1. Rate of discard of blood and its components as a quality indicator for blood utilization in a tertiary care haemato-oncology centre Dr Shashank Ojha, Dr Sumathi S H, Amol Tirlotkar, Dr S B Rajadhyaksha Advanced Centre for Treatment, Research & Education in Cancer, Kharghar, Navi Mumbai

2. BACKGROUND The rate of discard of blood components serve as a quality indicator, for implementation of corrective measures to rationalise blood utilization and inventory management. Determination of quality indicators requires thorough exploration of the processes underlying particular service, assessment of the risk and frequency of particular problem, and the possibilities of improvement.

3. Quality indicators Measurements Deviations /Trends Corrective Actions Improvements Quality Indicators for Blood Utilization

4. AIM To determine the rate of discard of blood and blood components as well as blood utilization And Reasons for discard of blood and blood components

5. STUDY DESIGN & METHODS A Six years (2006-2011) retrospective data Following rates were assessed for their mean annual trends (%) ◦ Unit expiration ◦ Unit discard (Wastage) ◦ Reason for discard ◦ Cross-match to transfusion (C:T) ratio

6. DTM - ACTREC Established in 2005 ~2,000 Donations /year ~3,600 Components/year ~ 21,000 TTI testing/year ~ Specialised products/year ◦ Leucodepleted PRBC’S (800) & Platelets (600) ◦ Gamma Irradiated products (1,600) ◦ e-BDS tested products ~ Specialised procedures/year ◦ Peripheral blood stem cell collection (100) working with second large BMT Unit ◦ Granulocyte collections (10) ◦ Bone marrow Harvest & processing (10) QM since 2007

7. Expired Unit: component unit that had its lifespan exceeded that allowable for transfusion, that is, its maximum storage time was reached Discarded Unit: component unit that was discarded due to, expiration but not limited to, handling and storage errors, such as breakage etc Expiration Rate =No. of Expired component units X100 No. of component units (Transfused + Expired) Discard Rate = No. of Discarded component units X100 No. of component units (Transfused +Discard) Crossmatched-Transfused (C:T) Ratio=No of Crossmatched RBC Units No of Transfused RBC Units

8. RESULTS Total 21,179 components were prepared from 8,998 collections Mean annual component unit discard rate was 16.5% (Total 3,512 components)

9. MEAN TOTAL COMPONENT DISCARD RATE Mean annual infectious discard rate was 2.8% (range: 2.0 - 4.13%) Mean annual Non-infectious discard rate was 13.7% (range: 4.07 - 23.66%) Infectious HIV HBsAg HCV MP Syphilis Bacterial Contamination Non Infectious Outdate/Expiration QNS/QI Leakage Mean Annual discard rate 16.5%

10. MEAN ANNUAL DISCARD RATE (%) OF COMPONENTS %

11. MEAN ANNUAL D ISCARD RATE (%) Compo- nent Discar d Rate (%) Infect (%) Non- Infect (%) WB18.424.114 PRBC11.32.78.6 FFP20.22.717.5 RDP20.92.717.95 SDP5.70.65.1 % Mean annual discard rate

12. REASON FOR DISCARD Infectious (2.8%)Non-Infectious (13.7%) HIV 0.56 %Expiration11.55 % HBsAg 1.6 %QI0.49 % HCV 0.49 %Leakage0.34 % MP 0.0 % VDRL 0.03 % Bacterial contamination 0.014%

13. EXPIRATION RATE OF COMPONENTS (%) Mean annual WB expiration rate= 10% (range: 3.8-25.4%) Mean annual PRBC expiration rate= 7.94% (range: 2.54-19.1%) Mean annual RDP expiration rate= 17.7% (range: 2.0-34.0%) Mean annual FFP expiration rate= 12% (range: 9.27-49.73%) Mean annual SDP expiration rate= 4.8% (range: 0.7-10.3%)

14. MEAN C:T RATIO Mean annual C:T ratio was 1.4 (range: 1.3-1.7) Maximum Desirable Level

15. MEAN ANNUAL DISCARD TREND (%) OF WB, PRBC & FFP Mean annual WB Discard rate = 18.42% ( range: 10.3-31.0%) Mean annual PRBC’s Discard rate =11.3% (range: 6.4-22.7%) Mean annual FFP Discard rate = 20.2% ( range: 4.1-63.4%) % Mean annual discard Trend

16. MEAN ANNUAL TREND(%) OF PLATELETS Mean annual RDP Discard rate = 20.92% ( range: 4.4-37.6%) Mean annual SDP Discard rate = 5.74% (range: 1.4-11.4%) % Mean annual discard Trend

17. DISCUSSION Discarded blood components accounts for the lost production output, thus should not be ignored. The Mean annual discard rate was higher in our study. However, there has not been any guidelines established in the literature.

