ORIGINAL ARTICLE Year : 2021  |  Volume : 46  |  Issue : 4  |  Page : 243-248

Evaluating the rate of blood components discarded at a private transfusion facility as a first step toward tailoring wastage

Sidra A Ali MBBS, FCPS 1, Huma Mansoori2, Maria Ali3
1 Laboratory, Patel Hospital, Karach, Pakistan
2 Department of Pathology, Dow University of Health Sciences, Karach, Pakistan
3 Department of Transfusion Medicine, Regional Blood Center, Karach, Pakistan

Date of Submission16-Sep-2020Date of Acceptance23-Feb-2021Date of Web Publication18-May-2022

Correspondence Address:
Sidra A Ali
Consultant in Laboratory, Medicine at Patel Hospital, Karachi, 75300, Sindh
Pakistan

Source of Support: None, Conflict of Interest: None

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DOI: 10.4103/ejh.ejh_40_20

Background and objectives Abstract Transfusion of blood and blood products plays a central role in various life-saving procedures and clinical conditions. Wastage of blood and blood products in a country where concept of voluntary blood donation is still naïve and blood banks strive to fulfill the ongoing requirement is inexcusable. This study focused on collecting the baseline wastage data of various blood products and identifying reasons behind wastage.
Materials and methods The study was conducted from January 2018 to December 2019 in a hospital blood bank of a tertiary care center. Retrospective analysis was done on the data retrieved. Wastage rate and potential reasons of wastage of different blood products were analyzed.
Results A total of 11 594 U of blood were issued from blood bank during the study duration. Expired platelets were found to be the most frequently wasted blood products (3998/4861). Overall wastage rate as a percentage of issue was 41.9%.
Conclusion Blood product wastage in our institute is high, translating to immense financial burden. The study highlighted various key elements and malpractices that contributed to overall wastage. A follow-up study after implementation of corrective measures is planned to regularly monitor wastage of blood and blood products.

Keywords: blood products, transfusion, wastage

How to cite this article:
Ali SA, Mansoori H, Ali M. Evaluating the rate of blood components discarded at a private transfusion facility as a first step toward tailoring wastage. Egypt J Haematol 2021;46:243-8
How to cite this URL:
Ali SA, Mansoori H, Ali M. Evaluating the rate of blood components discarded at a private transfusion facility as a first step toward tailoring wastage. Egypt J Haematol [serial online] 2021 [cited 2022 May 18];46:243-8. Available from: http://www.ehj.eg.net/text.asp?2021/46/4/243/345385   Background 

The life-saving potential of blood is undeniable. Till date, blood products are considered as nonpareil resource obtained from healthy blood donors. A lot of time, resource, finance, and manpower is incurred right from the recruitment of donor till the transfusion to the recipient. With respect to diminutive supply, the demand of blood and its products is mounting every year [1]. As per WHO data, developing nations hardly make up to their actual transfusion needs [2]. Implementation of the strict protocols for donor selection and collection of blood from healthy nonremunerated voluntary donors has further restricted the process. Human age also plays an infelicitous role. It not only limits the number of donors being recruited but simultaneously results in increased demand of transfusion in aging population owing to morbidities [3],[4].

Expenses related to blood products are ever escalating owing to radical approach in collection, processing, and screening which further burdens the trivial health budget of low socioeconomic countries. Lack of centralized blood processing units, leading to mushrooming of substandard blood banks, is another contributing element to already vexed situation. Cherry on the cake is occurrence of unfavorable events like breakage, low-volume collection, or positive donor screening results, leading to wastage of units even before reaching the storage shelf.

As Pakistan is an under-resourced developing country with a weakened healthcare infrastructure [5], the country cannot withstand the jeopardy of resourceful supply of blood down the drain. Wastage of blood products is becoming a subject of crucial value globally in all hospital settings [6]. Minimal imperative losses can be allowed owing to short half-life of products owing to indigenous demand of availability of stock in inventory at all time [6],[7]. However, undue ordering of blood products and holding them in reserve not only leads to wastage but also results in unavailability of product when needed by others [8],[9].

