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4.2 Blood Transfusion Science > Blood Stock Management > Flashcards

Blood Stock Management Flashcards

1
Q

What have been the headlines in the papers in the past year, why was this significant

A

‘Hospiatals told to use blood supply ‘conservatively’’ -> amber alert was issued to have to conserve blood etc

People started to think hospitals were wasting their donated blood

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2
Q

Good blood stock management is dependent on teamwork between who?

A

Consnultant haematologist
Membersof HTC
IBTS
First Direct Medical
Haemovigilance team
Clinical Teams
Hospital groups
Laboraotry staff

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3
Q

Comment on the expenses of the BT lab

A

The BT lab is one of the most expensive places in the hospital

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4
Q

What are the important topics covered in blood stock management

A

BOSS
Web Apps
Forecasting
Essential factors for IBTS to manage stock
Benefits of good management
Re-routing blood as a tool for stock management

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5
Q

What is the BOSS system

A

The BOSS system is in place in the IBTS

There is super high IT security in IBTS ever since a computer was left in a taxi in america

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6
Q

Why do we re-route blood

A

Its just out of good faith
Its a way of reducing waste
No hospitals are paid for this etc

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7
Q

Talk about the Cohen equation

A

An equation for determening blood stock requirements however this isnt really followed anymore since we now have daily deliveries and not weekly etc

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8
Q

How would the IBTS like to run blood stock management?

A

The IBTS doesnt know how much blood is in hospital fridges of each hospital unlike in the UK
In the UK Venesa is used to keep track of hospital blood stock
This allows for rerouting of O-s from one hospital to another in terms of emegency etc
The IBTS would preer to be able to tell hospitals how much blood theyre getting rather than answeing how much blood they want and only special order if staff request etc

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9
Q

Who is our blood transporters, talk about their role?

A

First Direct couriers
Technicaly a blood establishment under EU directive

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10
Q

Where is blood collected and processed?

A

Only collection and aphersis in Cork IBTS
All samples processed in Dublin IBTS

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11
Q

Talk about the role of the IBTS in Ireland

A

Collects Approximately 150,000 Blood donations per year
Blood processed into red cells, platelets and plasma for therapeutic use
Available for distribution to hospitals within 24 hours of collection
During donation blood samples are collected for testing purposes
Unique barcode assigned to each donation

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12
Q

Talk about the storage of red cells and platelets

A

Red cells @4 degrees shelf lie 35 days
Platelets @22 shelf life 5-7 days

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13
Q

How is the blood transfusion service organised in ireland

A

6 mobile teams teams that cover the whole country
4 fixed centres:
- 1 platelets only
- 1 hybrid
- 2 whole blood only - Dublin

260 venues

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14
Q

Talk about the Blood transfusion service in Irish hospitals

A

48 publically funded acute hospitals:
- 37 of which receive blood from the IBTS
- 37 or 38 hospitals in Ireland have a casualty ward and therafore need blood but psychiatric hospitals etc wont need blood
- Arranged into 8 groups

21 private hospitals
- 9 of which receive blood from the IBTS

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15
Q

How many orders does the IBTS receive each yea

A

35,380 product orgers received in 2019
28,623 (81%) were received in the NBC
6,757 (19%) in MRTC

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16
Q

How is blood distributed in Ireland

A

3rd party distibuter - first direct -> contract with Health Service Executive

Temperature controlled vans

Dedicate storage compartment - 22 degrees, 4, degrees, <18 degrees etc

Distributed from NBC and MRTC

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17
Q

Talk about delivery schedules today

A

All hospitals both public and private receive at least one delivery 7 days a week

Deliveries depart between 6:45 and 9:30am

2nd daily delivery to select dublin hospitals departs at 15:00

7 routed from NBC

2 routes from MRTC

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18
Q

Talk about blood delivery schedules in the past

A

Used to have a once a week delivery particulalry down the country
Would have to send blood down in taxis or on the train as hospitals would often run out of blood e.g. if there was a big emergency

