The Impact of Dynamic Inventory Management on Blood ComponentManagement on Blood Component

Utilization

M T h Sh b i R d MD FRCPC &ABPDM. Taher Shabani-Rad, MD, FRCPC &ABPDDivision of Hematopathology

Director for TM PBM & RBC Genotyping Labyp gUniversity of Calgary/CLSCalgary, Alberta Canada

The impact of dynamic inventory management on Blood Componentmanagement on Blood Component

Utilization

1. Red Cell Utilization

2. Plasma Utilization

l l ili i3. Platelet Utilization

The impact of dynamic inventory management on red cell utilization

Focus on chronically transfused patientsFocus on chronically transfused patients

Choosing Right Strategy for Efficient Use of Blood Resources

• Where does the blood go?

• Categorization of TransfusiongClinical Requirements

• Elective TransfusionElective Transfusion

• Critical Transfusion

• Emergent/Life Saving Transfusiong / g

Clinical Disciplines • Medical Transfusion

• Surgical Transfusion

• Outpatient Transfusion (Chronically Transfused Patients)

Choosing Right Strategy for Efficient Use of Blood Resources

Categorization of Transfusions Based On Clinical Requirement

• Where dose the blood go?gClinical Requirements

• Elective Transfusion; CTP• Critical Transfusion; Surgeries & Mild• Critical Transfusion; Surgeries & Mild

to Moderate Bleeding/Hemolytic Anemia

• Emergent/Life Saving Transfusion; Massive Transfusions, Extensive Surgical Procedure (CVS, Extensive Lapratomies)

Where the blood goes? gCategorization of Transfusions Based On Clinical Requirement

Type of Tn RCU/Inpts% 50%60

Pediatric & Neonatal RC utilization was excluded (6%) – Calgary Region Data

Type of Tn RCU/Inpts%Supportive Tn 24

50%

40

5040%

30%

Critical Tn 2024%

20%

10

20

30

Life Saving Tn ~50

T t l RCU/Ad lt 94

0

10

Supportive Critical Tn Life Saving Total RCU/Adult ~94

Minimal amount of Red cell required to maintain the life saving transfusion (LS Tn) is 40-50% of DRCU (Daily Red Cell Utilization)

Tn Tn

7

transfusion (LS Tn) is 40-50% of DRCU (Daily Red Cell Utilization).SuppTn: Source of DSP Amber Phase - CrTn: Source of DSP Red Phase

Hospital Risk Stratification Based on Clinical Requirement Categories Simulation Model

80%

90%

100%

60%

70%

80%

Supp-Tn

30%

40%

50% Cr-Tn

LS-Tn

0%

10%

20%

FMC RGH PLC CHC VHC

Hospital FMC RGH PLC CHC VHC

Ave Daily-RCU 50 30 40 10 20Ave Daily-RCU 50 30 40 10 20

Green Phase 50 30 40 10 20

Amber Phase 40 23 30 6 12

Red Phase 25 10 14 2 2

Applications of Risk Stratification Strategies for Efficient Use of Blood Resources

Categorization of Transfusions Based On Clinical Requirement

• Recognition of high risk hospitals by Blood Supplier• Self-recognition of hospitals to the type and risk of

their operation• Development of appropriate clinical and laboratory

tools and protocols h k f lHigh risk operation; Massive Transfusion protocol, POC

(Point of care testing), Rapid TAT Coagulation Testing (Super STAT Protocol)(Super STAT Protocol)

Low risk operation; Pre-Op screening for treatable anemia-Iron deficiency, Ferritin monitoring program

• Blood shortage contingency planning

Applications of Risk Stratification Strategies for Efficient Use of Blood Resources

Categorization of Transfusions Based On Clinical Disciplines

• Where does the blood go?Clinical Disciplines

• Medical/Non surgical Transfusions• Medical/Non-surgical Transfusions• Surgical Transfusions (including ED

)patients requiring surgery)• Outpatient Transfusion (Chronically p ( y

transfused patients for more than 3 month and at least 2 RC unit/month)month and at least 2 RC unit/month)

Where the blood goes? Categorization of Transfusion based on Clinical Disciplines

43%

50%

Total Red Cell Units Transfused to ALL Pts: 34447 Units (1.1 Million population)

43%

34%35%

40%

45%

25%

30%

35%

15%15%

20%

2%0%

5%

10%

0%Surgical Services Non-Surgical

InpatientsOutpatients Emergency Dept.

