Rate of discard of blood and its Rate of discard of blood and its components as a quality indicator components as a quality indicator for blood utilization in a tertiary for blood utilization in a tertiary care haemato-oncology centrecare haemato-oncology centre

Dr Shashank Ojha, Dr Sumathi S H, Amol Tirlotkar, Dr S B Rajadhyaksha

Advanced Centre for Treatment, Research & Education in Cancer, Kharghar, Navi Mumbai

BACKGROUNDBACKGROUNDThe rate of discard of blood components

serve as a quality indicator, for implementation of corrective measures to rationalise blood utilization and inventory management.

Determination of quality indicators requires thorough exploration of the processes underlying particular service, assessment of the risk and frequency of particular problem, and the possibilities of improvement.

Corrective Actions

Improvements

Quality Indicators for Blood Utilization

AIMAIMTo determine the rate of discard of

blood and blood components as well as blood utilization

And Reasons for discard of blood and

blood components

STUDY DESIGN & METHODSSTUDY DESIGN & METHODS

A Six years (2006-2011) retrospective data

Following rates were assessed for their mean annual trends (%)◦ Unit expiration◦ Unit discard (Wastage)◦ Reason for discard◦ Cross-match to transfusion (C:T) ratio

DTM - ACTRECDTM - ACTRECEstablished in 2005~2,000 Donations /year~3,600 Components/year~ 21,000 TTI testing/year~ Specialised products/year

◦ Leucodepleted PRBC’S (800) & Platelets (600)◦ Gamma Irradiated products (1,600)◦ e-BDS tested products

~ Specialised procedures/year◦ Peripheral blood stem cell collection (100) working with

second large BMT Unit◦ Granulocyte collections (10)◦ Bone marrow Harvest & processing (10)

QM since 2007

Expired Unit: component unit that had its lifespan exceeded that allowable for transfusion, that is, its maximum storage time was reached

Discarded Unit: component unit that was discarded due to, expiration but not limited to, handling and storage errors, such as breakage etc

Expiration Rate =No. of Expired component units X100

No. of component units (Transfused + Expired)

Discard Rate = No. of Discarded component units X100

No. of component units (Transfused +Discard)

Crossmatched-Transfused (C:T) Ratio=No of Crossmatched RBC Units

No of Transfused RBC Units

RESULTSRESULTS

Total 21,179 components were prepared from 8,998 collections

Mean annual component unit discard rate was 16.5% (Total 3,512 components)

MEAN TOTAL COMPONENT MEAN TOTAL COMPONENT DISCARD RATEDISCARD RATE

Mean annual infectious discard rate was 2.8% (range: 2.0 - 4.13%) Mean annual Non-infectious discard rate was 13.7% (range: 4.07 - 23.66%)

Infectious• HIV•HBsAg•HCV•MP•Syphilis•Bacterial Contamination

Non Infectious• Outdate/Expiration• QNS/QI• Leakage

Mean Annual discard rate 16.5%

MEAN ANNUAL DISCARD RATE (%) OF MEAN ANNUAL DISCARD RATE (%) OF COMPONENTSCOMPONENTS

18.42%

11.30%

20.20%20.90%

5.70%

0.00%

5.00%

10.00%

15.00%

20.00%

25.00%

Mean Annual Discard rate (%)

Whole Blood (WB)

packed Red Blood Cell (PRBC)

Fresh Frozen Plasma (FFP)

Random Donor Platelets (RDP)

Single Donor Platelets (SDP)

%

MEAN ANNUAL DMEAN ANNUAL DISCARD RATE ISCARD RATE (%)(%)

4.4 2.7 2.7 2.7 0.6

14

8.5

17.5 17.95

5.10

5

10

15

20

25

WB PCS FFP RDP SDP

Non-inf

INF

Compo-nent

Discard Rate (%)

Infect (%)

Non-Infect

(%)

WB 18.42 4.1 14

PRBC 11.3 2.7 8.6

FFP 20.2 2.7 17.5

RDP 20.9 2.7 17.95

SDP 5.7 0.6 5.1

% M

ean

annu

al d

isca

rd r

ate

REASON FOR DISCARDInfectious (2.8%) Non-Infectious

(13.7%)HIV 0.56 % Expiratio

n11.55 %

HBsAg 1.6 % QI 0.49 %HCV 0.49 % Leakage 0.34 %MP 0.0 %VDRL 0.03 %Bacterial contamination

0.014%

EXPIRATION RATE OF COMPONENTSEXPIRATION RATE OF COMPONENTS (%) (%)

10

7.9

12

17.7

4.8

0 5 10 15 20

MeanExpiration

rate%SDPRDPFFPPRBCWB

Mean annual WB expiration rate= 10% (range: 3.8-25.4%)Mean annual PRBC expiration rate= 7.94% (range: 2.54-19.1%)Mean annual RDP expiration rate= 17.7% (range: 2.0-34.0%)Mean annual FFP expiration rate= 12% (range: 9.27-49.73%)Mean annual SDP expiration rate= 4.8% (range: 0.7-10.3%)

MEAN C:T RATIOMEAN C:T RATIO

Mean annual C:T ratio was 1.4 (range: 1.3-1.7)