Daily deliveries have actually saved the HSE a lot of money as there was much less delivery fees on taxis and trains etc

Daily deliveries also meant there was less waste as hospitals tended to over order

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19
Q

Give an example of a delivery route

A

National Blood Centre
Blanchardstown
Cavan General
Our lady Navan -> then back to dubin
OLOL Drogeda
Beaumont
Cappagh
Bons Secours
Temple Street
Rotunda
Mater Private
Mater Public
national Blood Centre

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20
Q

How does the IBTS control and monitor how much blood is spent by hospitals

A

Meet indiidual hospitals at least once a year with hospital groups

Meet each hospital group quarterly

Monitoring of usage - follow up

Sharing of expertise

Monitoring of returns and follow up

Review of transport

Regular communication and assistance

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21
Q

What is a good way of knowing how many platelets you will need to order?

A

Checking the platelets less than 50 every day beore the delivery to see what youll need to order

This stops out of hour delivery of platelets by taxis and thus saving thousands per year

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22
Q

Talk about the IBTS meeting with hospital groups

A

By meeting with Hospital Groups the IBTS can tell hospitals how much they are spending IBTS has a scientific officer that goes out to each hospital every year

This shows hospitals how they compare in usage to other hospitals etc e.g. overuse of O-s which is sometimes unavoidable e.g. In maternity hospital down the country who have to keep blood for both maternity and paeds etc

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23
Q

What does eBOSS stand for?

A

electronic Blood Operations Support System

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24
Q

Talk about eBOSS

A

Developed by the New York Blood centre
Went live on the 20th April 2009 in Ireland
Includes eProgesa

