Overcoming Inventory

Management Hurdles in a Rural

Versus Urban Transfusion

ServiceJenna Khan, MD

Assistant Director of Transfusion Medicine Service

Dartmouth-Hitchcock Medical Center

October 18, 2021

Faculty Disclosure

• I have no relevant disclosures for this session

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Blood Supply

• Multiple Suppliers– Hospital-based Donor Center

– 3 National Suppliers

– National Blood Exchange

– Affiliates/Friendly Regional Hospitals 3

General Utilization Management

Red Blood Cells

• Guidelines– Single unit orders in all non-bleeding patients

– Post-transfusion hemoglobin prior to ordering additional units

– Hemoglobin ≤ 7 g/dL for all medical and surgical inpatients

– Hemoglobin ≤ 8 g/dL for inpatients with Active Acute Coronary Syndrome (ACS)

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General Inventory

Management

Red Blood Cells

• O positive RBCs for

men and women not of

child bearing age for

MTPs

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General Inventory

Management

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Red Blood Cells

• 1 to 10 degree C acceptable range for RBC returns

General Utilization/Inventory Management

Plasma

• Prospective audits

– Plasma orders with INR < 2.0 (or no INR available)

– Weight based dosing

• Low-titer type A plasma for Massive

Transfusion Protocol

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General Utilization/Inventory Management

Cryoprecipitate

• Prospective audits

– Non-bleeding patients with fibrinogen > 100 mg/dL

– Weight based dosing

• Fibrinogen concentrate is not available at our

institution

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General Utilization ManagementPlatelets

• Prospective audits

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Condition of patient Platelet count (x103/mcL)

Stable inpatient: < 5

Febrile inpatient or recent hemorrhage: < 10

Patient on prophylactic anticoagulation (BMT VOD or DVT PPX): < 10

Outpatient or pediatric patient: < 20

Active bleeding or invasive procedure: < 50

Stable premature infants: < 50

ECMO patient: < 80

CNS, eye or respiratory bleeding or surgery: < 100

Critically ill premature infants: < 100

Platelet dysfunction due to cardiac bypass or medication (LIMIT ONE UNIT)

Slichter, SJ, et al. Transfusion. 2021; Slichter SJ, et al. N Engl J Med. 2010.

General Inventory Management

Platelets

• Extend to 7 days with secondary bacterial testing

• Titer all group O units for anti-A/B

• Split units when inventory is low:

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Shortage severity Platelet Count (x1011) Eligible Recipients

Mild 5.0-5.9 Any

Medium 4.0-4.9 Prophylactic

High 4.0-4.9 Any

Slichter SJ, et al. Dose of prophylactic platelet transfusions and prevention of

hemorrhage. N Engl J Med. 2010 Feb 18;362(7):600-13.

Massive Transfusion Protocol

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Crisis

Management

• Definitions

• Communication

– Daily inventory

status email

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Routine Inventory Levels

Contingency Inventory Levels

Crisis Inventory Levels

After a trauma filled night… We have 10 O pos on the way. Platelets will improve when our standing orders arrive and when labeling can be done.

INVENTORY 3/17/2020 3/18/2020 3/19/2020 3/20/2020

TOTAL RED BLOOD CELLS

Target Level =

Critical Level =

OPOS RED BLOOD CELLS

Target Level =

Critical Level =

ONEG RED BLOOD CELLS

Target Level =

Critical Level =

TOTAL PLATELETS

Target Level =

Critical Level =

TOTAL PLASMA

Target Level =

Critical Level =

AB PLASMA

Target Level =

Critical Level =

INTERNAL COLLECTIONS 3/17/2020 3/18/2020 3/19/2020 3/20/2020

TOTAL RED BLOOD CELLS COLLECTED

OPOS RED BLOOD CELLS COLLECTED

ONEG RED BLOOD CELLS COLLECTED 0 0NEW DONOR RED BLOOD CELLS COLLECTED (ABO/RH PENDING) 0

TOTAL PLATELETS COLLECTED 0TOTAL CONVALESCENT PLASMA COLLECTED

Crisis Management - RBCs

Routine Inventory Levels Contingency Inventory Levels Crisis Inventory Levels

Total RBCs > XX unitsOPOS RBCs > XX unitsONEG RBCs > XX units

Total RBCs > XX unitsOPOS RBCs > XX unitsONEG RBCs > XX units

Total RBCs > XX unitsOPOS RBCs > XX unitsONEG RBCs > XX units

Blood Collection Measures:• Routine Collections

Blood Collection Measures:• Increased collections as needed

to support demand; pull cross-trained staff to collect blood

Blood Collection Measures:• Emergency blood drives;

train new staff

Blood Utilization Measures: Blood Utilization Measures: Blood Utilization Measures:

