Sequestration and cost reduction

[kirkaw]

Hi All,

I have just come from a meeting where our CEO has 'mandated' a 8-10% reduction in expenses due to decreased reimbursement from Medicare and Medicaid. (57% of our inpatient business is Medicare patients). What is everyone doing to cut costs? Are you decreasing your inventory at all? Renegotiating contracts? How about use of rare antisera? We stock anti-M, anti-N and anti-Lea to antigen type patients even though we do not give antigen negative blood for these antigens. Should I stop stocking it? Looking for any way possible to meet the mandate.

Thanks for the input.

[David Saikin]

I decided not to pay the exhorbitant price everyone is asking for anti-Lea (and Leb) - haven't seen either in decades; I could do without anti-N too. I do like having anti-M around - don't ask me why. What technology are you using - tubes, gel, capture, automated? How many beds, transfusions? Trauma center/open hearts/? Some more info on your operation would be helpful.

[kirkaw]

David,

We're licensed for about 375 beds. We have a provue that we use for type and screens and gel crossmatches. We transfuse about 800 units of red cells/month. We also have a heart program, usually 1 or 2 cases per day, although we did 15 cases in a week 2 weeks ago. Unfortunately, we do not have an active transfusion committee. Hope that helps.

Thanks for the input.

[Malcolm Needs ☆]

I agree wholeheartedly with David.

Anti-Lea, anti-Leb and anti-N in a patient are rarely clinically significant (anti-Leb never), whilst anti-M can be if it reacts at strictly 37oC.

In the case of anti-Lea, any reaction is usually self-limiting, because of the Le(a) substance (which is Type 1, and so adsorbed onto the red cell surface, rather than being an integral part of the membrane) in the plasma of the unit being transfused, will inhibit the anti-Lea in the recipients circulation. Mind you, you have to be absolutely certain that the specificity really is anti-Lea in such circumstances!

Unfortunately, the technology you are using is particularly good at detecting Lewis antibodies and anti-M (because 1] the reactants are added at RT, rather than at 37oC, and 2] the gel is slightly acidic, which anti-M loves!).

Edited March 25, 2013 by Malcolm Needs

[Dansket]

Is your department a separate cost center? Are you being held directly responsible or is the Clinical Laboratory Administrator?

Look at the numbers of units returned to the donor center as a percentage of units received. If it is high, you need to re-think your inventory control as each unit returned is a unit you spent time/money confirming.

How do you confirm your donor units? Can your testing requirements be reduced?

Are you doing IgG crossmatches on all patients or just those with positive screen or history of clinically significant antibody? Electronic?

Are you doing a 3-cell screen versus 2-cell antibody screen?

Does your hospital host mobile blood donations? We negotiated a price reduction on rbc units if we met mutually agreed donation goals.

Do you have more than one blood supplier?

Have you optimized your reagent red cell shipments with your usage? Do you monitor them monthly?

Have you optimized your gel card shipments with your usage?

Do you make your own ProVue controls or purchase them?

Do you use both tube and gel methodologies? If so, you must purchase proficiency surveys accordingly. I purchase JAT only and no longer do J.

Just some thoughts, hope they help.

Dan

[jmm8427]

We've started incorporating Quotient and BioRad products which are significantly cheaper and they work as well as Ortho and Immucor. Also monitor your reagent supply (like ABO/Rh) and make sure you are not expiring a lot and you are ordering what you can use. Making your own controls can help a lot, too!

[Mabel Adams]

Personnel is always a big cost. Limit overtime and otherwise get more efficient. If someone leaves or retires evaluate staffing.

[David Saikin]

Do you "waste" a lot of plasma? If so, have your Med Director address this issue with the Med Staff. We only thaw what there are orders to infuse. I also try not to thaw more than 2 at a time (when they order 4 or 5). Look at plt wastage also. Big bucks there.

[kirkaw]

These are great questions and suggestions everyone, Thanks!

To answer Dansket's questions, I do have my own cost center, and since my blood budget is so large, it sticks out like a sore thumb.

We use a 2-cell screen, do not do IgG crossmatches on everyone and do employ electronic crossmatches. Out biggest waste is platelets; we outdate about 7/month. It's something I've been working on for months! Since we don't have a transfusion committee, I'm using this as leaverage to get one started to address just these types of issues.

I feel that my predecessor addressed many of the other cost savings, like consolidated shipments, negotiating better pricing through a 3-year contract with our (single) blood supplier and we do make our own Provue controls. I just got a good deal on some Immucor reagents but have not investigated Quotient or BioRad. Thanks for that tip. I know that we have a contract with Ortho, so I need to find out how restrictive that is.

[tbostock]

Sounds like a lot has been done already. Yes, I would get rid of some antisera that you keep in-house. Since you transfuse a lot of blood, I don't really think your platelet wastage is that bad. Going after red cell usage is where you have the potential to save a lot of money. Do you have any kind of Blood Management Program? Do physicians have to select criteria when ordering blood products?