Blood Utilization Management Programg g(BUMP Project)

BUMP i i ll d l d E i i l• BUMP was originally developed as Empirical Based Blood Shortage Contingency Plan;

Defining Inventory index which is different from DOH (blood supplier indicator) by ( pp ) y~25% (Inventory/Average Daily RC demand)

Well defined Cut off levels for differentWell defined Cut-off levels for different phases of shortage

Defining optimal RC inventory at hospital, regional, provincial and national levelsg , p

8-12

Annual Red Cell Utilization 2007-8f i / l% d l iNo of Patients or RCU/Total% - Adult patients

(Clinical services with RCU>1%of Total)

15

15 0

20.0 #Pts/T%

RCU/T%

9 0 9.1

11

9 010 0

15.0

9.0

5.64.4

5.5

8.09.1

4.3 4.3 4.8

9.0 8.57.8 7.7

5.8

4.6 4.13 2

5.0

10.0

3.1

1.7 1.4 1.4 0.9

2.0

0.6

3.22.4 2.3

1.7 1.6 1.2 1.21.1

0.0

13

Clinical services with potentials for blood savings are among high Red cell utilizers. Services with RCU of <1% of total have no potential to be considered for blood saving.Clinical services with less number of affected patients by saving plans are better candidates.

Annual Red Cell Utilization 2007-8

100

Ranking Clinical Services with High Red Cell Utilization Based onTransfusion Rate% (Tn Index)

100

80

90

100

60

70

41 39

31 3130

40

50

16 1613

96 6 5 4 410

20

0

14

Clinical services with high RCU (Red Cell Utilization) and high transfusion rate have potential for blood saving. Services with low RCU and transfusion rate have less potential for blood saving.

Annual Red Cell Utilization – Calgary Health Region(Adult & Pediatric Patients)

Total Red Cell Units Transfused to ALL Pts: 34447 Units

25000

30000

77%

20000

15000

5000

10000

6%

15%

0

Adult-Inpts Adult-Outpts Adult-ED Pts Pediatric

6%2%

15

Adult Inpts Adult Outpts Adult ED Pts Pediatric

Pediatric RCU (Red cell utilization) has been excluded from BUMP

Applications of Risk Stratification Strategies for Efficient Use of Blood Resources

Categorization of Transfusions Based On Clinical Disciplines

• Future planning based on age distribution of population by blood supplierblood supplier

• Future planning based on expansion of health care centres to keep up with blood demand

• Self-recognition of hospitals to the type of service provided to main clinical services

• De elopment of appropriate clinical and laborator tools• Development of appropriate clinical and laboratory tools and protocols Cardiovascular surgery; Massive Transfusion protocol, POC

(Point of care testing), Rapid TAT Coagulation Testing (Super STAT Protocol)

Low risk operation; Pre-Op screening for treatable anemia-Iron p p gdeficiency, Ferritin monitoring program for chronically transfused Pts

Applications of Risk Stratification Strategies for Efficient Use of Blood Resources

Strategies used in Management Blood Component Utilization

• Blood Management Blood Inventory Management Blood Inventory Management

• Donor pool/Blood collection management

• Management of Blood component production (Collaboration Management)

D i it i f i t (I t M t )• Dynamic monitoring of inventory (Inventory Management programs)

Patient Transfusion Management• Establishment of evidence based transfusion indications & thresholds

• Development of algorithmic decision making process

• Use of Anti-Fibrinolytic medication & Factor concentrate

• Improvement in patient monitoring (laboratory tools & Protocols)

• Peer/Hospital comparison data

Establishment of HLG (Hospital Liaison group)

Management of TAAR (Transfusion associated adverse reactions)g ( )

Reduction in AHS-CLS Red Cell inventory Following BUMP-Inventory Management Protocol 2011

No Change in Any Other Operational Parameter

Targetg

The Impact of Dynamic Inventory Management & Red cell Age on Clinical Disciplines

