Managing Blood in Rural Areas

[Brenda K Hutson]

As I mentioned previously, I have moved from Calif. (where I worked 30 years in all med-large Urban areas with multiple Donor Centers), to Rural Maine. We have NO Distribution Center in our state (we get it from Massachusetts).

Problems include:

1. Costly and time-consuming to get blood products "urgently"

2. Have to place Orders for following day, by 7pm the evening before

3. Because of 1 & 2 and not wanting to be caught short, we try to keep

certain levels; but ALL of the Hospitals in Maine struggle with a lot of wasted products (especially RBCs and Platelets)

4. Certain Hospitals have been designated as Overstock Hospitals; given "extra" stock in case smaller ones need it.

5. Larger Hospitals expected to "help out" smaller Hospitals by taking in their short-dated units when called; but then that sets us up to waste even more products; so now the larger Hospitals are starting to decline those units.

Just wondering if anyone else in a scenario such as this has come up with a "system" in your area/state whereby all of the Hospitals can communicate with each other (without it taking up a lot of anyone's time) to "assist" each other in getting the short-dated units transferred and used (win-win situation)??

Thanks,

Brenda Hutson, CLS(ASCP)SBB

[Deny Morlino]

Brenda,

Are you supplied by ARC? We are here and have similar issues with stock levels. The arrangement ARC has made is that a 250 bed hospital located about 35 minutes from us takes the shorter dated units. This larger hospital performs open hearts and uses far more blood products than the 6 or 7 smaller hospitals they receive shorter dates from. This hospital receives blood deliveries 6 days per week from ARC. One day per week the smaller hospitals send a transfer list to the larger hospital with a transfer list for the following day of units that have a minimum of 10 days until expiration and a maximum of 17 days. The larger hospital adjusts their order for the following day with the expectation of receiving the units from the smaller hospitals. Net result is lower wasteage numbers for several smaller hospitals than they could reasonably expect to achieve on their own. We have been doing this for several years and it works very well.

[mollyredone]

Brenda, we are a 150 bed hospital in southern Oregon. We get our products from ARC, three hours north. Our maximum ON stock is 6 units, ABP and ABN 2 units, OP (including 4 OP IRR) and AP 45 units, AN 12, including 4 AN IRR, BP 6 and BN 4. We get one PPH delivered three times a week. I don't know why, but we rarely waste any units of blood. We try to give sure transfusions the short dates, and all pre-ops long dates. Our shortest date OP is 4/10 and our longest date is 4/17. We send our PPH to a neighboring hospital (90 minutes south-they keep 5-8 on hand at all times) the day before they expire. We do try to have one PPH on hand all the time. I know you probably know all this, but this has worked well for us. If we urgently need a unit, we can have the highway patrol speed one up or down the highway to us.

[Mabel Adams]

We are also an ARC overstocked hospital. We rotate the short-dates (<17 days) back from our 4 surrounding hospitals once weekly for 3 of them and bi-weekly for the other most remote one. We don't rotate all of the O negs at once. We usually order in extra blood (mostly O negs) then rotate the other hospitals and return any extra O negs to our supplier with over 14 days on them if we need to. We always use up the O+ and A+ excess with no trouble. We have 261 beds, do open hearts and are a level II trauma center. There's a lot of logistics involved but it seems to work.

[David Saikin]

Brenda

I am an overstock in northern NH . . . still have problems getting the larger hospitals to take shorter dates, esp A+. I have had to rotate stock on a weekly basis to accommodate the hosp that takes my products and even then sometimes they don't want any. I get my regular stock every other week. I have reduced my A+ inventory 40% in an attempt to not outdate. I am lucky in that I get a courier 2x a day from Burlington, which is the ARC distribution point for me.

Welcome again to Northern New England

[Auntie-D]

We have a 'backup' fridge where we have units that we don't take into stock unless we have an emergency. Every two weeks our donor centre swaps these out for fresher dated blood. That way wastage has been reduced and we have been able to confidently lower our stocking to minimal levels with the knowledge that we stall have reserves. The two weeks left on the units means there is plenty of time to use them (or region still hasn't moved over to 42 day shelf life).

Our donor centre were very anti to this at first but when they realised it actually meant us ordering less, and less 'blue light' requests, they changed their minds. It's worked really well and we have only had to order blood from the centre 'blue light' once in the 18 months since it was implemented.