Typically, the reasons observed for wastage are preventable. Component wastage is an important quality indicator to be analyzed and can be explained as fraction of blood products discarded from the total number of blood products issued [10]. Key factors responsible for product losses are severed bag, damaged seals, expired units, visible contamination, clotted bags, and over and under blood collections [11]. Other constituents that accredit the losses outside the blood bank are apparently owing to inappropriate management of temperature during transport, discrepant reading of temperature indicators, and lack of accountability while requesting the blood products [12].

Inappropriate clinical utilization bears a fair share of blood wastage. Tuckfield et al. [13] believes that reviewing transfusing request forms beforehand can reduce the nonjudicial usage of blood products. A multifaceted electronic approach for ordering blood component implies to be a practical alternative to reduce blood product losses [14]. Implementation of detailed plans for Maximum Surgical Blood Order Schedules and Major Hemorrhage Protocols can also bring about significant reduction in product losses [15].

The study was structured comprehensively to scrutinize the elements involved in component losses at our hospital setup which will be followed by implementation of amendments to improve the overall quality services to patients.

  Materials and methods 

Procedure

Location of the study

Patel Hospital is a multidisciplinary hospital in a private sector located in a district east of the largest city of the country providing postgraduate training in many specialties. It is a 250-bedded hospital catering a wide spectrum of individuals from different categories with some of the specialties like plastic surgery, burns, and ophthalmology, being one of the best in the city. The hospital has its own blood bank since its inception which developed gradually over the years and is now issuing more than 5000 blood products annually.

Hospital transfusion system

Registered by Sindh blood transfusion authority, the blood bank not only caters the need of admitted patients sufficiently but also provides blood and blood components to outside sources when requested, with up to 4000 blood donors per year. The majority of these donations are exchange donations for relatives and friends admitted in the hospital. After blood collection in donor area, the blood bags are moved to main processing area of blood bank for component preparation and screening for transfusion transmitted infections (TTI). Before storage in inventory, all blood products are vigilantly inspected and removed if found unsatisfactory on physical examination. Packed red blood cells (PRBC) are stored in CPD-A1 for 35 days in temperature-controlled refrigerators maintained at 4–6°C, whereas platelets are kept at room temperature (20–24°C) with continuous agitation for 5 days. The storage time for fresh frozen plasma (FFP) is 1 year, and it is stored at −18°C. As majority of blood is utilized for admitted patients, blood bank maintains its own blood product supply proportionate to the hospital’s volume of transfusion events for each product. If a specific blood group is deficient, then donors of those groups are recruited, and likewise if any blood group reaches beyond the set limits, predonation blood grouping is performed, and donors are selected accordingly.

Procedure of recording wastage of blood/blood products

Blood and blood components that are wasted are recorded daily, and the data are compiled at the end of each month. It includes the wastage of blood products before and after release from blood bank. Common mechanisms are outdated and expired products, blood bags with inadequate volume, improper handling or storage, visible hemolysis, clots, breakage, bacterial contamination, and platelets with visible red cells. Other than that, products ordered by physician but not transfused and returned after 30 min are also included. Units that expired after issuance from the blood bank but before transfusion like washed PRBC, whole blood, thawed FFP, etc., fall in the category of outdated products. Improper storage includes units that are improperly transported or stored in refrigerators in the clinical areas without proper temperature monitoring. All these wasted products are disposed via chemical disinfection as per the institutional policy.

Determination of wastage rate

The study was conducted as phase 1 of wastage reduction plan and preliminary collection of data with a focus to have baseline wastage rate as a percentage of issue (WAPI) of blood products both before and after releasing blood products from blood bank.

Data were retrieved retrospectively from all categories of wastage over a period of 24 months from January 2018 till December 2019. Information on the collection and wastage of blood components was taken from blood bank software and verified manually from blood bank indicators maintaining monthly utilization and wastage of blood and blood components. The root cause of the wastage of blood components was evaluated to minimize loss of this irreplaceable human resource.

Statistical analysis

All the data were analyzed using SPSS, version 19.0 (SPSS Inc., Chicago, Illinoi, USA). The wastage and issuance of blood/blood components were computed for each category of blood component like PRBC, platelets, and FFP. The calculated indices included WAPI, which was calculated by keeping all blood components discarded in the study duration in denominator versus total number of blood components issued from blood bank. Reasons of discarding blood product were evaluated. Descriptive data were given as number (%) and frequency for qualitative variables.

