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The cost-effective reorganization of a small transfusion service laboratory.

Transferring the majority of the workload to the shift, anticipating inventory needs, and forging a "blood issue policy" helped this small community hospital blood bank realize a net savings of almost $24,000 a year.

How does a community hospital blood bank striving to meet the quality assurance standards of today's health care remain customer oriented and cost effective? Specifically, how does a blood bank that allowed 28 employees to rotate infrequently through its department on all shifts demonstrate, document, and maintain proficiency? This was our challenge; what follows is our solution.

Nearly five years ago, the need for change within the blood bank began revealing itself. Two consecutive inspections by the American Association of Blood Banks (AABB) recommended we reduce the number of employees rotating through the department, or develop and implement a system to maintain competency and provide continuing education. At this time, our department structure and work flow were very traditional. We had scheduled coverage in the department seven days a week from 6:30 am to 11:00 pm. Approximately 50% of the workload was done on the day shift, 50% was done on the afternoon shift, and less than 5% was done on the midnight shift. We discussed departmentalization as a way to reduce staff but feared that would create a scheduling problem, especially for our second and third shifts.

As we evaluated our second-shift patient demographics, we discovered most of the testing being done on this shift was routine prenatal and preadmission testing. We began to think "outside of the box" for our solution.


Instead of doing all procedures 24 hours a day, most of the work would be performed by a core of five fully competent blood bank techs during the day shift. The day shift would be redefined as scheduled coverage from 6:00 am to 5:00 pm Monday through Friday and 6:00 am to 2:30 pm on weekends and holidays. The blood bank techs would be on call to resolve any special after-hours needs.

In addition, we would plan our inventory needs by obtaining a surgery schedule 48 hours in advance, move our Red Cross product processing from afternoons to mornings, batch all prenatal and preadmission specimens that arrived in the evening the next day, and develop what we would call a "blood issue policy."

The blood issue policy. The blood issue policy is that all routine work, crossmatches, and specialized testing is done from 6:00 am to 5:00 pm. After 5:00 pm, the lab would process only Star type-and-screen and crossmatch tests. If it was necessary to transfuse a patient between 5:00 pm and 6:00 am, however, only the type and screen would be done along with a review of the patient's history. Provided the patient history did not reveal any discrepancies in type, previous antibodies, or transfusion reactions, and the antibody screen is negative, [O.sub.+]+ or [O.sub.-] packed cells (respective of the patient's Rh) are issued, and an antihuman-globulin crossmatch is done the next day. This eliminates the possibility of an ABO incompatible unit being issued, since, at this time, our computer system does not allow an electronic crossmatch. Similarly, if fresh frozen plasma is requested between 5:00 pm and 6:00 am, only AB plasma is transfused.
Figure 1

Percentage of non-type specific units issued between 5:00 pm and
6:00 am

Month % of non-type Total monthly
 specific transfusions transfusions

April 1994 3% 184
May 11 223
June 2 170
July 2 180
August 3 124
September 5 200
October 6.7 248
November 9 249
December 8 161
January 1995 1 109
February 0 94
March 7 133
April 3 129
Monthly average = 4.7%

Rotating on-call system. A rotating system was established to resolve any problems that occurred from 5:00 pm to 6:00 am. If an ABO discrepancy or a positive antibody screen is encountered, a day-shift tech is called in to resolve the problem and issue type-specific, antigen-negative, crossmatch-compatible units. Our afternoon and midnight shifts would have to maintain proficiency for only type-and-screen and direct Coombs testing.

Provide education. The final stage of our policy implementation was to provide nursing and physician education. We hosted nursing in-services for all our RNs, and used our Tissue and Transfusion Committee as well as our Surgery Committee to educate the physicians.

The blood issue policy was instituted April 11, 1994. We agreed that if the O blood supply was not abused, the policy would continue until we could institute a computer crossmatch. Abuse of the inventory was defined as non-type-specific transfusions greater than 10%.

Currently the blood issue policy transfusion statistics are reviewed monthly. On average, 4.7% of our units transfused within the guidelines of the policy are not type specific (see Figure 1). By our definition, the O blood supply has never been abused.

The combination of a restructured workflow, a blood issue policy, and a redefined day shift allowed us to complete 93% of our work during the day while averaging only 1 call-in per month. We save 40.5 hours of tech time a week. This has saved us $23,946.68 a year (see Figure 2). Since March of 1994, we have reduced our cost per billable unit by $16.19! An unexpected benefit of the policy has been a reduction in the number of routine transfusions between 5:00 pm and 6:00 am. We believe this has reduced the need for call-ins.

How does a community hospital blood bank striving to meet the quality assurance standards of today's health care remain customer oriented and cost-effective? We believe the greatest control is within the blood bank and that the success of our blood issue policy demonstrates this point. We have significantly reduced costs, improved the skills of our core blood bank staff while relieving the blood bank anxieties of our evenings shifts, and still provided our customers with a satisfactory product.

Figure 2

Blood issue policy cost savings stat sheet

43.5 hrs. of tech time saved per week with restructure -3.0 hrs. (7% of work done after 5:00 pm) = 40.5 hrs. of tech time saved per week.

40.5 hrs. per week x $14.79 (the average hourly rate w/shift differential) = $598.995 saved per week.

$599 saved per week x 52 weeks = $31,148 saved per year.

$31,148 - $6,669 (the cost for on-call techs per year @ $1.35 per hour) = $24,479 per year.

$24,479 per year - $532.32 per year (average one 2-hr. call-in a month at time-and-a-half) = an annual cost savings of $23,946.68.

Jerry W. Davis is blood bank supervisor at Geisinger Medical Center in Danville, Pa. Pam J. Perone is blood bank supervisor at Good Samaritan Medical Center in Zanesville, Ohio.
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Author:Davis, Jerry W.; Perone, Pam J.
Publication:Medical Laboratory Observer
Date:Oct 1, 1996
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