Alleviating blood shortages in a resource-constrained environment

Cryopreserved red blood cells maintain allosteric control of oxygen binding when utilizing trehalose as a cryoprotectant

One of the most common life-saving medical procedures is a red blood cell (RBC) transfusion. Unfortunately, RBCs for transfusion have a limited shelf life after donation due to detrimental storage effects on their morphological and biochemical properties. Inspired by nature, a biomimetics approach was developed to preserve RBCs for long-term storage using compounds found in animals with a natural propensity to survive in a frozen or desiccated state for decades. Trehalose was employed as a cryoprotective agent and added to the extracellular freezing solution of porcine RBCs. Slow cooling (-1 °C min-1) resulted in almost complete hemolysis (1 ± 1 % RBC recovery), and rapid cooling rates had to be used to achieve satisfactory cryopreservation outcomes. After rapid cooling, the highest percentage of RBC recovery was obtained by plunging in liquid nitrogen and thawing at 55 °C, using a cryopreservation solution containing 300 mM trehalose. Under these conditions, 88 ± 8 % of processed RBCs were recovered and retained hemoglobin (14 ± 2 % hemolysis). Hemoglobin's oxygen-binding properties of cryopreserved RBCs were not significantly different to unfrozen controls and was allosterically regulated by 2,3-bisphosphoglycerate. These data indicate the feasibility of using trehalose instead of glycerol as a cryoprotective compound for RBCs. In contrast to glycerol, trehalose-preserved RBCs can potentially be transfused without time-consuming washing steps, which significantly facilitates the usage of cryopreserved transfusible units in trauma situations when time is of the essence.

Blood bank programs and transfusion sustainability. A serial mediating model

INTRODUCTION

Researchers establish that the current challenges of blood safety and shortage are based on relationship between master production scheduling and blood transfusion sustainability of blood banks.

OBJECTIVE

The objective of this study is to evaluate program relationship between master production scheduling and blood transfusion sustainability through total quality management and blood production.

METHODS

A survey questionnaire was adopted with staff from regional and government university teaching hospital blood banks. Simple random sampling was used to collect data from respondents. Preliminary and main data analysis was done using SPSS AMOS23.

RESULTS

The results revealed that master production scheduling influence blood transfusion sustainability when serially mediated by total quality management and blood production with 34% variation change at 95% confidence interval. Again, the results obtained show that master production scheduling influence total quality management significantly. Furthermore, total quality management influence blood production significantly. Finally, blood production influence blood transfusion sustainability significantly.

CONCLUSION AND RECOMMENDATIONS

Master production scheduling program actions has a positive significant relationship with blood transfusion sustainability through total quality management and blood production programs as serial mediators. This research contributes to the management of blood banks and suggests to have a greater relational management of total quality management, blood production and master production scheduling program actions in order to achieve high levels of blood transfusion sustainability, and in general, a greater benefit for society.

A discrete-event simulation model for analysing and improving operations in a blood donation centre

Background and objectives

Healthcare systems require effective and efficient blood donation supply chains to provide an adequate amount of whole blood and blood components to hospitals and transfusion centres. However, some crucial steps of the chain, for example blood collection, are not adequately studied in the literature. This work analyses the operations in a blood collection centre with the twofold aim of analysing different configurations and evaluating the effectiveness and feasibility of schedules defined at higher planning levels.

Materials and methods

The analyses are performed through a discrete event simulation (DES) model that describes a customizable collection centre. Moreover, a feedback loop from the DES to the higher planning level allows to adjust scheduling decisions if they determine criticalities or infeasibilities at the operational level.

Results

Numerical tests have been conducted considering a real Italian provider. An experimental plan has been designed to compare different configurations for the blood collection centre and evaluate the best ones in terms of cost and service quality for the three main actors involved (donors, workers and managers). The best configurations have been also used to test the feedback loop.