Inventory Management Measures:

Inventory Management Measures: Inventory Management Measures:

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Crisis Management - RBCs

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• Increase

collections in

response to

Contingency/

Crisis

Inventory

Levels

Crisis Management - RBCsContingency Inventory Levels Crisis Inventory Levels

Blood Utilization Measures:• Best Practice Alert modified to support

more restrictive transfusion triggers• Hgb </= 6.5 for stable non-bleeding

inpatients• Hgb </= 7.5 for patient with ACS

• Closely monitor patients requiring significant blood product support (MTPs, other high utilization situations)

Blood Utilization Measures:• Activate Transfusion Triage Team (TTT)

to prospectively audit all RBC orders for patients requiring >1 RBC unit per day

• Split units; provide ½ unit transfusions to non-bleeding inpatients

• Place an upper-limit on blood use for MTPs and other bleeding situations

• For outpatient Heme/Onc: only single unit transfusions; do not transfuse forHgb >/=7.5

15Cohn CS, et al. Transfusion. 2020 Sep;60(9):1897-1904.

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Best Practice Advisory (BPA)

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Crisis Management - Plasma

• Hospital-based Donor Center– Increased whole blood collections for RBCs resulted in

increased FFP units

– Increased apheresis AB plasma collections

• Expand acceptable criteria for return to inventory– Room temperature transported units returned within </= 4

hours of dispense

– Coolers units returned within </= 8 hours of dispense, units are cool to the touch and ice or cold packs are present

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Crisis Management - Cryoprecipitate

• Increased use of single units

• Updated our transfusion policy to allow for any ABO

type to be used for adult patients1

– The probability of making a pool of cryoprecipitate with a

titer ≥1:100 was calculated to be less than 1:3,000,0002

• Fixed dose of 2 pools for adults

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1Khan J, Dunbar NM. Time to stop worrying about ABO incompatible

cryoprecipitate transfusions in adults. Transfusion. 2021 Jan;61(1):1-4.

2Hadjesfandiari N, et al. Risk analysis of transfusion of cryoprecipitate without

consideration of ABO group. Transfusion. 2021 Jan;61(1):29-34.

Crisis Management - Platelets• Increase internal collections

• Expand acceptable criteria for return to inventory– Returned within </= 4 hours of dispense AND swirling

– Platelets stored on ice, preferentially give to trauma/bleeding patients

• Prospective audits– Audit all requests for platelets

– Stricter thresholds

– Defer/decline prophylactic transfusions

• Accept all types of platelet products from suppliers

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Primary Strategy? Suspended in? Irradiation? Expires?

Can extend

with testing?

Discard

on? Notes RE: Discard

Primary culture

>/= 24 hours

Plasma YES Day 3YES (D4, D5,

D6, D7)Day 8 Discard

PAS YES Day 3 YES (D4, D5) Day 8Quarantine after D5, use

on D6/D7 with approval,

2ndary testing required

Pathogen

Reduction (aka

Psoralen Treated)

Plasma NO Day 5 NO Day 8

Quarantine after D5, use

on D6/D7 with approval,

no additional testing

required

PAS NO Day 5 NO Day 8

Quarantine after D5, use

on D6/D7 with approval,

no additional testing

required

LVDS 36 hours

Plasma YES Day 5 YES (D6, D7) Day 8 Discard

PAS YES Day 5 NO Day 8Quarantine after D5, use

on D6/D7 with approval,

2ndary testing required

LVDS 48 hours Plasma YES Day 7 NO Day 8 Discard

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Conclusions

• Optimize standard practice

• Maximize and diversify supply chain options

– Hospital-based Blood Donor Program

• Use data to guide your interventions and monitor

their impact

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Acknowledgements

• Blood Donor Program Staff– Diana Main

• Blood Bank Staff– Teresa Lambert

• Transfusion Medicine Research Center– Louise Marsh

• Laboratory Information Systems– Jody Barna

25Questions: jenna.khan@hitchcock.org