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25
Talk about the different web applicaions involved in blood stock management
Delivery tracking Appointment scheduler clinic scheduler blood stock management scheme Message board Information request manager enterprise solution e.g. forecasting
26
What is the IBTS message board
It shows daily amount of blood left and provides live updates on apheresis donations
27
What is a red cell forecast
A form of eBOSS reporting A way of predicting when we will have a dip in different groups of units etc Allows us to know when we should start phonin in donors etc
28
How does eBOSS put out its reports?
Provides 2 reports every day: One at 6:30 am and one a 15:00 Provides stock information on all the different bloood grouops and all the different types of platelets
29
What is the traffic light system
A way of describing the levels of blood stock remaining: green, amber, red Tells us what category of surgeries should be cancelled etc
30
What is category 1 surgeries
These patients will remain highest priority of transfusion, they will always be transfused regardless of shortage, these include Resuscitation of life-threatening/on-going blood loss including trauma Surgical support e.g. - During emergency surgery including cardiac and vascular surgery and organ transplantation as well as - Cancer surgery with the intention of cure Non surgical anaemias/life-threatening anaemia including: - patients requiring in-utero support and high dependeny care/SCBU. - stem cell transplantation or chemotherapy - severe bone marrow failure - thalassaemias but consider lower threshold - Sickle cell disease crises affecting organs - sickle cell patients aged <16 with past histoy of CVA
31
What are category 2 surgeries
Patients that will be transfused in the amber but not the red phase of shortage, they include: Surgery/obstetrics: - cancer surgery (palitative) e.g. leukaemia will still require blood - symptomatic but not life threatening post-operative or post-partum anaemia - urgent but not emergency surgery Non surgical anaemias: - symptomatic, but not life-threatening anaemia
32
What are category 3 surgeries?
Patients which will not be transfused in the amber phase - only in green, these include: Elective surgery which is likely to require donor blood support e.g. elective scoliosis surgery Surgery on patients with >20% chance of needing 2 or more units of blood during or after surgery NB: its no joke to delay these surgeries -> dont want to make headlines -> wouldnt want to be the person making this call
33
Define an urgent vs an emergency surgery
Emergency: patient likely to die within 24 hours without surgery Urgent - patient likely to have major morbidity if surgery not carried out
34
What usually comes before an amber alert
A pre-amber alert letter to warn hospitals to reduce usage to prevent an amber alert occuring
35
What are some essential factors in blood stock management
Recruitment and donor management Collection management Manufacturing and testing Inventory, distribution Despatch and sales
36
What are the main benefits to good stock management
Donor numbes need to correspond to the distribution of blood groups in the irish population -> we are overbleeding ou O -/ves and we dont have enough of these donors Donor numbers do not match available stocks O RhD neg red cell demands exceeds the % distribution in the population -> this requires careful management in hospital blood banks to prevent over use Jan-June 2018 14.2% of all red cells issues are group O Rh D Neg
37
When did we introduce a daily delivery?
Introduced in 2013
38
What have been the benefits of daily deliveries
Redued number of non-scheduled deliveries Reduced transport Reduced administrative costs Controlled stock entry Patients generally receive fresher blood
39
What is re-routing of blood, when was it introduced
Re-routing has been done since 2015 It involves local arrangements between hospitals Smaller hospitals rerout blood about to expire to larger centres e.g. maternity and medium hospitals rerouting to larger hospitals National service level agreement (SLA) in place Requires validation
40
How exactly is blood rerouted?
Couriers delivering blood from the IBTS can also now reroute blood from one hospital to another on its delivery route e.g. between the smaller hospitals and the mater etc
41
What blood is rerouted and why
A lot of O - rerouted -> 15.7% or 497 units in 2018 Plaelets can also be rerouted A lot of O-/ves are reroouted as blood banks have to maintain large enough stocks for emergencies -> but if there isnt any then the short dated blood can be given to a larger hospital who has a large a/E department Larger hospitals will definitely use blood -> platelets maybe not
42
How manny rerouted red cells are ther
3,500-5,000 units rerouted per year (2018) - think of all the money saved here 98.5% of these were transfused - so many units saved from waste
43
How many rerouted platelets are there
550-650 per year (2018) 76.5% are transfused Theres still quite a large % not used -> in the mater this was due to platelets being too short dated to use in time
44
What considerations are there for blood stock management
