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Reducing blood outdating: an incentive program saves a shrinking resource.

Reducing blood outdating: An incentive program saves a shrinking resource

In 1985, the transfusion service at our 700-bed tertiary-care hospital received a challenge from its blood supplier: If blood outdating could be reduced over a 12-month period, the hospital would get a rebate of $22 per conserved unit. The supplier extended this offer to all hospitals in and around Fort Wayne, Ind., because of the area's high percentage of outdating.

With expanded screening raising the cost of acquiring blood, and donors becoming scarcer, it made sense to create the incentive plan. The supplier would not have to draw so many units if hospitals did not waste so much blood.

Our institution transfuses about 11,000 units of blood a year, and its outdating rate was a fairly high 3.2 per cent. A consignment arrangement with the supplier had provided no financial incentive to manage blood inventory effectively. As units expired, the hospital returned them to the supplier and obtained full reimbursement. Although reimbursement continued under the new plan, the rebates provided motivation for careful inventory management.

An analysis of the hospital's transfusion service system revealed several factors besides consignment that contributed to the high rate of blood outdating. Listed below are the targeted problems uncovered and the solutions that were developed:

Problem: Our blood bank's transfusion policy prevented our technologists from using Rh-negative donor units for Rh-positive recipients. This resulted in unnecessary outdating of Rh-negative blood units. It is well documented that transfusing Rh-negative red cells to Rh-positive recipients will not cause increased Rh antibody production from exposure to antigens that are more common on Rh-negative red blood cells.1

Solution: Within two days of expiration, Rh-negative units were transfused to Rh-positive patients to avert outdating.

Problem: Hold orders, calling for blood to be crossmatched and kept in the blood bank, were being filled with nearly outdated units (one to five days left). So were surgical blood orders. After being out of circulation for 48 hours, unused units either had expired or went back to stock one or two days before outdating.

Solution: All hold and surgical blood orders now must be filled with blood dated at least seven days before expiration, preferably longer. The only exceptions are patients with rare blood types or special antibody requirements.

Selected surgical cases (heart bypass, kidney, and liver) always receive the freshest units. For example, heart bypass and cardiac patients in general need fresh blood because it contains high levels of adenosine triphosphate and 2,3-diphosphoglycerate, substances that help release oxygen to tissues. Such patients, unlike those who receive routine transfusion therapy, can't adjust easily to the decreased oxygen-carrying capacity of stored red blood cells.1

The majority of surgical blood orders are for packed cells. We also receive whole blood orders for both surgical and nonsurgical transfusions, however. Under our new policy, any whole blood with fewer than seven days to expiration is converted to packed cells. These are still close to outdating, but they may be used for nonsurgical transfusion orders, which are filled with the oldest units first.

Problem: The hospital has a daily blood inventory of approximately 250 units (whole blood and packed cells). Three problems made it difficult to maintain this inventory.

First, about 20 per cent of the blood inventory consisted of less prevalent blood types. This led to frequent outdating of type B and AB units.

Second, the blood inventory fluctuated, and on some days 70 to 80 units had to be ordered from the supplier--about one-third of total daily inventory. With so many units coming in at one time, a significant number of them would outdate on the same day.

Third, too many whole blood units were kept in stock. These represented 40 to 50 per cent of the blood inventory. Often they outdated without being used as packed cells.

Solution: To solve the first problem, the transfusion service decided to decrease the number of type B and AB units to 12 to 15 per cent of total inventory, approximating the percentages of these blood types in the general population.2 The supplier was also asked to send fresher B and AB units. The total number of these units is now being tracked, so that, for instance, AB whole blood is not ordered from the supplier when the number of AB packed cells is adequate.

Secondly, to keep expiration dates varied and guard against too many units outdating at the same time, a minimum number of type A and O units are ordered daily. Shorter dated units now have time to be transfused before they become unusable.

Finally, we have also decreased the number of whole blood units in stock. If whole blood is ordered for transfusion but is not available in inventory, we automatically substitute packed cells.

As noted earlier, whole blood is packed when it approaches its expiration date. The price difference between whole blood and packed cells was reimbursed when the plasma from the whole blood was returned to the supplier.

Problem: Two problems thwarted smooth blood typing operations. First, transfusion service policy called for a crossmatch to be done when the number of blood units was specified with a type and screen order. In addition, some physicians began ordering crossmatches at the outset because type and screen orders were not getting them blood any faster.

Solution: Now when a type and screen is ordered, even with a specific number of blood units requested, only the type and screen is performed. This eliminates the need for taking blood out of stock when the probability of a transfusion is small.3 The type and screen is a more economical procedure than the comprehensive crossmatch, and we promote it.

If blood that has been typed and screened is needed, the transfusion service can release it directly after an immediate-spin crossmatch. Then the service completes the antiglobulin testing phase of the crossmatch. Thanks to this consistent policy, physicians became less reluctant to order a type and screen, knowing blood would be readily available.

Problem: There was minimal managerial supervision to insure that the blood inventory was being used carefully. The problems listed above attested to the need for inventory utilization changes.

Solution: In May 1985, the hospital hired a specialist in blood banking with an MT(ASCP)SBB certification and 10 years' blood bank experience, both in a regional medical center and a regional blood center. The staff's acceptance of new ideas was a major step toward improving the transfusion service operation.

Another initiative coincided with improved inventory management. Continuing education outside the hospital was provided to all technical staff, not just supervisors. The technologists became better informed about the changing blood bank field by visiting other institutions and attending lectures. Our continuing education budget was more fairly shared, allowing everyone on all shifts to attend a seminar, workshop, or meeting annually.

How effective were all these steps? The supplier's special one-time offer applied to blood conserved during the fiscal year from July 1, 1985, to June 30, 1986. Our outdating rate for that period (1.29 per cent) was subtracted from the outdating rate for the same period a year earlier (4.50 per cent, see Figure I).

The 3.21 per cent difference was then multiplied by the number of blood units obtained from the supplier in the targeted fiscal year. The result--the number of units conserved from waste--was multiplied by the supplier's payment of $22 per conserved unit, producing a total rebate of $7,825 (see Figure II).

The decrease in blood outdating stemmed largely from the eagerness of bench technologists to carry out all of the solutions when they were presented for evaluation. Although changes were difficult, the results made the efforts worthwhile. Inventory management proved so effective that outdating dropped to zero in the months of July and December 1986. Figures III and IV chart the decline. Figure III also shows that outdating became more consistent on a month-to-month basis, compared with wide fluctuations in rates during 1984 and 1985.

Blood is too precious a resource to waste. That really should be incentive enough for any transfusion service to manage its blood inventory effectively.

1. Mollison, P.L. "Blood Transfusion in Clinical Medicine,' 7th ed. St. Louis, C.V. Mosby, 1985.

2. Widmann, F.K., ed. "AABB Technical Manual,' 9th ed. Arlington, Va., American Association of Blood Banks, 1985.

3. Boral, L.I., and Henry, J.B. The type and screen: A safe alternative and supplement in selected surgical procedures. Transfusion 17: 163-168, 1977.

Table: Figure I The decline in outdated blood units

Table: Figure II Calculating the blood bank's rebate

Table: Figure III Monthly blood outdate percentage

Table: Figure IV Annual average outdate percentage
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Author:Arvin, Kathleen S.
Publication:Medical Laboratory Observer
Date:Jan 1, 1988
Words:1446
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