Red blood cell (RBC) component wastage in hospitals

Transcription

1 BLOOD MANAGEMENT Implementation of a new blood cooler insert and tracking technology with educational initiatives and its effect on reducing red blood cell wastage Emmanuel A. Fadeyi, 1,2 Wanda Emery, 2 Julie H. Simmons, 2 Mary Rose Jones, 2 and Gregory J. Pomper 1,2 BACKGROUND: The objective was to report a successful implementation of a blood cooler insert and tracking technology with educational initiatives and its effect on reducing red blood cell (RBC) wastage. STUDY DESIGN AND METHODS: The blood bank database was used to quantify and categorize total RBC units issued in blood coolers from January 2010 to December 2015 with and without the new inserts throughout the hospital. Radiofrequency identification tags were used with special software to monitor blood cooler tracking. An educational policy on how to handle the coolers was initiated. Data were gathered from the software that provided a real-time location monitoring of the blood coolers with inserts throughout the institution. RESULTS: The implementation of the blood cooler with inserts and tracking device reduced mean yearly RBC wastage by fourfold from 0.64% to 0.17% between 2010 and The conserved RBCs corresponded to a total cost savings of $167,844 during the 3-year postimplementation period. CONCLUSIONS: The implementation of new blood cooler inserts, tracking system, and educational initiatives substantially reduced the mean annual total RBC wastage. The cost to implement this initiative may be small if there is an existing institutional infrastructure to monitor and track hospital equipment into which the blood bank intervention can be adapted when compared to the cost of blood wastage. Red blood cell (RBC) component wastage in hospitals is reported to range from 0% to 6.7%. 1,2 Particularly in the era of blood management, transfusion medicine physicians and clinical pathologists often endeavor to reduce laboratory expenses while simultaneously increasing productivity and improving patient safety. Although health care providers who order or administer blood products are aware that every effort should be made to prevent wastage of this precious resource, institutional protocols and regulatory standards to ensure safety remain a priority and may present limits to the complete elimination of product wastage. Blood transfusion therapy can be very expensive to operate and manage, especially when supporting oncology services. According to the JournalofClinicalOncology,the cost to have a blood transfusion can range from $1800 to $3000 per unit of RBCs transfused. 3-5 The acquisition cost of a unit of RBCs is approximately $200. This cost does not include the indirect costs of labor and reagents when preparing a unit of RBCs for transfusion, which are lost since the unit cannot be reissued to another patient. In ABBREVIATIONS: BTSI 5 blood transport and storage initiative; RFID 5 radiofrequency identification; RTLS 5 real-time location services. From the 1 Department of Pathology and Laboratory Medicine, Wake Forest University School of Medicine; and the 2 Department of Pathology and Laboratory Medicine, Wake Forest Baptist Health, Winston-Salem, North Carolina. Address reprint requests to: Emmanuel A. Fadeyi, MD, FCAP, FASCP, Department of Pathology and Laboratory Medicine, Wake Forest University School of Medicine, Winston- Salem, NC 27157; efadeyi@wakehealth.edu Received for publication February 21, 2017; revision received May 12, 2017; and accepted May 14, doi: /trf VC 2017 AABB TRANSFUSION 2017;57; Volume 57, October 2017 TRANSFUSION 2477

2 FADEYI ET AL. Fig. 1. The insert with lid maintains the temperature at 1 to 68C temperature for 10 hours. [Color figure can be viewed at wileyonlinelibrary.com] addition, there is laboratory expense incurred when blood components expire or are removed from inventory for various reasons. Therefore, blood component wastage reduction strategies afford the opportunity to directly improve the laboratory s operating budget and sustainability while preserving this valuable resource for other patients needs. Under adequate storage conditions, RBCs with additive solution may be stored for 42 days. According to US Food and Drug Administration (FDA) and AABB guidelines, RBCs should be stored at 1 to 68C. 6 During transport, acceptable RBC temperature can be assessed by a temperature indicator seal that attaches to the surface of the RBC pouch. The indicator seal changes color if the RBC unit has exceeded the maximum tolerated temperature, assuming that the surface temperature represents the thermal state of RBC pouch. When an RBC component exceeds the