Blood Stock Management

Question 1

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

Answer 1

‘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

Question 2

Good blood stock management is dependent on teamwork between who?

Answer 2

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

Question 3

Comment on the expenses of the BT lab

Answer 3

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

Question 4

What are the important topics covered in blood stock management

Answer 4

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

Question 5

What is the BOSS system

Answer 5

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

Question 6

Why do we re-route blood

Answer 6

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

Question 7

Talk about the Cohen equation

Answer 7

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

Question 8

How would the IBTS like to run blood stock management?

Answer 8

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

Question 9

Who is our blood transporters, talk about their role?

Answer 9

First Direct couriers
Technicaly a blood establishment under EU directive

Question 10

Where is blood collected and processed?

Answer 10

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

Question 11

Talk about the role of the IBTS in Ireland

Answer 11

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

Question 12

Talk about the storage of red cells and platelets

Answer 12

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

Question 13

How is the blood transfusion service organised in ireland

Answer 13

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

260 venues

Question 14

Talk about the Blood transfusion service in Irish hospitals

Answer 14

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

Question 15

How many orders does the IBTS receive each yea

Answer 15

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

Question 16

How is blood distributed in Ireland

Answer 16

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

Question 17

Talk about delivery schedules today

Answer 17

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

Question 18

Talk about blood delivery schedules in the past

Answer 18

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

Question 19

Give an example of a delivery route

Answer 19

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

Question 20

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

Answer 20

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

Question 21

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

Answer 21

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

Question 22

Talk about the IBTS meeting with hospital groups

Answer 22

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

Question 23

What does eBOSS stand for?

Answer 23

electronic Blood Operations Support System

Question 24

Talk about eBOSS

Answer 24

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

Question 25

Talk about the different web applicaions involved in blood stock management

Answer 25

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

Question 26

What is the IBTS message board

Answer 26

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

Question 27

What is a red cell forecast

Answer 27

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

Question 28

How does eBOSS put out its reports?

Answer 28

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

Question 29

What is the traffic light system

Answer 29

A way of describing the levels of blood stock remaining: green, amber, red Tells us what category of surgeries should be cancelled etc

Question 30

What is category 1 surgeries

Answer 30

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

Question 31

What are category 2 surgeries

Answer 31

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

Question 32

What are category 3 surgeries?

Answer 32

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

Question 33

Define an urgent vs an emergency surgery

Answer 33

Emergency: patient likely to die within 24 hours without surgery Urgent - patient likely to have major morbidity if surgery not carried out

Question 34

What usually comes before an amber alert

Answer 34

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

Question 35

What are some essential factors in blood stock management

Answer 35

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

Question 36

What are the main benefits to good stock management

Answer 36

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

Question 37

When did we introduce a daily delivery?

Answer 37

Introduced in 2013

Question 38

What have been the benefits of daily deliveries

Answer 38

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

Question 39

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

Answer 39

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

Question 40

How exactly is blood rerouted?

Answer 40

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

Question 41

What blood is rerouted and why

Answer 41

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

Question 42

How manny rerouted red cells are ther

Answer 42

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

Question 43

How many rerouted platelets are there

Answer 43

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

Question 44

What considerations are there for blood stock management

Answer 44

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

Question 45

How much money does the IBTS spend each yea

Answer 45

IBTS turnover >120.00 million

Question 46

What are the five main characteristics of our blood inventory management

Answer 46

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

Question 47

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

Answer 47

Shortage Shortage rate Demand Outdate Outdate Rate

Question 48

Define a shortage

Answer 48

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

Question 49

Define shortage rate

Answer 49

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

Question 50

Define demand

Answer 50

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

Question 51

Define outdate

Answer 51

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

Question 52

What is an outdate rate?

Answer 52

The number of outdates expressed as a % of the total number of units received i.e. the % that are going out of date

Question 53

What are the costs of shortages?

Answer 53

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

Question 54

Talk about the importance of outdate rate

Answer 54

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

Question 55

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

Answer 55

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

Question 56

What are the affects of understocking?

Answer 56

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

Question 57

What are the affects of overstocking?

Answer 57

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

Question 58

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

Answer 58

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

Question 59

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

Answer 59

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

Question 60

Define supply chain management

Answer 60

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

Question 61

What are the five basic components of supply chain management

Answer 61

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

Question 62

Why is measuring so important in blood stock management

Answer 62

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

Question 63

What are the two types of deliveries from the IBTS

Answer 63

Scheduled deliveries Non scheduled deliveries/Ad hoc deliveries

Question 64

What are the scheduled IBTS deliveries

Answer 64

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

Question 65

What are ad hoc deliveries?

Answer 65

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

Question 66

What factors contribute to operational cost of blood management

Answer 66

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

Question 67

How much does an out of hurs deliver cost

Answer 67

100.00 if in dublin 150 if outside Not including IBTS supplementary out of hours charge

Question 68

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

Answer 68

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

Question 69

What are the supplementary charges applied by the IBTS

Answer 69

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

Question 70

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

Answer 70

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

Question 71

What is meant by red cell usage

Answer 71

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?

Question 72

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

Answer 72

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?

Question 73

What is our issue with outdating O-s

Answer 73

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

Question 74

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

Answer 74

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

Question 75

What are the four inventory decision variables

Answer 75

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

Question 76

How does a lab decide how much they need

Answer 76

Often done emperically MS knows they always need 20 units so they always order 20 without questioning it MS is usually correct on this

Question 77

What is mean daily demand

Answer 77

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

Question 78

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

Answer 78

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

Question 79

What is the crossmatch release period?

Answer 79

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

Question 80

What is the C/T ratio?

Answer 80

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

Question 81

What does a C/T ratio reflect?

Answer 81

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

Question 82

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

Answer 82

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

Question 83

how has MSBOS and EI imporoved C/T ratio

Answer 83

Historically knee surgery required 2 units crossmatched but nowadays its just a type and screen procedure as you can IE units at any time

Question 84

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

Answer 84

Cohen et al Model: using the optimal decision rule In house formula: mean daily demand for each blood type x 7

Question 85

What is the Cohen et al model

Answer 85

S = dont need to know equation (dm)(p)(L)/ (D) But S = equation whereby S is the target inventory level for eah blood type

Question 86

How is blood ordered today

Answer 86

MS tend to work of an in house formula - emperical They watch their waste and reduce ordering when needed etc

Question 87

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

Answer 87

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

Question 88

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

Answer 88

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

Question 89

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

Answer 89

Blood group guarantee from IBTS -> ensures blood can be used via electronic crossmatch Regular supply - daily deliveries

Question 90

What are the features of the optimal decision rule?

Answer 90

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

Question 91

What are the features of the optimal decision rule?

Answer 91

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

Question 92

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

Answer 92

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

Question 93

How do you go about measuring existing performance of your inventory

Answer 93

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

Question 94

How do you do about optimising decision variables?

Answer 94

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

Question 95

How do you go about setting your inventory

Answer 95

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

Question 96

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

Answer 96

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

Question 97

What blood types are more difficult to manage?

Answer 97

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

Question 98

Which hospitals struggle more with blood management

Answer 98

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

Question 99

Which hospitals struggle more with blood management

Answer 99

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

Question 100

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

Answer 100

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

Question 101

What are the benefits of a standardised system for inventory management

Answer 101

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

Question 102

What does BSMS stand for

Answer 102

Blood stock management scheme UK

Question 103

What is the BSMS

Answer 103

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

Question 104

What are some possible future developments

Answer 104

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

Question 105

What are some changes at the IBTS

Answer 105

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