  Results 

During the study duration, 7735 donors were recruited. A total of 685 (8.8%) donors were deferred based on history and physical examination. Of 7050 (91.1%) donors who donated blood after initial verbal screening, 7024 U were processed further for preparation of adult and pediatric PRBC, platelets, FFP, and cryoprecipitate, whereas 26 (0.3%) bags were discarded owing to inadequate volume. A total of 814 (11.5%) products were found positive during screening for TTI and were not added in inventory. These included viral hepatitis (696, 85.5%), syphilis (77, 9.4%), HIV (36, 4.4%), and malaria (five, 0.6%). During the study duration, 11 594 were issued, whereas 4861 were discarded owing to various reasons, as shown in [Table 1].

Before storage, all blood components were examined for any breakage and leaks, and platelets are specifically checked for red cell contamination. At this step, nine (0.1%) bags were not added in inventory owing to breakage during centrifugation and 21 U of platelets were discarded owing to cellular contamination. Among inevitable reasons of discard like expired products (n=4538, 93.3%), platelets having the shortest half-life contributed the most (n=3998, 88.1%).

At the time of dispatch, 94 (1.9%) FFP bags were found damaged when thawed and seven (0.1%) PRBC were disposed owing to visible hemolysis before release. Bacterial contamination was found in two (0.04%) products, whereas 26 (0.5%) bags were removed from inventory owing to miscellaneous reasons, including clotting, foaming, and discoloration.

After issuance from blood bank, 99 (2.1%) bags were returned to blood bank after the hospital’s policy of ’30-min return;’ hence, all such units were discarded and not taken back in inventory. A total of 26 (0.5%) outdated products were discarded owing to delay in transfusion. The cumulative WAPI was found to be 41.9%. The breakage of wasted blood products before and after release is shown in [Table 2].

Financial burden

Wastage of blood products when translated in coinage, the hospital suffered above 55 000 USD loss for 4861 products which is equivalent to over nine million PKR in a country where per capita income is less than 1500 USD.

  Discussion 

Blood product is an indispensable and a much valuable resource. To ensure adequate availability and synchronize the demand and supply at all time is a daunting task, allowing certain level of discarding of blood and blood product as inevitable and appropriate [16]. However, crossing the benchmark of wastage is intolerable when majority of blood donations are derived by exchange donors in whom the deferral rate is as high as 8% as evident from this study. Hence, understanding the key factors leading to wastage is an important first step in executing blood product wastage reduction reforms. The study is an attempt to highlight the baseline wastage of blood products with an insight to the reasons behind it.

The study demonstrated that overall WAPI in a tertiary care setting was 41.9%. When compared with the local data, Raghuwanshi et al. [17] reported approximately the similar rate of wastage, that is, 38.9%. However, in contrast, international data show much lower numbers. For instance, a neighboring country Iran had an overall wastage rate of 9.8% [1], South America had 25% [11] whereas Australian Red Cross Life blood claims that their rate of laboratories and hospitals wastage is less than 1%. In the similar lines, Beckwith et al. [18] reported wastage rate to be 3% in UK.

The major cause of blood wastage in this study was owing to expiration followed by return of the blood product after 30 min, broken, and the least affected component was plasma. Among different blood components, the maximum ordered component by physicians is PRBC, comprising 59.7% of the total followed by plasma (20.3%) and platelets (19.8%). These data are synchronous with the data presented by Kurup et al. [11] and Amini Kafi-Abad et al. [19].