[cbaldwin]

We are a 25 bed hospital, 4 hours from our blood supplier (although the Highway Patrol can make the trip to deliver emergency blood products to us in 2 hours). We are an overstock hospital for two smaller hospitals near us. We stock 14 OP, 12 AP, 4 AN, 2 ABP, 4BP, and 8 ON. We need to order before 7am if we want delivery and delivery is only Monday through Friday. Otherwise, it's the highway patrol.

We seldom waste units, not because we use them—our usage is low—but because our blood supplier has asked us to return units between 14 and 21 days outdate. It seems odd at times, but it works. When we order blood we always request “long dated” units.

But it is worrisome. Last week, Thursday afternoon, an A, Rh negative GI bleeder came in. She went from 7.2 to 5.1 hemoglobin in an hour, took 2 units AN, then was whisked off to surgery. The physician ordered 4 more units. Friday morning, her H/H was stable, but I was in a quandary as to how many ON units to stock up for the weekend. Would our patient need a lot more blood? Would there be a big trauma? It turned out that our blood supplier had no ON to send us, the patient didn't need anymore blood, and there were no traumas.

Except for a 10 year stint in Oregon, I have been at this hospital since 1983. The one thing that has really helped us maintain an adequate blood supply and reduce usage was when the narrow 2 lane highway that winds up our valley from metropolitan Southern California to the ski resort north of us was enlarged to 4 lanes. 2 lanes to 4 lanes—much fewer Friday evening head-on crashes.

[AMcCord]

Our situation is very similar to mollyredone - stock, size and distance from our ARC blood center. We also are an overstock facility for our smaller neighbors. We are restocked by the ARC once a week and return shortdates at that time. The ARC doesn't always take what we want to return - sometimes they prefer not to send us fresher units for supply management reasons such as a temporary surplus of a particular type (like AB Pos) or a shortage of O neg. We outdate some B Pos and AB red cells that the ARC has chosen to leave with us, though this isn't a large number. We rotate platelets back to the center Monday through Friday. If we need something between weekly reloads, we order by 2 PM on weekdays so that it can be shipped with the platelet restock. Some weeks we need blood between the weekly restock runs and some weeks we don't. Our maximum stock is 15-20% (a little more at times in the winter months) over what we use in a week - we do not maintain maximum stock on a daily basis, but do reload between the weekly runs if a particular type runs low. We manage our blood supply very agressively by checking Hgbs daily and making sure that any give orders are crossmatched with the short dates. We double tag short dates and release crossmatches on some patients early, based on Hgb, so that we can use those shortdated units for a give order. We use a neighbor of similar size about 25 minutes away for emergency help, though we very rarely need to do that. Other than the units our supplier chooses to outdate here, we outdate very little blood.

Edited March 14, 2012 by AMcCord

[Brenda K Hutson]

Yes, that is the system we have here; it just isn't working well for any of the Hospitals in the state; the larger overstock Hospitals, or the smaller Hospitals. The large Hospitals need to keep a fair amount of blood on hand for the types of patients they treat, and have to make sure they always have enough; there would be no quick way to stock up again. So since the large Hospitals are wasting a lot of product, they are starting to tell the smaller Hospitals NO more frequently when asked to take short-dated units.

Not sure why it seems to be working out for you?? Some more questions I would ask you:

1. How large of a geographical area are you talking (in which all of the Hospitals in your system are operating)?

2. How far away is the ARC distribution center? How many miles from the center are the "closest" Hospitals?

3. If the large Hospitals are short because of bleeders, do they take the overstock blood and use it; or, is that only supposed to be used for other Hospitals?

Thanks

Brenda

Brenda,

Are you supplied by ARC? We are here and have similar issues with stock levels. The arrangement ARC has made is that a 250 bed hospital located about 35 minutes from us takes the shorter dated units. This larger hospital performs open hearts and uses far more blood products than the 6 or 7 smaller hospitals they receive shorter dates from. This hospital receives blood deliveries 6 days per week from ARC. One day per week the smaller hospitals send a transfer list to the larger hospital with a transfer list for the following day of units that have a minimum of 10 days until expiration and a maximum of 17 days. The larger hospital adjusts their order for the following day with the expectation of receiving the units from the smaller hospitals. Net result is lower wasteage numbers for several smaller hospitals than they could reasonably expect to achieve on their own. We have been doing this for several years and it works very well.

[Brenda K Hutson]

Well, I think part of our problem (and it just hit me in looking at the great outdates you have), is that we give ALL Irradiated RBCs! Not my decision, and I am moving to change that. But that means we cannot get dates like that.

However, that can't account for all of the problem because I don't think all of the other Hospitals in the state do that and yet they still have a lot of wasted products. Having never been in this situation, I am just not quite sure how to approach it (though I imagine changing our IRR Policy will help some).