18. The mean annual non-infectious discard rate was higher than the mean annual infectious discard rate. This is because of stringent donor screening & inclusion of sensitive methods for TTI testing. DISCUSSION

19. The highest mean annual discard rate recorded for RDP followed by FFP then WB & PRBC & lowest for SDP. In platelets, expiration rate was high due to short shelf life and hence were discarded, whereas SDP’s were used judicially. Components are held a longer time in quarantine, which may contribute to outdating of PLTs. DISCUSSION

20. In our centre, FFP’s were not required as much, hence, the higher discard in 2007. After 2007, FFP’s were send to fractionation centre quarterly. Due to 35 day shelf life of WB, apt utilization was not possible as blood centre cannot generate request. Since our institutional bed size increased in 2009 (82 bed hospital now), over blood stocking from camps was responsible for discard. DISCUSSION

21. In non-infectious, the cause for discard was major due to expiration (11.5%) than others. This is in sharp contrast to expiry rates of 5.8- 6.4% quoted by Q-Probes study while evaluating 1,639 hospitals throughout United States 4. This is because in Q-Probes study, expiry rate was calculated from units which were received by hospitals from collection centres and were not utilized during the prescribed time interval. DISCUSSION

22. Mean Annual trend of expiration of RDP’s was similar with most of the studies. Sullivan et al. 3 1/5 th of produced PLT concentrates has been reported to become outdated and the expiration rate was more than 25% for random donor PLTs and more than 10% for aphaeresis-PLTs in every tenth blood bank of 1639 U.S. hospitals studied 5. Discussion

23. Mean annual C:T ratio was lower than 2.0 or less by monitoring requests for blood components. As per our study highest number of infectious donor blood wastage is due to HbsAg positive. This is due to high prevalence of HBsAg in healthy population as compared to HIV & HCV. However, it is showing a downward trend with the use of HBsAg vaccination. DISCUSSION

24. CORRECTIVE MEASURES Launched by QM personnel engagement and motivation for implementation of corrective measures. Effectiveness of measures taken for responsible management of blood products on stock - planning of blood collections - planning of manufacture - collaboration with clinicians

25. Mean annual RBC wastage can be lowered by exchanging units on credit-debit basis with other blood centres. Rationale utilization of FFP by sending units to NPFC. Performing the concept of common cross- match to further conserve and maintain inventory. Training of personnel for improving the collection procedures. Use of automated bio-mixers to reduce causes of improper collections CORRECTIVE MEASURES

26. Processing of WB for further component preparation. Adequate spacing in organization of voluntary blood camp. Collaboration with clinicians to monitor request for blood component therapy. CORRECTIVE MEASURES

27. CONCLUSION Regular audit of blood utilization and discard rate with simple mathematical models serve as an important tool for accomplishment of the quality goals. Since blood centers cannot regulate demand, the stochastic need for blood components can be achieved by production, planning and improving inventory management to minimize discard rate.

28. Quality indicators for blood establishment can be done by exchange of experiences with high level of transparency & comparing the trends with corrective measures 1.

29. REFERENCES 1. T. Vuk. Quality indicators: a tool for quality monitoring and improvement. ISBT Science Series (2012) 7, 24–28 2. Rossi’s Principle of Transfusion Medicine, fourth ed. 3. Sullivan MT, Wallace EL et al. Blood collection and transfusion in the United States in 1999. Transfusion 2005;45:141-8. 4. Novis DA et al. Three College of American Pathologists Q-Probes Studies of 12 288 404 Red Blood Cell Units in 1639 Hospitals. Arch Pathol Lab Med—Vol 126, February 2002 5. David A. Novis et al. Quality Indicators of Fresh Frozen Plasma and Platelet Utilization. Arch Pathol Lab Med— Vol 126, May 2002