Supply unpredicatable - reliance on random donors Demand unpredictable: - emergencies or major incidences could mean a huge demand - extreme weather which could close hospitals - ward closures - strikes resulting in cancelation of blood orders etc Perishable limited shelf life - canno keep months supply etc Strict storage requirements - cant be stored everywhere etc High cost of blood products
45
How much money does the IBTS spend each yea
IBTS turnover >120.00 million
46
What are the five main characteristics of our blood inventory management
Optimises the trade off between outdates and shortages Minimises total operating costs Requires a constant supply of blood Cannot accommodate unforeseen events e.g. ward closures Cannot provide for once off excessive demands
47
What are the five important definitions applicable to hospital blood bank management
Shortage Shortage rate Demand Outdate Outdate Rate
48
Define a shortage
When a request for blood cannot be satisfied either partially or in full Might result in cancellaion of surgeries Shortage is twice as expensive as an oudate
49
Define shortage rate
The number of times a shortage occurs expressed as a % of th total number of requests
50
Define demand
The number of units requested for transfusion usually expressed as a daily mean
51
Define outdate
A unit of blood that has exceeded its maximum shelf life i.e. 35 days
52
What is an outdate rate?
The number of outdates expressed as a % of the total number of units received i.e. the % that are going out of date
53
What are the costs of shortages?
Delay in elective transfusion resulting in increased hospital stay -> think about cost of this Delay in surgery May result in patients being given the wrong group -> another form of waste as that unit shouldnt have been given e.g. giving an A- person our valuable O-s May require extra orders from the IBTS -> again costly Shortage is estimated at twice the cost of an outdate i.e. double the cost of a unit
54
Talk about the importance of outdate rate
Its the most commonlu used measure but its a very misleading idicator Significant improvements in outdats can be achieved at the expensive of good management: - understocking can mimise outdating Minimum outdating can also be achieved by limiting the range of blood types stocked e.g. by only stocking O pos and O negs
55
How does the IBTS prevent hospitals from only stocking O-s
The IBTS will give money back on any A or B units not used to encourage hospitals to stock them
56
What are the affects of understocking?
Shortages resuling in transfusion delays Risk of under supply Increased running costs Increase compatible blood transfusions e.g. Aneg to A pos Increased O neg usage
57
What are the affects of overstocking?
Increased outdating Increased suitable vs compatible transfusions Increase in mean age of blood transfused Contributes to national suppl shortages
58
How does the IBTS get hospitals to take on old blood and why might this occur
The IBTS tends to hold onto R1R1s or R2R2 packs for 14 days -> used in panels The blood is already 14 days old by the time it reaches the hospitals So if the blood is not used then th hospital will get a full refund on the pack
59
How much outdating is there in Ireland, compare 2010 to 2018 for rbcs and platelets
In 2010: - > 10% of red cells were outdated - > 10% of platelets were outdated In 2017: - 0.43% of red cells are outdated - 4.10% of platelets are outdated NB: platelets still high due to 7 day expiry date but weve gotten very efficient at managing blood
60
Define supply chain management
the combination of art and science that goes into improving the way your company finds the raw components its needs to make a product or service, manfactures that product or service and delivers it to customers
61
What are the five basic components of supply chain management
Plan: - establish inventory for your hospital based on appropraite decision variables Source: - arange delivery schedules and transportation with supplier Make: - accept into stock and prepare for processing Deliver: - co-ordinate products with orders and prepare for tissue/transfusion Return: - return to supplier outdates, recalls, defects etc. Handle complaints
62
Why is measuring so important in blood stock management
If you dont measure you cant manage Measuring effective blood stock management through: - outdating - shortage - operational costs - usage Measuring all of these allows us to capture waste etc
63
What are the two types of deliveries from the IBTS
Scheduled deliveries Non scheduled deliveries/Ad hoc deliveries
64
What are the scheduled IBTS deliveries
Delivered by first direct medical couriers delivery service Vehicle is temperature controlled and is under the supervision of an employee who is trained in blood product handling Service is free to hospitals Frequency is daily to all hospitals on weekdays
65
What are ad hoc deliveries?
All other deliveries and collection of blood products from the IBTS that arent schdules Theyre usually by taxi, courier or train Driver is usually known to the IBTS and also untrained The hospital pays a significant charge for this service
66
What factors contribute to operational cost of blood management
Non-scheduled deliveries Placing of orders Packaging of orders Delivery costs Documentation Invoicing Payment Extra out of hours fees which are increased if outside dublin etc
67