Conclusions

Results confirm the appropriateness of the proposed DES model, which can be considered a useful decision support tool for dimensioning and managing a blood collection centre, either as a standalone tool or in conjunction with a scheduler.

Exploring the impact of terminology differences in blood and organ donor decision making

Because the global shortage of blood and organ donors across all medical markets is a serious concern for health care provision, we aim in this study to better understand decisions (not) to participate in these two forms of medical donation, which can save or prolong another's life. Using unique responses from over 1,000 online survey respondents, we compare the reasons given for the donation decision given by blood and/or registered organ donors versus non-donors. To do so, we categorize responses based on five dimensions of language choice: egocentric (referring to self), social, moral, positively emotional, and negatively emotional. Our results reveal statistically significant differences between blood donors and non-donors in the use of all five categories. With respect to organ donation, we find statistically significant differences between donors and non-donors in the use of social, moral and positive emotional terms but not in the use of egocentric or negatively emotional justifications. Such results suggest that the 'gift of life' terminology used universally to market to potential blood and organ donors may only be relevant in the blood donation market and unlikely to incentivize or change organ donation behaviour.

The effects of tranexamic acid on blood loss and transfusion rate in colorectal surgery

BACKGROUND

The present study aimed to evaluate safety of tranexamic acid (TA) administration and to assess bleeding risk in colorectal surgery (CRS).

METHODS

Retrospective cohort study including consecutive patients undergoing elective CRS by a single surgeon between August 2014 and May 2015. All patients received 1 g of TA intravenously at induction and at closure. Demographics, operative and postoperative details were prospectively assessed and compared to a historical control cohort.

RESULTS

213 patients were evaluated. TA did not increase complications, readmissions, or reoperation rates. Significant postoperative hemoglobin (Hgb) drop (≥3 g/dL) (TA: n = 6, 7.4%, Control: n = 22, 16.6%; p = 0.193) and transfusion rates (intraoperative: TA: n = 2, 2.5%, Control: n = 2, 1.5%; p = 0.586, postoperative: TA: n = 1, 1.2%, Control: 9, 6.8%; p = 0.065) were not statistically different.

CONCLUSIONS

Postoperative hemoglobin drop and transfusion rates were not decreased statistically. Further study is warranted given the large clinical differences in favor of TA.

Assessing productive efficiency and operating scale of community blood centers

BACKGROUND

In recent years demand for blood products has decreased, and as a result, the blood product marketplace has become much more competitive. Reducing inefficiency in the procurement and processing of blood products at blood centers can reduce costs while assuring that demand for blood products is met.

STUDY DESIGN AND METHODS

This study uses data envelopment analysis to compare the productive efficiency of 65 community blood centers to determine to what extent efficiency can be improved, what cost savings and increases in platelet (PLT) production may be obtained by eliminating inefficiency, and what scales of operation are the most efficient from a budgetary and staffing standpoint. Data were collected from the 2012 to 2013 AABB Directory of Community Blood Centers and Hospital Blood Banks.

RESULTS

The study found that 27 of 65 blood centers are efficient. The remaining 38 blood centers can reduce budget and staff levels and may be able to expand output. If inefficient centers were to eliminate all inefficiency, the total savings would be $671 million, approximately 20% of the aggregated budget ($3.45 billion) of all centers in the study. In addition, the centers would also see a 36% increase in PLT production. Inefficiency of some large blood centers stems from operating at too large a scale, while inefficiency of most small blood centers is scale independent.

CONCLUSION

The results suggest that reducing inefficiency in blood procurement may be a good strategy to maximize competitiveness in the blood product marketplace. These findings further suggest that the trend of blood center consolidation may be ill advised from a cost containment perspective.