3 50

4.00

4.50

Jul-Sep 2010

Jul-Sep 2011

2.50

3.00

3.50

1.50

2.00

0.50

1.00

0.00

rgic

al

sfus

ions

em/O

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nc

utpa

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GI B

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Dia

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Day

Med

Sur

Tran

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Ren

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The Impact of Inventory Management on Alberta Blood Disposition/1000 Capita

The Impact of Inventory Management on National Blood Disposition/1000 Capita

National CBS InventoryInventory 30,000 RC

20,000 RCRC

50% decrease in inventory 13% Reduction in Red Cell Demand

The Impact of Inventory Management on Calgary Zone Blood Disposition/1000 Capita

29.8/100035000

40000

Adjusted Red Cell Utilization-Calgary Zone

25.3/100022.8/1000 21/100030000

35000

20000

25000

10000

15000

0

5000

٢٠١٠ ٢٠١٢ ٢٠١٣ ٢٠١۴

The impact of Blood Inventory Management on Blood Utilization

D l/Bl d ll ti t• Donor pool/Blood collection managementEstablishment of A dynamic online Booking system

for blood donationfor blood donation • Blood producing process managementThe recommended total Red cell inventory in bloodThe recommended total Red cell inventory in blood

system (Blood Supplier & Hospitals) is inventory index of 12+/- 2 (10-14 days)

• Dynamic monitoring of inventory (Inventory Management programs) bli h f N i l i S i hEstablishment of National inventory System with

capability of smart decision making process

Trials show no benefit from fresher red cellsAnne Paxton (Drs AuBuchon-Klein & Nancy Heddle)

• September 2015—Whether transfusion recipients are better off receiving fresher red p gblood cells has probably been the most pressing and controversial question in bloodpressing and controversial question in blood banking in the past several years.

• ABLE Study

• PROPPR StudyPROPPR Study

• RECESS Study

AABB Recommendation for Transfusion Th h ld b Cli i l I di tiThreshold by Clinical Indications

AABB recommended hgb thresholds (g/L)

Recommendations by other studies (g/L)hgb thresholds (g/L) studies (g/L)

Adult and pediatric ICU patient

70 NA

Postoperative surgicalPostoperative surgical patient

Symptoms* or 80 NA

Hospitalized hemodynamically stable pre-

*hemodynamically stable preexisting cardiovascular disease

Symptoms* or 80 NA

Hospitalized phemodynamically stable with acute coronary syndrome

Not enough data to recommend

NA

Chronically transfused patient (marrow failure)

Not Specified Post-transfusion target 90-100

Acute hemorrhage – follow Not Specified

GI Bleeding - not clinical guidelines

Not Specifiedrecommended at >70

Summary of Transfusion Thresholds by Indication per AABB 20122

*Symptoms: chest pain, orthostatic hypotension or tachycardia not responsive to fluid resuscitation, or congestive heart failure

The impact of PCC (Prothrombin ComplexThe impact of PCC (Prothrombin Complex Concentrate) on plasma utilization

Thawed Plasma (TP) – Patient ( )Transfusion Management (Coagulation Cascade)

• Thawed plasma; kept in fridge up to 5 daysMajor indications (CVS & Trauma Surgery, High risk

surgeries)

TAT decreased from 30-40 minutes to 5-10 minutes

Thawed Plasma Inventory: 2 AB (Universal plasma) & 2A thawed plasma (could be given to A & O groups; 85% of p ( g g pPts)

A Plasma could be given to B & AB (low titre Anti-B)g ( )

National Plasma UtilizationNational Plasma Utilization

47% DDecrease

Introduction of PCC (Prothrombin Complex Concentrate)for Warfarin/Off label INR Reversalfor Warfarin/Off label INR Reversal

The impact of dynamic inventory t Pl t l tmanagement on Platelet

Utilization

Platelets – Patient Transfusion Management g

Dynamic Platelet Inventory Management

Dynamic Platelet Inventory ManagementStep-1 Optimized Inventory Management

Dynamic Platelet Inventory ManagementStep-2

Outcomes of Dynamic Platelet Inventory Management - Calgary

35% ER

20-25% ERER

5-7% ER5 7% ER

Management of Blood Component Production (Collaborative CBS/TM Management)