How much does an out of hurs deliver cost
100.00 if in dublin 150 if outside Not including IBTS supplementary out of hours charge
68
Comment on the operational costs of extra ad hoc deliveries per annum
7 extra per week: in a year - 36,500.00 euro if in dublin - 54,750.00 euro if outside 10 extra per week: - 52,000.00 in dublin - 78,000.00 ouside 20 extra per week: - 104,000.00 in dublin - 156,000.00 outside dublin
69
What are the supplementary charges applied by the IBTS
All orders for non standard items out of hours incur a supplementary charge over and above all other charges Current fee is approx 150.00 to the following items: - CMV negative - irradiated - phenotyped red cells - other miscellaneouos requests IBTS used to charge an extra 100 for K- blood even though it was already labelled on the blood pack
70
How has in hospital storage of O-s changed over the years
Used to keep 50+ O-ve units in fridges before daily deliveries but now hospitals only keep about 20 O-s
71
What is meant by red cell usage
Excluding emergencies how often do patients in your hospital receive blood which is not of their own ABO or Rh D type and for what reason? What % of O Rh D negative blood is used in your hospital?
72
What % of donors bled by IBTS are O- vs the % of the population?
Almost 15% of donors bled by the IBTS are O RhD negative 8-9% of the population are O RhD negs Were overbleeding our O negs, where are all of these units going?
73
What is our issue with outdating O-s
Which is the greater sin, to outdate an O neg or a B + unit? Its worse to outdate the O-, the B+ outdating is inevitable But both units have been donated by donors in good faith and both should be cherished
74
What happened when the question of where all the O negs were going was asked by the IBTS
The IBTS accused the hospital labs of overusing O negs This came across as 'the labs are inappropriately usin O-s' - the academy had to write a letter defendin them from the IBTS Fabian was incharge of this letter - he had to prove that there was no evidence that labs were using O-s incorrectly - proved using stats on emergvency O negs
75
What are the four inventory decision variables
Mean daily demand The age of supply or the maximum shelf life of the product The crossmatch release period The C/T ratio
76
How does a lab decide how much they need
Often done emperically MS knows they always need 20 units so they always order 20 without questioning it MS is usually correct on this
77
What is mean daily demand
The number of units of each blood type requested daily expressed as a mean
78
What is the age of supply or the maximum shelf life of the product?
The number of days remaining to expiry on the blood when delivered
79
What is the crossmatch release period?
How long is the blood left crossmatched before returning unused to stock NB: before electronic crossmatch it took time to do -> blood was left in the fridge for 72 hours historically as this is how long crossmatch was valid for but now we take them back into stock after 24 hours
80
What is the C/T ratio?
The ratio of crossmatched blood actually transfused This is auditted regularly as this is how we know wards are overordering blood -> done regularly to prevent waste and overordering etc
81
What does a C/T ratio reflect?
This reflects excessive crossmatching to usage Considerable amount of inventory is crossmatched but not likely to be used - result in overstocking and outdating Ratio of 1.5 is the optimum C/T ratio can be improved by auditing ordering patterns Develop MSBOS from these audits -> agreed upon tariffs of blood requirement per procedure C/T can be improved by electronic issue
82
Why is a ratio of 1.5 optimal for C/T ratio
A ratio of 1.1 is impossible to achieve Impossible to transfuse every single order Also cant accoun for emergencies This where MSBOS comes in to prevent overordering
83
how has MSBOS and EI imporoved C/T ratio
Historically knee surgery required 2 units crossmatched but nowadays its just a type and screen procedure as you can IE units at any time
84
What are the two different formulas for calculating blood orders for a weekly order
Cohen et al Model: using the optimal decision rule In house formula: mean daily demand for each blood type x 7
85
What is the Cohen et al model
S = dont need to know equation (dm)(p)(L)/ (D) But S = equation whereby S is the target inventory level for eah blood type
86
How is blood ordered today
MS tend to work of an in house formula - emperical They watch their waste and reduce ordering when needed etc
87
Wha does p, D, L and dm of the Cohen model mean
p = crossmatch to transfusion ratio (c/t) D = crossmatch release period in days i.e. issue time L = the maximum shelf life of the product dm = mean daily demand for each blood type
88
What are different ways to improve inventory management, following the Cohen equation
L: increase shelf life to 42 days or platelets from 5-7 in recent years Dm = reduce mean daily demand via MSBOS D = reduce crossmatch release period P = reduce c/t ratio e.g. electronic issue
89
What have been two methods put in place by the IBTS to improve inventory management in hospitals
Blood group guarantee from IBTS -> ensures blood can be used via electronic crossmatch Regular supply - daily deliveries
90
What are the features of the optimal decision rule?
