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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
Q

Talk about the different web applicaions involved in blood stock management

A

Delivery tracking
Appointment scheduler
clinic scheduler
blood stock management scheme
Message board
Information request manager
enterprise solution e.g. forecasting

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26
Q

What is the IBTS message board

A

It shows daily amount of blood left and provides live updates on apheresis donations

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27
Q

What is a red cell forecast

A

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

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28
Q

How does eBOSS put out its reports?

A

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

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29
Q

What is the traffic light system

A

A way of describing the levels of blood stock remaining:
green, amber, red

Tells us what category of surgeries should be cancelled etc

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30
Q

What is category 1 surgeries

A

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

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31
Q

What are category 2 surgeries

A

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

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32
Q

What are category 3 surgeries?

A

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

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33
Q

Define an urgent vs an emergency surgery

A

Emergency: patient likely to die within 24 hours without surgery

Urgent - patient likely to have major morbidity if surgery not carried out

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34
Q

What usually comes before an amber alert

A

A pre-amber alert letter to warn hospitals to reduce usage to prevent an amber alert occuring

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35
Q

What are some essential factors in blood stock management

A

Recruitment and donor management
Collection management
Manufacturing and testing
Inventory, distribution
Despatch and sales

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36
Q

What are the main benefits to good stock management

A

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

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37
Q

When did we introduce a daily delivery?

A

Introduced in 2013

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38
Q

What have been the benefits of daily deliveries

A

Redued number of non-scheduled deliveries
Reduced transport
Reduced administrative costs
Controlled stock entry
Patients generally receive fresher blood

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39
Q

What is re-routing of blood, when was it introduced

A

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

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40
Q

How exactly is blood rerouted?

A

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

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41
Q

What blood is rerouted and why

A

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

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42
Q

How manny rerouted red cells are ther

A

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

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43
Q

How many rerouted platelets are there

A

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
Q

What considerations are there for blood stock management

A

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
Q

How much money does the IBTS spend each yea

A

IBTS turnover >120.00 million

46
Q

What are the five main characteristics of our blood inventory management

A

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
Q

What are the five important definitions applicable to hospital blood bank management

A

Shortage
Shortage rate
Demand
Outdate
Outdate Rate

48
Q

Define a shortage

A

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
Q

Define shortage rate

A

The number of times a shortage occurs expressed as a % of th total number of requests

50
Q

Define demand

A

The number of units requested for transfusion usually expressed as a daily mean

51
Q

Define outdate

A

A unit of blood that has exceeded its maximum shelf life i.e. 35 days

52
Q

What is an outdate rate?

A

The number of outdates expressed as a % of the total number of units received

i.e. the % that are going out of date

53
Q

What are the costs of shortages?

A

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
Q

Talk about the importance of outdate rate

A

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
Q

How does the IBTS prevent hospitals from only stocking O-s

A

The IBTS will give money back on any A or B units not used to encourage hospitals to stock them

56
Q

What are the affects of understocking?

A

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
Q

What are the affects of overstocking?

A

Increased outdating
Increased suitable vs compatible transfusions
Increase in mean age of blood transfused
Contributes to national suppl shortages

58
Q

How does the IBTS get hospitals to take on old blood and why might this occur

A

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
Q

How much outdating is there in Ireland, compare 2010 to 2018 for rbcs and platelets

A

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
Q

Define supply chain management

A

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
Q

What are the five basic components of supply chain management

A

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
Q

Why is measuring so important in blood stock management

A

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
Q

What are the two types of deliveries from the IBTS

A

Scheduled deliveries
Non scheduled deliveries/Ad hoc deliveries

64
Q

What are the scheduled IBTS deliveries

A

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
Q

What are ad hoc deliveries?

A

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
Q

What factors contribute to operational cost of blood management

A

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
Q

How much does an out of hurs deliver cost

A

100.00 if in dublin
150 if outside

Not including IBTS supplementary out of hours charge

68
Q

Comment on the operational costs of extra ad hoc deliveries per annum

A

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
Q

What are the supplementary charges applied by the IBTS

A

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
Q

How has in hospital storage of O-s changed over the years

A

Used to keep 50+ O-ve units in fridges before daily deliveries but now hospitals only keep about 20 O-s

71
Q

What is meant by red cell usage

A

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
Q

What % of donors bled by IBTS are O- vs the % of the population?

A

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
Q

What is our issue with outdating O-s

A

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
Q

What happened when the question of where all the O negs were going was asked by the IBTS

A

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
Q

What are the four inventory decision variables

A

Mean daily demand
The age of supply or the maximum shelf life of the product
The crossmatch release period
The C/T ratio

76
Q

How does a lab decide how much they need

A

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
Q

What is mean daily demand

A

The number of units of each blood type requested daily expressed as a mean

78
Q

What is the age of supply or the maximum shelf life of the product?

A

The number of days remaining to expiry on the blood when delivered

79
Q

What is the crossmatch release period?

A

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
Q

What is the C/T ratio?

A

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
Q

What does a C/T ratio reflect?

A

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
Q

Why is a ratio of 1.5 optimal for C/T ratio

A

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
Q

how has MSBOS and EI imporoved C/T ratio

A

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
Q

What are the two different formulas for calculating blood orders for a weekly order

A

Cohen et al Model: using the optimal decision rule

In house formula: mean daily demand for each blood type x 7

85
Q

What is the Cohen et al model

A

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
Q

How is blood ordered today

A

MS tend to work of an in house formula - emperical

They watch their waste and reduce ordering when needed etc

87
Q

Wha does p, D, L and dm of the Cohen model mean

A

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
Q

What are different ways to improve inventory management, following the Cohen equation

A

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
Q

What have been two methods put in place by the IBTS to improve inventory management in hospitals

A

Blood group guarantee from IBTS -> ensures blood can be used via electronic crossmatch

Regular supply - daily deliveries

90
Q

What are the features of the optimal decision rule?

A

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
Q

What are the features of the optimal decision rule?

A

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
Q

What are the three steps in seetting the inventory, why are they important

A
  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
Q

How do you go about measuring existing performance of your inventory

A

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
Q

How do you do about optimising decision variables?

A

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
Q

How do you go about setting your inventory

A

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
Q

What should you do if unsure on how to manage your blood stock?

A

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
Q

What blood types are more difficult to manage?

A

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
Q

Which hospitals struggle more with blood management

A

Larger hospitals with greater turnover will achieve better outdate rates than smaller centres just by virtue of use

99
Q

Which hospitals struggle more with blood management

A

Larger hospitals with greater turnover will achieve better outdate rates than smaller centres just by virtue of use

100
Q

What are the policies you should follow when selecting red cells for transfusions

A

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
Q

What are the benefits of a standardised system for inventory management

A

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
Q

What does BSMS stand for

A

Blood stock management scheme UK

103
Q

What is the BSMS

A

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
Q

What are some possible future developments

A

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
Q

What are some changes at the IBTS

A

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 (18 decks)

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