0

0.5

1

1.5

2

2006 2007 2008 2009 2010 2011

C:T Ratio

C:T Ratio

Maximum DesirableLevel

MEAN ANNUAL DISCARD TREND (%) MEAN ANNUAL DISCARD TREND (%) OF WB, PRBC & FFPOF WB, PRBC & FFP

63.4

0

10

20

30

40

50

60

70

2006 2007 2008 2009 2010 2011

WB

PRBC

FFP

Mean annual WB Discard rate = 18.42% ( range: 10.3-31.0%)Mean annual PRBC’s Discard rate =11.3% (range: 6.4-22.7%)Mean annual FFP Discard rate = 20.2% ( range: 4.1-63.4%)

% M

ean

annu

al d

isca

rd T

rend

MEAN ANNUAL TREND(%) OF PLATELETSMEAN ANNUAL TREND(%) OF PLATELETS

Mean annual RDP Discard rate = 20.92% ( range: 4.4-37.6%)Mean annual SDP Discard rate = 5.74% (range: 1.4-11.4%)

% M

ean

annu

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rd T

rend

DISCUSSIONDISCUSSION

Discarded blood components accounts for the lost production output, thus should not be ignored.

The Mean annual discard rate was higher in our study. However, there has not been any guidelines established in the literature.

The mean annual non-infectious discard rate was higher than the mean annual infectious discard rate.

This is because of stringent donor screening & inclusion of sensitive methods for TTI testing.

DISCUSSIONDISCUSSION

The highest mean annual discard rate recorded for RDP followed by FFP then WB & PRBC & lowest for SDP.

In platelets, expiration rate was high due to short shelf life and hence were discarded, whereas SDP’s were used judicially.

Components are held a longer time in quarantine, which may contribute to outdating of PLTs.

DISCUSSIONDISCUSSION

In our centre, FFP’s were not required as much, hence, the higher discard in 2007.

After 2007, FFP’s were send to fractionation centre quarterly.

Due to 35 day shelf life of WB, apt utilization was not possible as blood centre cannot generate request.

Since our institutional bed size increased in 2009 (82 bed hospital now), over blood stocking from camps was responsible for discard.

DISCUSSIONDISCUSSION

In non-infectious, the cause for discard was major due to expiration (11.5%) than others.

This is in sharp contrast to expiry rates of 5.8-6.4% quoted by Q-Probes study while evaluating 1,639 hospitals throughout United States4.

This is because in Q-Probes study, expiry rate was calculated from units which were received by hospitals from collection centres and were not utilized during the prescribed time interval.

DISCUSSIONDISCUSSION

Mean Annual trend of expiration of RDP’s was similar with most of the studies. Sullivan et al.3

1/5th of produced PLT concentrates has been reported to become outdated and the expiration rate was more than 25% for random donor PLTs and more than 10% for aphaeresis-PLTs in every tenth blood bank of 1639 U.S. hospitals studied5.

DiscussionDiscussion

Mean annual C:T ratio was lower than 2.0 or less by monitoring requests for blood components.

As per our study highest number of infectious donor blood wastage is due to HbsAg positive.

This is due to high prevalence of HBsAg in healthy population as compared to HIV & HCV. However, it is showing a downward trend with the use of HBsAg vaccination.

DISCUSSIONDISCUSSION

CORRECTIVE MEASURESCORRECTIVE MEASURESLaunched by QMpersonnel engagement and motivation

for implementation of corrective measures.

Effectiveness of measures taken for responsible management of blood products on stock

- planning of blood collections- planning of manufacture- collaboration with clinicians

Mean annual RBC wastage can be lowered by exchanging units on credit-debit basis with other blood centres.

Rationale utilization of FFP by sending units to NPFC.

Performing the concept of common cross-match to further conserve and maintain inventory.

Training of personnel for improving the collection procedures.

Use of automated bio-mixers to reduce causes of improper collections

CORRECTIVE MEASURESCORRECTIVE MEASURES

Processing of WB for further component preparation.

Adequate spacing in organization of voluntary blood camp.

Collaboration with clinicians to monitor request for blood component therapy.

CORRECTIVE MEASURESCORRECTIVE MEASURES

CONCLUSIONCONCLUSIONRegular audit of blood utilization and

discard rate with simple mathematical models serve as an important tool for accomplishment of the quality goals.

Since blood centers cannot regulate demand, the stochastic need for blood components can be achieved by production, planning and improving inventory management to minimize discard rate.

Quality indicators for blood establishment can be done by exchange of experiences with high level of transparency & comparing the trends with corrective measures1.

REFERENCESREFERENCES1. T. Vuk. Quality indicators: a tool for quality monitoring

and improvement. ISBT Science Series (2012) 7, 24–28

2. Rossi’s Principle of Transfusion Medicine, fourth ed.

3. Sullivan MT, Wallace EL et al. Blood collection and transfusion in the United States in 1999. Transfusion 2005;45:141-8.

4. Novis DA et al. Three College of American Pathologists Q-Probes Studies of 12 288 404 Red Blood Cell Units in 1639 Hospitals. Arch Pathol Lab Med—Vol 126, February 2002

5. David A. Novis et al. Quality Indicators of Fresh Frozen Plasma and Platelet Utilization. Arch Pathol Lab Med—Vol 126, May 2002