Implicit shortage rates: - 0.1% for larvger volume blood types - 1.0% for rarer blood types -> were probably at optimal blood usage point now Outdate rates: - more sensitive to decision variables 0.1-7% - implicit supply in stock for approximately 6 days - based on a daily inventory top-up
91
What are the features of the optimal decision rule?
Implicit shortage rates: - 0.1% for larvger volume blood types - 1.0% for rarer blood types -> were probably at optimal blood usage point now Outdate rates: - more sensitive to decision variables 0.1-7% - implicit supply in stock for approximately 6 days - based on a daily inventory top-up
92
What are the three steps in seetting the inventory, why are they important
1. Measure existing performance 2. Opimise decision variable 3. Setting the inventory These are the things we measure to improve stock management From these we calculate what we can do to improve these More likely to waste a unit with a short date etc
93
How do you go about measuring existing performance of your inventory
Shortages, outdates, no. of deliveries, usage for each blood type Decide where improvements can be made Calculate mean daily demand for each type Monitor age of units received from IBTS Calculate the C/T ratio
94
How do you do about optimising decision variables?
Improve C/T ratio and mean daily demand Where possible set crossmatch release at 24 hours Negotiate routine supply with days to expiry Rationalise frequency of ordering In the morning doing a query for low platelets in haematology etc
95
How do you go about setting your inventory
Decide on priority i.e. where is greatest improvement needed Decisions usually made emperically on instinct or historical experience - if done effectively there are huge savings In house formula Computer simulated model Calculate your inventory and decide on your delivery frequency Audit your results Review improve your system
96
What should you do if unsure on how to manage your blood stock?
Contact the blood centre for advice before starting The IBTS wants to be involved in your blood stock -> if you think your overusing contact them and they can help It stock is badly managed at hospital level there will be national shortages hence why the IBTS will monitor hospitals and get involved if necessary
97
What blood types are more difficult to manage?
Blood types of lower frequency such as B or AB NB: you should always include B and AB in your inventory, if they are on your shelf you will have some opportunity to use them, the IBTS offer sale or return for B and AB blood
98
Which hospitals struggle more with blood management
Larger hospitals with greater turnover will achieve better outdate rates than smaller centres just by virtue of use
99
Which hospitals struggle more with blood management
Larger hospitals with greater turnover will achieve better outdate rates than smaller centres just by virtue of use
100
What are the policies you should follow when selecting red cells for transfusions
FIFO -> first in first out for all but cardiac surgeries and neonates Must be ABO RhD compatible except: - during blood shortages - patients with multiple antibodies -> SCD patients - blood issued uncrossmatched (emergency) - non matched ABO organ transplantation
101
What are the benefits of a standardised system for inventory management
With the aid of on-line links to each major blood user national inventory levels could be established Inventory levels could be monitored constantly -> would allow IBTS to see the whole picture of blood in hospitals and prevent waste -> 'why is this hospital using less O-s then yours' If a run was occurring on any blood type this would be apparent at the blood centre. Rescheduling of donors to prevent a storage -> the IBTS really want to implement this During periods of reduced blood supply, stocks could be distributed more equitably Blood stock management scheme UK
102
What does BSMS stand for
Blood stock management scheme UK
103
What is the BSMS
A joint venture between the national blood service in England and North Wales and participating hospitals. Commenced in 2001 April 2004 259 of 304 (85%) of hospitals registered Web based. Eah site has an account number and they submit data on the ' Daily stock data page The Scheme collects and displats red cell stocks and wastage data Measures stock levels by the issuable stock index (ISI) at the hospitals and blood centres Pros: collects and presents data and promotes benchmarking Cons: crude attempt at inventory management
104
What are some possible future developments
Hospital exchange networks- laready a reality known as rerouting - required validated systems Standard inventory approach among blood users Establishment of National Inventory Levels Supplier controlled inventory management: - IBTS woulf top up your blood as required daily and only allow special requests Elimination of routine ordering Establishment of a participants performance league
105
What are some changes at the IBTS
Blood Establishment Computer project Contract signed for iintroduction of eProgesa - Live 2014, ISBT 128 Survey al hospitals on label information Electronic despatch note Vanessa - electronic data project UK Linked to blood track

4.2 Blood Transfusion Science (21 decks)

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