[David Saikin]

7 plt/month being wasted amounts to about 60 grand/year (at my prices - if they are apheresis products) . . . depends on your overall budget for components and comfort level. If the blood center is close you could just order when you needed them. I inspected a place a few years ago with a huge amoung of plt wastage. Their blood center was a half mile away. They now save a considerable amount of $$$.

[Eagle Eye]

7/month that is high...We are level one trauma center and our benchmark is 2 aphereis platelets/month. We try to reach our goal most of the time...

[John C. Staley]

Recognize that you will reach a point where the phrase; "the cost of doing business" will have significant meaning to you. One of my biggest black holes for blood waste was NICU. We had done everything possible to reduce the waste but we finally reached a point where administration and physicians had to come together and understand that if they wanted an NICU and the service they expected then they would have to accept a certain level of waste. That does not mean we stopped looking but there comes a time when you just have to say, "this is all we can do and maintain the level of care/service you desire".

Administrations love to say that everyone must cutback but there will be no loss in service, quality, patient care or any thing else. There comes a point this is not possible but they will never admit that. Good luck in your quest and may god have mercy on our souls!

:lonely: If you can't tell I just got back from 10 days of sick leave and not feeling terribly chipper at the moment.

[PAWHITTECAR]

I just changed my ABO typing reagents from Immucor to Bio-Rad and ended up with > 16K a year savings. I had received mixed reports about the Bio-Rad reagents so I did a very extensive correlation and everything worked great.

[PAWHITTECAR]

We are also about 30 minutes from our blood supplier and I have been very closely monitoring platelet orders. Many times I have called the doctor that wanted to have plts "on hold" for surgery on a patient with 100 plt count and explained that if we get them in and they are not used then they are wasted. I have (for the most part) been able to convince them to wait and order them if they need them. I do have some really good docs that are willing to listen to reason especially coming from me rather than another physician..

[carolyn swickard]

If you haven't started a blood management program (lower transfusion triggers, etc), try to push for that too while trying to get a transfusion committee started - or just make it a blood/blood products management committee to begin with! The money saved with true blood management practices completely dwarfs any reagent savings you can even think about and(!) puts some of the onus for cost cutting back on administration and the Drs - where it truly belongs. Good luck and let us know how you do - the rest of us will probably need the help soon too!

[Likewine99]

You are looking at all the right things and I agree with Mabel, if someone leaves/retires think about do you really need a whole FTE to replace them, if at all. With a Provue can you cross train "non-bloodbankers"?   Watch those early and late clock in and outs.  One 2 week pay period our lab had over 8 hours logged just from this.

 

Without a trans committee it will be difficult to lower your blood product costs.  My organization had an excellent blood conservation committee and the right players were on the team.  It was led by a physician champion and we had support from our blood supplier.

 

John is right about administrators "mandating" a certain percentage of cutbacks.  Blood Bank always gets hit b/c our blood product line item is so large.  We totally eliminated autologous units in our inventory, wasted 60% of them anyway.  It took the Orthos a while to get used to it but once they bought in that helped a lot.

 

Best of luck to you and like the others said, keep us posted.  

[BrianD]

If you haven't started a blood management program (lower transfusion triggers, etc), try to push for that too while trying to get a transfusion committee started - or just make it a blood/blood products management committee to begin with! The money saved with true blood management practices completely dwarfs any reagent savings you can even think about and(!) puts some of the onus for cost cutting back on administration and the Drs - where it truly belongs. Good luck and let us know how you do - the rest of us will probably need the help soon too!

 

this is very good advice.  especially, try to get the physicians' C/T ratios included in their "scorecard" or however they are evaluated from the administration's point of view.  we have been able to help several physician's improve and saved by the reduction is unnecessary testing and tech time.

[JoyG]

We've started incorporating Quotient and BioRad products which are significantly cheaper and they work as well as Ortho and Immucor. Also monitor your reagent supply (like ABO/Rh) and make sure you are not expiring a lot and you are ordering what you can use. Making your own controls can help a lot, too!

We done the same this as jmm8427. We have also renegotiated contracts.

[Liz0316]

If I were you - stop buying the Lewis antisera, dump the N. I do keep M because of the L&D patients. A close large academic hospital is near by and the patients are "shared." Implement the new AABB transfusion guidelines. I'm 2 hours from the blood center, so wasting 7 platelets a month is ok for me. I haven't changed any reagents yet, but since we do dispense albumin from the BB (ick), I have a new vendor with better prices.

Good luck. Tell administration what I tell them, "we may be expensive, but we are cute."...maybe it will work for you!

[amym1586]

I'm cutting out Lewis antisera.

 

The Quotient rep just left and I'm feeling mighty tempted!