Thanks,

Brenda

Brenda, we are a 150 bed hospital in southern Oregon. We get our products from ARC, three hours north. Our maximum ON stock is 6 units, ABP and ABN 2 units, OP (including 4 OP IRR) and AP 45 units, AN 12, including 4 AN IRR, BP 6 and BN 4. We get one PPH delivered three times a week. I don't know why, but we rarely waste any units of blood. We try to give sure transfusions the short dates, and all pre-ops long dates. Our shortest date OP is 4/10 and our longest date is 4/17. We send our PPH to a neighboring hospital (90 minutes south-they keep 5-8 on hand at all times) the day before they expire. We do try to have one PPH on hand all the time. I know you probably know all this, but this has worked well for us. If we urgently need a unit, we can have the highway patrol speed one up or down the highway to us.

[Brenda K Hutson]

Well, I see one major reason you can better utilize the blood; you perform open hearts and are a trauma center; we are not. But other larger Hospitals in our state that fit that same description, still have problems with wastage; I mean a lot of wastage. If I had patients like the one's you described, I feel confident I could also better manage our supply.

Brenda

We are also an ARC overstocked hospital. We rotate the short-dates (<17 days) back from our 4 surrounding hospitals once weekly for 3 of them and bi-weekly for the other most remote one. We don't rotate all of the O negs at once. We usually order in extra blood (mostly O negs) then rotate the other hospitals and return any extra O negs to our supplier with over 14 days on them if we need to. We always use up the O+ and A+ excess with no trouble. We have 261 beds, do open hearts and are a level II trauma center. There's a lot of logistics involved but it seems to work.

[mollyredone]

"Well, I think part of our problem (and it just hit me in looking at the great outdates you have), is that we give ALL Irradiated RBCs!"

Brenda, are you allowed to pass that charge on to the patient?? Seems like a waste of money, not to mention shorter outdates!

Mari

[Mabel Adams]

Brenda, I think one way to help compare our regions is to look at a map. Where in Maine are you and where in Mass. is your supplier? I am in Bend OR; our supplier is in Portland OR; the surrounding hospitals are in Madras (49 beds), Prineville (29 beds), Redmond (70 some beds) and Burns (20 some beds). My bed estimates are from memory and may be wrong. We keep some irradiated A & O RBCs which are mostly irradiated here with our Rad Oncology linear accelerator. We are not a terribly busy trauma center compared to some level II sites. We average maybe one massive transfusion a month or so and some of them don't turn out to be after they call it.

[Deny Morlino]

Yes, that is the system we have here; it just isn't working well for any of the Hospitals in the state; the larger overstock Hospitals, or the smaller Hospitals. The large Hospitals need to keep a fair amount of blood on hand for the types of patients they treat, and have to make sure they always have enough; there would be no quick way to stock up again. So since the large Hospitals are wasting a lot of product, they are starting to tell the smaller Hospitals NO more frequently when asked to take short-dated units.

Not sure why it seems to be working out for you?? Some more questions I would ask you:

1. How large of a geographical area are you talking (in which all of the Hospitals in your system are operating)?

2. How far away is the ARC distribution center? How many miles from the center are the "closest" Hospitals?

3. If the large Hospitals are short because of bleeders, do they take the overstock blood and use it; or, is that only supposed to be used for other Hospitals?

Thanks

Brenda

Brenda,

The hospitals involved with this transfer procedure are located across 7 counties I believe. We are the largest of the hospitals sending blood to the bigger hospitals and operate at around 75-80 beds. The hospital we transfer to is about 250 beds and does perform open hearts, etc. In the same city of 45,000 is a 400 bed hospital. My understanding is that the two large hospitals exchange blood back and forth as needed. Neither is listed as an official overstock center although we request units from both as needed if they are able to help us out. If they can't, ARC is about 60 miles from us (a good 80 minutes as their is not a direct route). The hospital that is closest to ARC is about 40 minutes away. If the large hospitals are short on units because of bleeders they would source from the distribution center if they are not able to help each other. I know the ARC tech support looks at the numbers on a rolling 6 months for each hospitals use to see if any adjustments in stock levels are recommended. Are you supplied by ARC? If so I could put you in touch with my tech rep. She could either offer suggestions or describe the process in more detail than perhaps I am able. Our outdating is very low (mainly AB positive LRBC) and the process seems to work here. Maybe there are some details or questions to be answered I have not thought of as of yet. Let me know how I can help.