maximum tolerated temperature and is returned to the laboratory, the component must be removed from the available patient inventory and is usually discarded. Reasons for RBC product wastage are multifactorial: the unit may exceed the maximum tolerated temperature; for example, the unit was dispensed, left in the transport cooler, not administered, or not returned to the blood bank within the requisite time frame a time after which the blood product s internal temperature may exceed 108C. Further, a component bag may fail or be inadvertently punctured; a component may outdate while held in the blood bank; or units may be lost/discarded and never returned, albeit lost units occur rarely. In an effort to reduce RBC wastage at our institution, the laboratory team devised a hybrid transportation strategy using a novel cooler that enabled long-term compliant storage partnered with advanced radiofrequency Fig. 2. The outside cooler shell insulates the insert. [Color figure can be viewed at wileyonlinelibrary.com] identification (RFID) tracking. We also initiated an educational policy and annual competency evaluation on how to handle the coolers. We report the findings of a new validated blood cooler insert and tracking device in addition to educational initiatives with the goal of virtually eliminating the wastage of RBC products. MATERIALS AND METHODS Our blood bank database was used to analyze 72 months (January 1, 2010-December 31, 2015) of RBC issuance, transfusion, and waste data. The original transport cooler was an Igloo picnic-style cooler (Igloo Products) packed with one frozen ice block attached to the lid of the cooler with Velcro strips and validated for 5 hours at 1 to 68C. The new cooler insert (Pelican Biothermal) consisted of a thermal isolation chamber containing integrated phase change material that was designed to maintain a temperature range of 1 to 68C for a minimum of 16 hours. We elected to validate our coolers for 10 hours for logistic reasons. The insert had an institutionally validated coolant life span of 10 hours at 1 to 68C without the need for replacement (Fig. 1). The insert is placed into a Golden Hour blood cooler (Pelican Biothermal; Fig. 2). Each insert needs to be conditioned by freezing for a minimum of 8 hours in a regulated 2208C freezer in the blood bank. The insert is prepared for use by allowing it to sit at room temperature until it reaches 2 to 58C and then either placed in a new cooler or placed in a regulated blood bank refrigerator for later use. Based on additional validation efforts, if a conditioned insert is held for later use, the allowable storage time is 72 hours when stored at 1 to 68C before reconditioning. The insert forms a cube around the blood product inside of the Golden Hour cooler (Fig. 3). The insert met acceptance criteria for maintaining an average load of blood (1-3 units) and a minimum load of blood (1 unit) for more than 10 hours in every validation 2478 TRANSFUSION Volume 57, October 2017

3 BLOOD COOLER TRACKING TECHNOLOGY AND RBC WASTAGE trial. The new cooler system extended the time an RBC unit can be outside of the blood bank for up to 10 hours with a temperature range from 1 to 68C, in compliance with the tighter AABB storage criteria rather than transport criteria (1-108C). RFID tags were used on each blood cooler with special software called real-time location services (RTLS; Infinite Leap, Winston-Salem, NC) to monitor blood cooler tracking throughout the hospital. The RTLS system was an existing institutional infrastructure investment to monitor and track hospital equipment into Fig. 3. Arrow showing insert properly placed in the cooler shell with its lid closed. To maintain the required 1 to 68C temperature, the insert lid must be tightly closed. [Color figure can be viewed at wileyonlinelibrary.com] which the blood bank intervention was adapted. RTLS uses infrared technology, similar to a television remote control, to identify and track the location of each blood cooler and transmit the cooler and location data to the medical center s network. Battery-powered tags on the blood coolers communicate via low-level bursts of infrared light with sensors installed in hallways, patient care, and storage areas, transmitting data to the network. The network then communicates the exact location of the coolers and the time left since issued out of the blood bank on monitors in the blood bank (Fig. 4). The RTLS monitor as shown in Fig. 4 tracks the coolers in the institution beginning from Status 5 and through 4, 3, 2, and 1 for each cooler tracked. The status available means the cooler is not yet in use and it is stored either in the blood bank or at the