The prevention of adverse reactions to transfusions in patients with haemoglobinopathies: a proposed algorithm

BACKGROUND

Transfusion therapy remains the main treatment for patients with severe haemoglobinopathies, but can cause adverse reactions which may be classified as immediate or delayed. The use of targeted prevention with drugs and treatments of blood components in selected patients can contribute to reducing the development of some reactions.The aim of our study was to develop an algorithm capable of guiding behaviours to adopt in order to reduce the incidence of immediate transfusion reactions.

MATERIALS AND METHODS

Immediate transfusion reactions occurring over a 7-year period in 81 patients with transfusion-dependent haemoglobinopathies were recorded. The patients received transfusions with red cell concentrates that had been filtered prestorage. Various measures were undertaken to prevent transfusion reactions: leucoreduction, washing the red blood cells, prophylactic administration of an antihistamine (loratidine 10 mg tablet) or an antipyretic (paracetamol 500 mg tablet).

RESULTS

Over the study period 20,668 red cell concentrates were transfused and 64 adverse transfusion reactions were recorded in 36 patients. The mean incidence of reactions in the 7 years of observation was 3.1‰. Over the years the incidence gradually decreased from 6.8‰ in 2004 to 0.9‰ in 2010.

DISCUSSION

Preventive measures are not required for patients who have an occasional reaction, because the probability that such a type of reaction recurs is very low. In contrast, the targeted use of drugs such as loratidine or paracetamol, sometimes combined with washing and/or double filtration of red blood cells, can reduce the rate of recurrent (allergic) reactions to about 0.9‰. The system for detecting adverse reactions and training staff involved in transfusion therapy are critical points for reliable collection of data and standardisation of the detection system is recommended for those wanting to monitor the incidence of all adverse reactions, including minor ones.

Quality indicators for discarding blood in the National Blood Center, Kuala Lumpur

Background and Objective:

The implementation of quality system and continuous evaluation of all activities of the Blood Transfusion Services (BTS) can help to achieve the maximum quantity and quality of safe blood. Optimizing blood collection and processing would reduce the rate of discard and improve the efficiency of the BTS. The objective of this study is to determine the rate of discard of blood and blood component and identify its reasons at the National Blood Centre (NBC), Kuala Lumpur, during the year of 2007 in order to introduce appropriate intervention.

Study Designs and Methods:

Data on the number of discarded whole blood units and its components, reasons for discard, and the number of blood components processed as well as the number of collected blood units were obtained from the Blood Bank Information System - NBC database. These were analyzed.

Results:

The total number of blood units collected in 2007 was 171169 from which 390636 units of components were prepared. The total number of discarded whole blood units and its components was 8968 (2.3%). Platelet concentrate recorded the highest of discard at 6% (3909) followed by whole blood at 3.7% (647), fresh frozen plasma (FFP) at 2.5% (2839), and cryoprecipitate at 2% (620). The rate of discarded packed red blood cells RBCs, plasma aphaeresis, and PLT aphaeresis was less than 1% at 0.6% (902), 0.6% (37), and 0.29% (14), respectively. RBC contamination of PLT and plasma were the major cause of discard at 40% (3558). Other causes include leakage (26% - 2306), lipemia (25% - 2208), and underweight (4% - 353).

Conclusion:

Good donor selection, training and evaluation of the staff, as well as implementation of automation will help to improve processes and output of BTS. This would reduce discard of blood components and wastage caused by non conformance.

Discarded cellular components and the technical efficiency of component preparation

Given increasing cost pressures, the need to improve the technical efficiency of the production chain used for collected blood in blood banking should be recognised. Data envelopment analysis (DEA) was used to study the relationship between discard rates and technical efficiency. Whole-blood (WB) collections, aphaeresis-platelets, produced and discarded red blood cells (RBCs) and platelets (PLTs) were included in the analyses. Technical efficiency tended to be higher when the proportion of the total of RBC and PLT discards from WB collections was low. In DEA modelling, the choice of relevant input and output variables is one of the most important factors affecting the validity of the results. Discarded components should not be ignored in analyses of efficiency, because lost production output also has monetary value.

