From the 2021 HVPAA National Conference
Amber Whitley (The Brody School of Medicine at East Carolina University), Brittany Stewart (Vidant Medical Center), Michael Passwater, Keosha Joyner, Susan Weiss
In 2013, there was a 9.4% decline in whole blood and apheresis red blood cell (RBC) units collected in the United States compared to 2011.1 Lean Sigma methodology demonstrated that reducing the number of RBC units wasted by approximately 4,300 per year saved $800,000 over a four year period.2 Blood wastage reduction is necessary to address both the decline in collections and the rising cost of health care.
The main objective was to reduce cryoprecipitate and plasma waste to 15% and 5% respectively, increase hospital savings and improve availability of blood at Vidant Medical Center (VMC).
Cryoprecipitate and plasma are received frozen to maximize shelf life and must be thawed before transfusions. Massive Transfusion protocols allow for a predetermined ratio of blood products to be issued in emergent situations. At VMC, cryoprecipitate was issued during the second round of the massive transfusion protocol (MTP) causing the transfusion service to thaw cryoprecipitate when the MTP was activated. If a second round was not needed, the thawed cryoprecipitate was discarded. Therapeutic plasma exchange (TPE) required pooled plasma to be thawed, preventing transfusion to a different patient if the original procedure was cancelled. RBC wastage often occurs due to improper blood handling during transport or if issued but not transfused within 30 minutes. Collaboration with multi-disciplinary teams including the transfusion services, apheresis service and trauma service identified opportunities to maximize blood management efficiency. The MTP was revised to issue cryoprecipitate in the third round and an extra unit of plasma was added to each round. Pooled plasma was discontinued and replaced with individual plasma units for TPE procedures allowing thawed plasma to be transfused to a different patient. Point of service emergency blood refrigerators were installed in the trauma bay area of the emergency room to minimize blood wastage related to “cold chain” disruptions during transport to critically ill patients.
Cryoprecipitate waste was reduced from 27.47% ± 9.57% to 18.2% ± 5.13% (p = 0.00163). Plasma waste was reduced from 10.77% ± 4.55% to 6.0% ± 2.71% (p = 0.01319). After implementation of blood refrigerators, the percentage of RBC’s units delivered to the emergency room, not transfused and returned to the blood bank decreased from 51.57% ± 4.22% to 28.57% ± 14.01% (p=0.0000422). Blood waste reduction led to hospital saving of $80,083 over a two year period.
This multifaceted approach produced significant reductions in cryoprecipitate and plasma over a short period. In addition, the decline in RBC return rate demonstrates the blood stored in the refrigerators is being adequately used to resuscitate patients. Future efforts aim to identify other sources of blood waste and services other than trauma with high wastage.
As the cost of health care steadily rises, hospitals are searching for innovative ideas to reduce expenses and minimize wastage. This study demonstrates an interdisciplinary approach to decreased blood waste, increased blood handling efficiency and blood availability. Our data suggests, delayed issue of cryoprecipitate in the MTP and the use of pooled plasma are low cost, high impact interventions resulting in copious hospital savings.
1Como JJ, Dutton RP, Scalea TM, Edelman BB, Hess JR. Blood transfusion rates in the care of acute trauma. Transfusion. 2004;44:809–13.
2Heitmiller ES, Hill RB, Marshall CE et al. Blood wastage reduction using Lean Sigma methodology. Transfusion. 2010;50(9):1887-1896.