nursing unit. A total of 180 coolers and approximately 200 inserts were purchased. The cost of each cooler with insert is approximately $275 plus the cost of the RFID tags which is $38 each. Rarely do the coolers or the RFID tags need to be replaced. The cost of the computer screen that displays the RTLS system is approximately $300. The time needed each day by the blood bank to monitor the screens and or s varies depending on the amount of coolers dispensed from the blood bank any given day; however, the blood bank staff may spend at least 60 minutes per shift to monitor the screens. Throughout the day, the blood bank staff on each shift monitors the s for coolers that are nearing expiration. After the cooler is issued, there is an issue slip Fig. 4. Sample monitor from RTLS in the blood bank showing status and location of the blood coolers. All coolers go through each status from 5 to 4 to 3 to 2 and 1. Available means cooler is not yet in use. Status 5 5 Cooler has been issued and has been detected by the RFID program. The cooler is in use less than 4 hours. Status 4 5 Out of the blood bank longer than 4 hours but less than 9 hours 45 minutes. Status 3 5 There are 15 minutes before the cooler is due back in the blood bank. warning is sent to the blood bank by the software. Status 2 5 Cooler has been out 10 hours and is due back in the blood bank. Another will be sent to the blood bank. Status 1 5 Cooler is 15 minutes or more overdue for return to the blood bank. Final e- mail is sent to the blood bank. [Color figure can be viewed at wileyonlinelibrary.com] Volume 57, October 2017 TRANSFUSION 2479

4 FADEYI ET AL. TABLE 1. Total number of RBC units issued and transfused before and after implementation of blood cooler with tracking device Year Number of units issued Number of units transfused Number of units wasted (out too long) Wastage rate (out too long) Estimated wastage cost Before ,592 26, % $89, ,985 25, % $80, ,632 26, % $46,434 Mean 26,403 26, % $72,278 After ,044 23, % $19, ,772 22, % $13, ,389 21, % $15,762 Mean 22,735 22, % $16,330 for each cooler that hangs in the issue workstation of the blood bank. This slip is checked for cooler number when an is received to identify the patient and location so staff can call the floor to have the cooler returned. The alerts the staff to notify end users to bring the coolers back. This additional cost notification process is estimated to take 30 to 60 minutes per shift based on a fulltime equivalent cost of $30/hr. For larger amounts of RBC units we have the Credo coolers (Pelican Biothermal), which can hold 10 to 12 units of RBCs and or plasma. Massive transfusion cases are dispensed in the Credo cooler plus a platelet cooler. Both are also monitored and used in the operating rooms. The blood coolers with inserts are used all over the hospital and outpatient clinic areas including the intensive care unit, cancer center, operating rooms, emergency department, interventional radiology, and medical and surgical inpatient units. The coolers are used for transporting plasma as well but our wastage rates for plasma are much lower compared to RBCs so this study was limited only to examining ways to reduce RBC wastage. To compare the effect that the new blood cooler transport system (blood cooler insert, Golden Hour cooler, and RFID/RTLS-revised shipper) and the original shipper (Igloo picnic-style cooler) had on blood product wastage, data on total RBC units issued and transfused, and total RBC waste were compared: 1) before implementation of the revised shipper between January 1, 2010, and December 2012; and 2) after implementation of the revised shipper between January 1, 2013, and December 31, Total units of RBCs issued and wasted in addition to a cost analysis of blood product waste were the primary outcomes. An estimation of institutional acquisition and processing costs for the transfusion of a single unit of RBCs ($426.00) was used for cost analysis. This cost included an acquisition cost of $200 plus the indirect costs of $226 such as labor and reagents, which are lost since the unit cannot be reissued to another patient. The saved RBCs corresponded to a total cost savings during the 3- year period of the new blood cooler with insert and tracking device. RESULTS Blood wastage was reduced using a combination of 1) RFID cooler tracking, 2) revised shipper system with doubled coolant time, and 3) educational initiative. The software tracking system provided the ability to track the blood coolers in real time for all hospital locations while concurrently monitoring each cooler for the 10- hour expiration. Monitoring data were fed in real time to video television screens