Management of blood shortages in a tertiary care academic medical center: the Yale-New Haven Hospital frozen blood reserve

Threats to national and local blood supplies in America mandate development of an effective blood management system for emergency preparedness and efficient blood inventory management. Seasonal or acute blood shortages could be compounded by the unavoidable distribution inefficiencies of the blood pipeline during an emergency. The Yale-New Haven Hospital (YNHH) Blood Bank has developed a comprehensive emergency blood management plan, which includes maintenance of a tactical, limited frozen blood supply. A computer spreadsheet-based disaster prediction model has been designed to guide the use of the frozen reserve by testing various emergency scenarios. The frozen blood reserve can likely support normal hospital red blood cell (RBC) demands during typical (3-4 days) seasonal shortages, provide a reduced supply for up to 10 days, or meet an unexpected transient increased RBC demand without requiring intensive support from the regional blood center. However, the frozen blood supply is not designed to meet the massive transfusion demand associated with extreme or sustained disasters. Rather, it serves as a short-term bridge-over supply until blood center support can be reestablished. We review the reasons for initiating a blood management plan and describe how YNHH has implemented and sustains a frozen blood reserve as part of a comprehensive disaster management plan. Despite the operational complexity, the benefits of self-sufficiency, the ability to support routine hospital requirements, and the security of having a backup supply justify the expense and difficulty of maintaining a frozen blood reserve.

Acetaminophen and diphenhydramine premedication for allergic and febrile nonhemolytic transfusion reactions: good prophylaxis or bad practice?

Febrile nonhemolytic and allergic reactions are the most common transfusion reactions, but usually do not cause significant morbidity. In an attempt to prevent these reactions, US physicians prescribe acetaminophen or diphenhydramine premedication before more than 50% of blood component transfusions. Acetaminophen and diphenhydramine are effective therapies for fever and allergy, respectively, so their use in transfusion has some biologic rationale. However, these medications also have potential toxicity, particularly in ill patients, and in the studies performed to date, they have failed to prevent transfusion reactions. Whether the benefits of routine prophylaxis with acetaminophen and diphenhydramine outweigh their risks and cost requires reexamination, particularly in light of the low reaction rates reported at many institutions even when premedication is not prescribed.

International comparison of the technical efficiency of component preparation

BACKGROUND

Under economical constraints, blood centers need to identify ways to improve their efficiency. Because there is little evidence regarding the technical efficiency of blood centers, international comparisons may be useful in identifying efficiency discrepancies and can reveal opportunities for enhancing efficiency, such as allocating resources more effectively.

STUDY DESIGN AND METHODS

Data were collected for years 2000 through 2002 from 16 blood centers in 10 European countries. Input variables included working hours, whole-blood (WB) collections, premises, and equipment, and the output variables were red blood cells and platelets (PLTs). A nonparametric method, data envelopment analysis (DEA), was used in the analyses of technical efficiency in blood component preparation departments. Efficiency scores were calculated with DEA linear programming techniques and evaluated for site characteristics that possibly affect efficiency, such as the production method of PLTs and the proportion of BCs (buffy coats) from WB and BC PLTs from all PLTs produced.

RESULTS

With working hours and equipment as inputs, median technical efficiency was 60 percent (range, 41%-100%). Four departments were efficient (efficiency, > 90%), and 12 were inefficient (range, 41-89). Efficiency remained roughly the same in 13 departments through the 3-year study period and decreased in 3. Efficiency was mainly affected by staffing levels (working hours). Efficiency did not directly relate to production volume, method, or any other site characteristic.

CONCLUSIONS

The major cause of inefficiency was excess staffing resulting from a suboptimal combination of manpower and production output levels. Further research is needed to manage factors affecting efficiency, such as the fluctuation of demand in production planning.

The economics of blood: Gift of life or a commodity?

Objectives:To calculate the costs of blood collection, testing, storage, and transfusion in Greece.

