacious blood components to hospitals depends on sound systems in the processing blood banks. Poorly managed systems lead to apparent blood shortages in hospitals and increase discard rates due to expiry before dispatch. Materials and methods: We reviewed records of 4126 units of whole blood delivered by the mobile collection teams to a major regional blood bank, in the period 1 March 2009 to 30 June 2009, to ascertain the time intervals between the critical steps in the blood processing chain. This was followed by interviews with staff in two blood banks to establish the causes of process delays. Results: The average duration between blood collection and final labelling (release from quarantine for final storage) was 15·4 (SD 10·8) days. In timeline, the step between matrix generation and grouping was (median duration 8 days) the longest, whereas grouping to labelling was the shortest (median duration 2 days). Blood expiry had the highest discard rate (0·17%) among the non‐transfusion transmissible infection marker causes. A minimally facilitated small staff contributed to the process flaws. Conclusion: A considerable amount of blood does not reach hospitals because of process delays between collection and ultimate dispatch. This is caused by a thin staff working with inadequate materials, out‐of‐date methods and in an overcrowded environment. Provision of adequate staff and improved financial allocations to the Uganda Blood Transfusion Services will mitigate this situation.     

Blood transfusion costs: a multicenter study

The cost of delivering a unit of blood (whole blood or red cells) to a hospitalized patient was examined in 19 United States teaching hospitals. The average hospital acquisition cost was calculated by using the prices charged by regional blood centers for blood products. To this cost was added an estimate of costs incurred by hospitals for handling, testing, and administering blood. Across study sites, the average hospital cost per unit transfused was $155 and the average charge to the patient was $219. Acquisition cost, the price that hospitals pay for blood, was 37 percent of the total cost to the hospital; the other 63 percent of the hospital cost included costs for blood bank handling (13%), laboratory tests (43%), and blood administration (7%). Significant variations in blood transfusion cost were found within our sample. Most of the variability can be attributed to geographic location of the blood supply source, type of red cell product transfused, prices charged by blood transfusion services, and the frequency of laboratory tests. The results of this transfusion cost study may be helpful in determining the costs of health care delivery, especially when blood transfusions are indicated.     

Fate of Blood Units—A Retrospective Study

A retrospective study of blood bank records for a two and a half year period for a relatively stable University Hospital Blood Bank serving a 385 bed teaching hospital and clinics has been completed. The source of blood units in terms of collection under the supervision of blood bank personnel versus blood units received from outside institutions revealed a comparable per cent of utilization but a decisive difference in discard rate with the greatest discrepancy attributed to outdating and reclamation as components. Over a consecutive two year period, percentage utilization remained virtually unchanged while the percentage discard was markedly decreased and reclamation significantly increased. The latter has been attributed to increased proficiency and efficiency of blood bank technical staff, a greater degree of accuracy by the clerical staff, tremendous progress in the education of house staff and faculty in the use of blood components and a shift of fresh frozen plasma procurement to a plasmapheresis system.