in the laboratory. The combined processes resulted in reduced blood wastage. Data gathered about the movement of the blood coolers within the hospital became an important aid in blood utilization and delivery. The implementation of the new blood cooler insert, tracking device, and educational initiatives reduced mean annual RBC wastage by fourfold from 0.64% to 0.17%. The saved RBCs corresponded to a total cost savings during the 3-year period of $167,844 after implementation (Table 1). Other blood product wastage after implementation was not attributable to improved tracking and extended storage, but was due to other variables. Other reasons for blood wastage not controlled by the new technology included when the cooler lid was left open (Fig. 3) or when the unit went unused and outdated in the blood bank. The amount of units outdating in the blood bank account for a small percentage of blood wastage in our institution and did not make any difference either before or after implementation. Before the implementation of the revised shipper, a mean of 43 units per year was outdated on the shelf and after implementation an average of 33 units per year was outdated on the shelf. Over a 3-year period before implementation of the revised shipper, the wastage at our institution averaged 0.64% of 26,403 issued RBC products. A total of 547 wasted RBC units were either dispensed but not administered individual units that were out of the blood bank for more than 30 minutes or the most common reason for RBC product waste in our hospital was blood left in the cooler for too long (units that were packed in a picnicstyle cooler plus ice block). Data indicated that 2480 TRANSFUSION Volume 57, October 2017

5 BLOOD COOLER TRACKING TECHNOLOGY AND RBC WASTAGE approximately 93% (509) of the wasted RBC units were blood left in the cooler for too long with the remaining 7% (38) of wasted units kept out of blood bank refrigeration for more than 30 minutes, a time period validated at our institution to be in compliance with AABB Standards. The 30-minute rule applies to the RBC units dispensed without the Igloo shipper. DISCUSSION The use of blood and blood products throughout the world s health care systems contributes substantially to overall health care costs. Hospitals should routinely monitor blood product wastage as a quality indicator, investigate factors contributing to the wastage, and establish systems to reduce wastage. Use of temperature-validated long-term storage containers may help reduce wastage while maintaining the safety of the RBC products. Most importantly, raising awareness of blood product wastage and educating staff regarding best practices in blood product handling and transfusion is a low-cost intervention with high impact. After the initial 3 years of monitoring using the revised shipper system, the subsequent interventions that were implemented likely contributed to the sustained reduction in blood wastage that are now being observed. The educational initiative in support of the revised shipper system includes an online PowerPoint presentation available to end users in addition to completing a required yearly competency education module on cooler maintenance. There is an electronic incident reporting system available that the blood bank uses to track blood wastage so each nursing unit manager or provider receives feedback on blood wastage within their individual unit or department. Holding providers, nurses, and staff accountable for blood product wastage contributed to the waste reduction and could be used as a component of the provider s ongoing performance profile, which has recently become a Joint Commission requirement. 7 Educational PowerPoint presentations to providers, nurses, and staff have further enhanced the ability to prevent wastage, particularly with respect to the handling of the blood coolers. Our staff understood the importance of keeping the RBC products within the required temperature limits and how best to manage the blood coolers. The FDA and AABB require that the internal temperature of blood products be maintained between 1 and 68C and not to exceed 108C. 6,8 Brown and colleagues 9 published a review of intraoperative blood transport and storage initiative (BTSI) over a 10-month period, in which the results showed that the amount of RBC and plasma units wasted was reduced from 1.2% to 0.06%. Furthermore, the waste trend over the period of implementation indicates improved management of both RBC and plasma units issued for perioperative transfusion as experience with the processes associated with the BTSI increased. The savings seen with the BTSI are likely attributed to a multidisciplinary