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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
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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
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The impact of dynamic inventory management on red cell utilization
Focus on chronically transfused patientsFocus on chronically transfused patients
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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)
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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)
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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
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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
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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
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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)
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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.
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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
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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.
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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.
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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
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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
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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 ( )
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Reduction in AHS-CLS Red Cell inventory Following BUMP-Inventory Management Protocol 2011
No Change in Any Other Operational Parameter
Targetg
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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
nc
npat
ient
em/O
nc
utpa
tient
GI B
leed
Dia
lysi
s
Oth
er
Day
Med
Sur
Tran
s H In He
Ou G
Ren
al/ D
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The Impact of Inventory Management on Alberta Blood Disposition/1000 Capita
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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
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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
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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
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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
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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
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The impact of PCC (Prothrombin ComplexThe impact of PCC (Prothrombin Complex Concentrate) on plasma utilization
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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 ( )
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National Plasma UtilizationNational Plasma Utilization
47% DDecrease
Introduction of PCC (Prothrombin Complex Concentrate)for Warfarin/Off label INR Reversalfor Warfarin/Off label INR Reversal
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The impact of dynamic inventory t Pl t l tmanagement on Platelet
Utilization
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Platelets – Patient Transfusion Management g
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Dynamic Platelet Inventory Management
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Dynamic Platelet Inventory ManagementStep-1 Optimized Inventory Management
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Dynamic Platelet Inventory ManagementStep-2
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Outcomes of Dynamic Platelet Inventory Management - Calgary
35% ER
20-25% ERER
5-7% ER5 7% ER
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Management of Blood Component Production (Collaborative CBS/TM Management)
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