Methods:Costing information was collected from two large public hospitals, in Athens and Crete, that also act as blood banks. Given that private health care accounts for 40 percent of total health spending, the same costs were also considered in a private setting by collecting key reagent cost data from a leading private hospital in Athens. Mainly direct costs were considered (advertising campaigns, personnel, storage and maintenance, reagent costs, transportation costs from blood bank to end-use hospitals, and cross-matching and transfusion costs in receiving hospitals) and some indirect costs (opportunity cost of blood donorship).

Results:Captive donorship accounts for over 50 percent of the national blood supply. A unit of blood transfused would cost between €294.83 and €339.83 in public hospitals and could reach €413.93 in a private facility. This figure may be an underestimate, as it excludes opportunity costs of blood transfusion for patients and the healthcare system.

Conclusions:Blood has a significant cost to the health system. Policy makers and practitioners should encourage its rational use, build on current policies to further improve collection and distribution, encourage further volunteer donorship in Greece, and also consider alternatives to blood where the possibility exists.

Variation of platelet production and discard rates in 17 blood centers representing 10 European countries from 2000 to 2002

BACKGROUND

New blood safety regulations raise costs and pressure blood centers to improve their efficiency. Evaluation of platelet (PLT) production and discards between centers of different size and nationality may provide a basis for more efficient PLT inventory management.

STUDY DESIGN AND METHODS

Data were gathered retrospectively for 2000 to 2002 from 17 blood centers in 10 European countries. The descriptive analyses comprised evaluation of PLT production methods and volumes. Discard rates were surveyed also for 2003 to 2004. The number of cellular blood components produced per working hour was expressed as an arbitrary labor index.

RESULTS

Seven hospital blood banks and 10 centers with other administrative systems participated in the study. Buffy coat (BC) and apheresis PLTs were used by all centers except two preparing all PLTs by apheresis. In 2002, 73 percent of all PLTs were produced by the BC method, and PLTs were utilized from 41 percent of whole-blood donations. One center also produced PLTs by the PLT-rich plasma method. Mean annual production volume of PLTs varied greatly, from 3,345 to 103,643 units, with an increase of 5.6 percent from 2000 to 2002. Three-year mean discard rates varied between 6.7 and 25 percent, and yearly mean discard rates remained at 13 percent in 2000 to 2002 and also in 2003 to 2004. Arbitrary labor index varied from 2.4 to 7.3 between centers.

CONCLUSIONS

PLT discard rates were relatively high in the European blood centers. Detailed information on specific causes for high discard rates would help improve the efficiency of PLT management, because blood centers cannot regulate demand. Use of labor resources in component preparation also remains an important target for further research.

Economies of scale in blood banking: a study based on data envelopment analysis

BACKGROUND AND OBJECTIVES

Exploitation of economies of scale is often argued in favour of blood-bank consolidation into large regional centres, despite a lack of adequate empirical support. This study was aimed at testing the economies of scale hypothesis in a sample of blood centres in the USA.

MATERIALS AND METHODS

An input-orientated data envelopment analysis (DEA) was used to calculate the technical efficiency scores of blood centres, and to determine whether they were operating under increasing returns to scale (IRS), constant returns to scale (CRS) or decreasing returns to scale (DRS). Correlation between the blood-centre efficiency score and the demographic and socioeconomic characteristics of the service area was further investigated.

RESULTS

Seventy-one blood centres were included in the analysis. The scale of operations ranged from 7270 to 275,500 red blood cell (RBC) units per year. Six (8%) centres operated under CRS, 29 (55%) under IRS, and most of their technical inefficiency was scale-independent, and 26 (37%) operated under DRS, and most of their technical inefficiency was size-related. Efficiency scores were unrelated to any demographic or socioeconomic characteristics of the blood centre service area.

CONCLUSIONS

Within the size range of blood centres included in this study, expanding the level of operations beyond a certain point leads to DRS.