approach. The results of this retrospective cohort investigation indicate that a multidisciplinary and multifaceted BTSI reduces median monthly waste of RBC and plasma units issued for perioperative transfusion. These savings are similar to the results of our study using a combination of institutionwide educational initiatives and a new blood cooler tracking technology. However, unlike our study where we actually track how long a cooler is outside of the blood bank, Brown and colleagues did not collect and report on the duration each cooler was away from the blood bank. Another method of reducing blood product wastage is the electronic enhancement to blood ordering published by Yazer and colleagues 10 in which the authors report the result of an electronic enhancement to blood ordering in addition to waste reduction campaigns. They found that there was significant reduction in the overall wastage rate for all blood products issued during their period of evaluation. We further agree that reductions in blood product wastage require a multifaceted approach in addition to ongoing education to achieve cost savings and reduce laboratory expense. When using the tracking system for blood coolers transported throughout the hospital, the coolers are constantly being monitored and tracked 24 hours a day, 7 days a week using the RTLS system on several video monitors located in the blood bank to ensure that the blood products are kept at the validated temperatures. For blood coolers nearing the 10-hour limit, the blood bank tracks the location and alerts the staff about the time left for the blood cooler to be returned to the blood bank for reconditioning. The data gathered about the movement of the blood coolers within the hospital became a rich source of information to aid in assessing blood utilization and wastage as well as improving blood delivery for nursing and the operating room personnel. In conclusion, the use of temperature-validated blood cooler inserts, state-of-the-art real-time tracking technology, and a continued educational initiative may help reduce wastage while maintaining the safety of the RBC products. The cost to implement this initiative was small if there is an existing institutional infrastructure to monitor and track hospital equipment such as asset tracking management system, which is already available in onethird of large academic medical centers and large hospitals into which the blood bank intervention can be adapted. The only associated blood tracking cost will be the cost of RFID tags, blood coolers, and monitors. This could result in a highly significant estimated return on investment that may be reproducible in other institutions. Most importantly, raising awareness of blood product wastage and educating staff regarding best practices in blood product handling and transfusion are low-cost interventions with high impact. Volume 57, October 2017 TRANSFUSION 2481

6 FADEYI ET AL. CONFLICT OF INTEREST The authors have disclosed no conflicts of interest. REFERENCES 1. Novis DA, Renner S, Friedberg R, et al. Quality indicators of blood utilization: three College of American Pathologists Q-Probes studies of 12,288,404 red blood cell units in 1639 hospitals. Arch Pathol Lab Med 2002; 126: Zarbo RJ, Jones BA, Friedberg RC, et al. Q-tracks: a College of American Pathologists program of continuous laboratory monitoring and longitudinal tracking. Arch Pathol Lab Med 2002;126: Cantor SB, Hudson DV Jr, Lichtiger B, et al. Costs of blood transfusion: a process-flow analysis. J Clin Oncol 1998;16: Cremieux PY, Barrett B, Anderson K, et al. Cost of outpatient blood transfusion in cancer patients. J Clin Oncol 2000;18: Shander A, Hofmann A, Gombotz H, et al. Estimating the cost of blood: past, present, and future directions. Best Pract Res Clin Anesthesiol 2007;21: Reference standard 5.1.8A: requirements for storage, transportation and expiration. In: Standards for blood banks and transfusion services. 30th ed. Bethesda (MD): American Association of Blood Banks; p Heitmiller ES, Hill RB, Marshall CE, et al. Blood wastage reduction using Lean Sigma Methodology. Transfusion 2010; 50: U.S. Food and Drug Administration. CFR Title 21 Part 640 Additional Standards for Human Blood and Blood Products, Subpart B Red Blood Cells Sec General requirements April 1, Brown JB, Button LM, Badjie KS, et al. Implementation of an intraoperative blood transport and storage initiative and its effect on reducing red blood cell and plasma waste. Transfusion 2014;54: Yazer MH, Deandrade DS, Triulzi DJ, et al. Electronic enhancements to blood ordering reduce component waste. Transfusion 2016;56: TRANSFUSION Volume 57, October 2017