As evident, the least required blood product, that is, platelets, was the one that suffered detrimental wastage of all, with the overall WAPI of platelet product alone mounting up to 83% (4036/4861). Almost third of the platelet products that were produced were wasted, and in 99% cases, the cause was expiry of the product while being on shelf. This high expiry rates may indicate excess blood product stocks being held in inventory than needed. When compared with the international data, the WAPI rate for platelet product in USA is as low as 2.8% [6], whereas platelet WAPI rate in England/North Wales and Northern Ireland hospitals in 2011–2012 was 4.0 and 7.6%, respectively [20]. This soaring high WAPI is attributed to uncertainty in daily demand and extremely short half-life of platelets. For instance when there is a surge of dengue fever, the inventories ran out of platelet components [21], but during the nonseasonal time, platelets expire, unconsumed on shelves. A need of statistical model that can adequately forecast patient platelet demand to guide inventory management and decrease wastage due to expiration, while avoiding platelet shortages is the need of the hour as implemented by Guan et al. [22]. Several stochastic programming models with a lot of computational complexities have been proposed keeping in view the fluctuating demand of this perishable product [23].

Microbiological testing with rapid culture system and cryopreservation, extending shelve life of the platelets, appears to be a promising approach for a subset of population [24]. Other plausible way outs are establishment of centralized blood distribution centers to ensure effective stock rotation and outsourcing the platelet products to other regional blood banks in need, especially those allied with cancer and transplantation centers. Cessation to make platelet products during nonendemic time of dengue or other viral fever associated with low platelets and bleeding and relying more on single donor platelet can be a practical approach. Giving nongroup-specific platelet component to low-risk patient group and during massive transfusion could be another solution to minimize the wastage [25]. A substantial number of platelets units were also discarded owing to cellular contamination stressing the significance of continuous training and evaluation of staff.

Red cells were the second most common component to be wasted after platelets with WAPI rate of 11%. Preferably, institutional RBC wastage rate should be less than 1% of the units issued. Like platelets, most of the red cells (76%) were discarded as they reached their expiry date, reflecting demand and supply disequilibrium. Collins et al. [6] reported the RBC wastage rate of 0.56% after intervention in USA. FFP, with the WAPI of ∼5.2%, stands last in the list of discarded components, but the rate is still high when compared with published data. Metcalf et al. [26] reported plasma wastage rate to be around 1.8% in USA, whereas Javadzadeh Shahshahani and Taghvai [27] reported plasma wastage of 2.3% in Iran. According to this study, the main reason of FFP wastage was again the expiry of the product followed by the damage to the product bag or seal while being stored at −30°. To curb this loss, the near expiry FFP can be specified for fractionation to prepare factor concentrates, albumin, or other hemostatic products like Prothrombin Complex Concentrates [28].

Repeatedly in our case, the expiry of the product superseded the cause followed by individual units that were out of blood bank for more than 30 min (that is RBC products were dispensed but not administered). Unfortunately, it was not an uncommon occurrence that blood product was cross-matched, dispatched, and delivered to the patient care unit, but not transfused nor returned in a timely fashion for re-entry into inventory. This miscommunication most often took place in the operating room, emergency room, followed by ICU and floor, as shown in [Table 3].

Table 3 Location wise breakage of ‘after issue’ wastage primarily in the clinical areas

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It was also observed that rate of TTI was high in our donor, questioning the credibility of initial verbal screening and efficiency of donor health performa. Blood donor attendants must be skilled to create a confidential environment for donors to disclose their involvement in high-risk activities before donation [29].

Wastage of blood components will continue to be an alarming subject at all hospitals unless effective and affordable interventions are implemented. Along with effective stock rotation to reduce expiry, simple measure like educational outreach, awareness among laboratory staffs, reiterating transfusion guidelines to nurses and physicians, print and digital messaging, and improved transportation and component identification modalities can have a prompt and dramatic effect on reducing blood wastage regarding both cost and resource savings [12]. Other technologies synchronizing supply and demand issues, end-to end accountability of the issued products using electronic barcodes, and scanners are critical for the meaningful results [30].

There are certain limitations to this study, for instance, hospital did not cater to hematological malignancy as well as renal, liver or bone marrow transplant patients, and hence the data are not comprehensive and cannot be generalized to other setups of the same region. A collaborative study with other tertiary care hospitals can yield much substantial and unbiased results.

  Conclusion 

High rate of wastage and the areas requiring improvement as highlighted in this study will serve as an important tool to amend the weaknesses and devising our own local policies and guidelines. The result of a reaudit would help to ascertain the improvement in practices once these guidelines will be implemented.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.

 

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  [Table 1], [Table 2], [Table 3]