Blood Stock Management Flashcards
What have been the headlines in the papers in the past year, why was this significant
‘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
Good blood stock management is dependent on teamwork between who?
Consnultant haematologist
Membersof HTC
IBTS
First Direct Medical
Haemovigilance team
Clinical Teams
Hospital groups
Laboraotry staff
Comment on the expenses of the BT lab
The BT lab is one of the most expensive places in the hospital
What are the important topics covered in blood stock management
BOSS
Web Apps
Forecasting
Essential factors for IBTS to manage stock
Benefits of good management
Re-routing blood as a tool for stock management
What is the BOSS system
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
Why do we re-route blood
Its just out of good faith
Its a way of reducing waste
No hospitals are paid for this etc
Talk about the Cohen equation
An equation for determening blood stock requirements however this isnt really followed anymore since we now have daily deliveries and not weekly etc
How would the IBTS like to run blood stock management?
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
Who is our blood transporters, talk about their role?
First Direct couriers
Technicaly a blood establishment under EU directive
Where is blood collected and processed?
Only collection and aphersis in Cork IBTS
All samples processed in Dublin IBTS
Talk about the role of the IBTS in Ireland
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
Talk about the storage of red cells and platelets
Red cells @4 degrees shelf lie 35 days
Platelets @22 shelf life 5-7 days
How is the blood transfusion service organised in ireland
6 mobile teams teams that cover the whole country
4 fixed centres:
- 1 platelets only
- 1 hybrid
- 2 whole blood only - Dublin
260 venues
Talk about the Blood transfusion service in Irish hospitals
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
How many orders does the IBTS receive each yea
35,380 product orgers received in 2019
28,623 (81%) were received in the NBC
6,757 (19%) in MRTC
How is blood distributed in Ireland
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
Talk about delivery schedules today
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
Talk about blood delivery schedules in the past
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
Give an example of a delivery route
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
How does the IBTS control and monitor how much blood is spent by hospitals
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
What is a good way of knowing how many platelets you will need to order?
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
Talk about the IBTS meeting with hospital groups
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
What does eBOSS stand for?
electronic Blood Operations Support System
Talk about eBOSS
Developed by the New York Blood centre
Went live on the 20th April 2009 in Ireland
Includes eProgesa
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
What is the IBTS message board
It shows daily amount of blood left and provides live updates on apheresis donations
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
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
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
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
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
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
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
What usually comes before an amber alert
A pre-amber alert letter to warn hospitals to reduce usage to prevent an amber alert occuring
What are some essential factors in blood stock management
Recruitment and donor management
Collection management
Manufacturing and testing
Inventory, distribution
Despatch and sales
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
When did we introduce a daily delivery?
Introduced in 2013
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
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
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
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
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
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
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
How much money does the IBTS spend each yea
IBTS turnover >120.00 million
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
What are the five important definitions applicable to hospital blood bank management
Shortage
Shortage rate
Demand
Outdate
Outdate Rate
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
Define shortage rate
The number of times a shortage occurs expressed as a % of th total number of requests
Define demand
The number of units requested for transfusion usually expressed as a daily mean
Define outdate
A unit of blood that has exceeded its maximum shelf life i.e. 35 days
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
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
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
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
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
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
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
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
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
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
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
What are the two types of deliveries from the IBTS
Scheduled deliveries
Non scheduled deliveries/Ad hoc deliveries
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
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
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
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
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
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
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
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?
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?
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
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
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
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
What is mean daily demand
The number of units of each blood type requested daily expressed as a mean
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
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
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
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
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
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
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
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
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
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
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
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
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
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
What are the three steps in seetting the inventory, why are they important
- Measure existing performance
- Opimise decision variable
- 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
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
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
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
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
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
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
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
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
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
What does BSMS stand for
Blood stock management scheme UK
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
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
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
