The Life Cycle of a Unit of Blood

and why it matters

Calvino Cheng, MD, FRCPC
2010 Blood Matters Conference October 29, 2010 Atlantica Hotel, Halifax, Nova Scotia

Associate Professor, Laboratory Medicine and Pathology, Dalhousie University Hematopathologist, Capital District Health Authority calvino.cheng@cdha.nshealth.ca

Disclosure
The presenter does not have any involvement with industry that may be perceived as potentially influencing the presentation of the educational material contained within

Objectives
1. To provide a framework for evaluating RBC unit trafficking and storage. 2. To provide an overview of the causes of red blood cell discards. 3. To provide recommendations on how to minimize red blood cell discards.

Outline
Background Methodology Results Conclusions and recommendations

Comprehensive survey of red blood cell unit life cycle at a large teaching institution in eastern Canada.
Cheng CK, Trethewey D, Sadek I.

Transfusion. 2010 Jan;50(1):160-5. Epub 2009 Sep 16.

Background:

Red Blood Cell Unit Lifecycle

Recent literature suggesting that RBC age impacts patient morbidity and mortality Continuous effort to decrease RBC expiry or discard rates RBCs migrate in the system and thus the system must be understood

Background:

Red Blood Cell Unit Lifecycle

How does a red blood cell travel in our institution?
How does it get here? (what characteristics does it have?) Where does it go in our transfusion system? Are there areas where RBCs unnecessarily age? What happens to RBCs that are in our inventory?

Inventory
Static and dynamic

Methodology:

Inventory Dynamics
Analysis period: January December 2007 15930 unique units in inventory, earliest unit received Nov 30, 2006

Static Inventory Statistics

Blood Group Frequency of total (percent) Age at receipt from supplier (mean, median, standard deviation) (days) 14.5, 13.5, 7.7 29.0, 32.5, 8.6 11.5, 10.5, 5.8 8.9, 7.6, 4.0 9.7, 8.5, 5.8 27.3, 29.7, 8.9 10.8, 7.7, 7.2 11.7, 10.6, 5.1 12.4, 9.8, 7.9 Number of units less than 14 days old on receipt N(%) 98 (64.1) 57 (11.4) 755 (76.6) 4635 (94.1) 228 (87.4) 112 (9.3) 1172 (79.9) 4862 (75.5) 11,919 (74.8) Number of units less than seven days old on receipt N(%) 24 (15.7) 10 (2.0) 190 (19.3) 1807 (37.7) 18 (30.7) 36 (2.0) 549 (37.4) 1084 (16.8) 3830 (24.0)

ABNEG ABPOS ANEG APOS BNEG BPOS ONEG OPOS Total

153(1.0) 501(3.1) 985(6.2) 4925(30.9) 261(1.6) 1202 (7.5) 1467(9.2) 6436(40.4) 15930(100.0)

Dynamic Inventory Plot

Inventory Knowledge
Units received mostly with <2/3 of shelf-life remaining Older units on receipt, as well as in inventory, tend to be those of uncommon blood groups (i.e. AB, B) Uncommon blood groups are difficult to turn around and demonstrate a cohort aging effect

Transfused RBC Characteristics

With and without system interaction

Transfused RBC Characteristics

Study period: March-December 2007 12,298 unique red cell units Mean age of RBC unit at receipt = 12 days Mean age of RBC unit at dispense = 19.6 days Mean time spent in transfusion system= 7.5 days 1.5% (182/12298) <7 days old 28.7% (3533/12298) <14 days old

Transfused RBC Characteristics

Blood Group Frequency of total N (%) 87 (0.7) 274 (2.2) 740 (610) 4069 (33.1) 143 (1.2) 873 (7.1) 1074 (8.7) 5038 (41.0) 12,298 (100) Age at dispense (mean, median, standard deviation) (days) 22.5, 18.6, 10.1 33.4, 36.3, 8.0 23.3, 22.9, 8.5 16.0, 14.9, 6.3 21.9, 21.3, 10.4 30.3, 32.5, 8.5 22.6, 21.7, 8.8 18.7, 17.0, 7.1 19.6, 17.5, 8.5 Number of units less than 14 days old at dispense N(%) 26 (29.9) 11 (4.0) 97 (13.1) 1691 (41.6) 44 (30.8) 45 (5.2) 189 (17.6) 1430 (20.4) 2533 (28.7) Number of units less than seven days old at dispense N(%) 0 (0) 0 (0) 6 (0.8) 100 (2.5) 7 (4.9) 5(0.6) 25 (2.3) 39 (0.8) 182 (1.5)

ABNEG ABPOS ANEG APOS BNEG BPOS ONEG OPOS Total

Transfused RBC units with prior system interaction

9689/12,298 (78.8%) units remained in BTS 2609 (21.2%) were returned a mean of 1.26 times from locations outside BTS
Mean time outside BTS = 18.4 hours Mean age of the dispense 21.3 vs. 19.2 days (p<0.005) for units always resident in BTS Mean time spent in transfusion system of 9.9 vs. 6.9 days (p<0.005) for units always resident in BTS

BTS Static vs. Mobile RBCs

blood group ABNEG ABPOS ANEG APOS BNEG BPOS ONEG OPOS Total N (in)/N(out) 70/17 231/43 590/150 3141/928 113/30 737/136 795/279 4012/1026 9689/2609 Mean age at receipt from supplier (days) 12.8/14.0 27.8/26.7 12.4/11.4 9.0/8.4# 8.0/9.0 25.3/27.3 11.1/9.7# 12.0/11.8 12.3/11.4# Mean age at dispense from BTS(days) 21.2/27.7^ 33.0/35.4 22.1/27.7# 15.6/17.3# 20.6/26.5# 29.6/34.1# 21.7/25.3# 18.3/20.3# 19.2/21.3# Days spent in transfusion system prior to dispense 8.4/13.7^ 5.2/8.6# 9.7/16.4# 6.6/8.9# 12.6/17.5^ 4.3/6.8# 10.6/15.6# 6.3/8.5# 6.9/9.9# Mean number of returns to BTS */1.24 */1.09 */1.28 */1.29 */1.30 */1.15 */1.18 */1.27 */1.26 Mean number of hours spent outside to BTS per unit */11.3 */6.9 */10.9 */12.2 */9.9 */12.5 */74.1 */11.8 */18.4
* = not applicable # = p0.005 ^ = p0.05

Transfused RBC Knowledge

A significant proportion of our transfused units have been previously returned (1/4)
Returned units are globally transfused at more advanced age vs. units resident in BTS
Some blood group units age 5 days more

With uncommon blood groups

Received into inventory later, and age in the system prior to transfusion effect worsened by being returned

Discarded RBCs

Discarded RBC units

Study period: March-December 2007 636/12258 (5.2%) wasted
Most common groups: AB+, B+, O+

410/636 (64.4%) remained resident in BTS

Time spent outside BTS: 28 hours vs. 18.4 hours (comparing discarded vs. transfused units)
Most common return location was ORH

Discarded RBC Units

N ABNEG ABPOS ANEG APOS BNEG BPOS ONEG OPOS Total 38 151 50 73 42 120 74 88 636 Mean RBC age at receipt from supplier (days) 15.2 31.2 11.9 13.3 10.7 33.5 11.6 14.6 21.2 Mean RBC age at Mean time spent discard system prior to (days) discard (days) 40.8 41.7 35.0 21.2 41.4 41.3 34.6 20.9 35.0 25.6 10.6 22.1 7.9 30.7 7.8 23.1 6.3 13.8

Discarded RBC Knowledge

Significant discards occur within BTS itself
Most common reason: expiry

A+ and O+ units
discarded with half of shelf life remaining Had frequently unacceptable characteristics on return (visual/temp failure, bag broken)

Non A/O units (less common blood groups)

Expiry is very commonly the cause of discard Other characteristics not as common

Overall lessons learned from RBC lifecycle analysis

Red cell units are received from the supplier with 2/3 shelf life remaining Red cells spend approximately 1 week in the BT system Units of uncommon blood groups tend to be older at transfusion Almost 2/3 of discarded units never leave blood transfusion services

Conclusions
By understanding the lifecycle, it is possible to target systemic intervention to improve quality of RBCs delivered
Age Discard rates Unnecessary handling, and reduced quality of RBC unit delivered

Recommendations

Reality Check
1. Blood is a precious resource, altruistically donated 2. Global economic constraints, especially in Nova Scotia. 3. We need to think outside the box and put aside geo-political barriers to serve patients better 4. We are all in this together.

8-15 year maturity provincial bonds

Recommendations
More supplier intervention to decrease age of red cells received
especially in blood groups that are more uncommon

Reduce inventory levels within BTS (3 day vs. 4 day inventory)

Especially with more uncommon blood groups (accept lower inventory thresholds)

Recommendations
Implement more efficient inventory management system within BTS and outside (i.e. operating rooms)
Especially with O+ and A+ units

Fresher blood should be sent outside blood transfusion services (i.e. in blood fridges in ER, OR etc.) to reduce overall aging within system

Recommendations
Minimize RBC transitions
Global management of blood supply
Single unified adult and pediatric inventory to reduce transition states and handling
Geographical blood management

Decrease transition of units in and out of blood transfusion services Minimal laboratory information system transitions
reduces electronic transition of units

Questions