Do Hospitals need what they request

BSMS Roadshow - 2018

Clive Hyam - BSMS Data Analyst

Overview of Presentation

• Do Hospitals NEED what they request

• Is there an O D Neg problem ?

• Supply chain Data and Information

• Where we are now

• How can this be improved ?

O D Neg RBC’s data v Information

• Data are simply facts. e.g. todays O D Neg stock is 8 units.

• Information is data that have a meaning within a context. e.g. todays O D Neg stock is 8 units, my Ideal stock is 8 units and my minimum stock level is 3 units.

• Tabular data and VANESA graphs are information, they have a context so allows some form of inference on performance.

• Data derived information gives you the tools to identify and understand a problem allowing a suitable course of action to be developed to resolve it.

Current situation – O D Neg RBC’s Issues

O Neg Issues have fallen 3.6% BUT

overall issues have fallen 5.9%

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NHSBT Served hospitals O D Neg Requests Issues Wastage and Centre Wastage

O D Neg Requests O D Neg Gross Issues O D Neg Hospital Wastage O D Neg Centre Wastage

O D Neg RBC’s - Hospital Wastage

• RBC wastage data for 2017/18 Q3 (Oct to Dec 2017) from BSMS RTC report

• Over 29% of all A,B, & O wastage was O D Neg; 1 in 4 units

• TIMEX over 33% of the total A,B & O wastage was O D Neg; 1 in 3 units

Note, this table excludes any group AB RBC

wastage

Initial Summary

• O D Neg issues higher than requests, by around 1,500 units a month.o Substitutions for Rₒ requests

o Issuing of phenotyped units for patients

• O D Neg wasted in hospitals more than any other group.oOver 1 in 4 units overall

oOver 1 in 3 units for TIMEX

• O D Neg issues falling BUT much slower than issues overalloO D Neg Issues fell by 3.6%

oOverall Issues fell by 5.9%

Specification of O Neg units

• Bit of blood group serology

• CDE/cde (Fisher notation)

• O D Neg simply means an absence of the D antigen, so a proportion of O D Neg donors will be C and / or E positive

r’ Cde

r” cdE

ry CdE

As well as r cde

Other blood group systems

• What is the next most important blood group system after ABO and Rhesus?

• Kell

• Kell antigens are the third most potent, after those of the ABO and Rh blood groups, at triggering an immune reaction. The Kell blood group system was discovered in 1946.

• What % of the population are K positive?

• Around 10% of the population are K positive

• Why is this important?

• Higher specification O D Neg units

Not all O D Neg units are equal

• So what is the specification for an Emergency unit?

• BSH Guideline

Dependant on the age and sex of the recipient plus the clinical speciality.

One possible outcome

Use of O D Pos in Trauma• Theoretical 100 cases

• Population Rh D Negative = 17.07% (BSMS report 1.4 million groups analysed, 2009)

• So 17 trauma cases should be Rh D Neg

• Percentage of females under 55 = 34% (but 8.5% under 14) (2016 Data)

• Approximately 6 of your 100 trauma patients will be female under 55 years old

• That assumes that females are as likely to be trauma patients as males, LAS report Oct 2017 over 75% of trauma patients were male

• So of your 100 trauma cases you can expect 2 to be a female less than 55 years old

O D Neg to non O D Neg Patients

• How many of your hospitals routinely transfuse O D Neg to non O D Neg patients to prevent time expiry.

• Data from BSMS O D Neg audit Feb 2016.

15% transfused to avoid time-expiry

72%

15%

8%

4%1%

8% due to unavailability of correct ABO group (either special requirements or ABO) OR due to patients group unknown

5% wasted (time-expiry and OTCOL)

Approx.72% of the units used appropriately Group O- PATIENT, ABO mismatch transplant or Solid Organ Transplant mismatch

O D Neg to non O D Neg Patients• The results from the BSMS Feb 2016 survey showed that 15% of

O D Neg units were transfused to avoid TIMEX.

• How many units do you think that equated to

• 1,000

• Between 1,000 and 5,000

• Between 5,000 and 7,500

• More than 7,500

• Based on last years issue figures it was 27,815, that is 15% of the 185,427 O D Neg issues for 2017 (Jan to Dec).

O D Neg enigma

• D Negative frequency 17%

• Large number of Emergency units are O D Neg (majority cde/cde) K Neg.

• Reason, so as not to stimulate anti-D production in women of child bearing age.

• c Negative frequency 18%

• O D Neg units (particularly emergency units nearing the end of their lifespan) are transfused to non O D Neg patients.

• Do hospitals limit these transfusions to male patients only or have an SOP.

• Does transfusion to non O D Neg recipient’s elicit formation of anti c

O D Neg Hospital Requesting – The Reality• Request and Issue data from February 2018

• Nationally what % of O D Neg requests (Non LVT) are for Higher Spec units

• We will define a higher spec unit as O cde/cde K Negative

• Was it 20%

• 30%

• 40%

• 50%

• None of the above

• Actually it was 62.2% (7,155 out of a total of 11,495)

O D Neg Hospital Requesting – The Reality (February 2018)

•But that is an over simplification

•There were also 1,138 requests for LVT’s

•Plus 1,500 units substituted, as previously discussed

•Plus 103 units X-Matched at NHSBT

•So 9,896 out of 14,032 (70.5%)

•70.5% of all O D Neg issues required Higher Spec units.

Hospital Higher Spec Requesting - Effects

• 10% of O D Neg Donors will be K positive

• Approx 1.7% of O D Neg Donors will pocess either the C or E antigen

• So approx 11.7% of donors do not meet O cde/cde K Neg

• BUT 70% of issues are of O cde/cde K negative units

• So the remaining 30% will contain proportionally more C+, E+, K+ units

• The initial 11.7% not meeting O cde/cde K Neg becomes 39% of the remaining units held in stock at NHSBT.

• Therefore, Approx 4 out of every 10 units remaining will be either K + or C + or E +

Summary

• The specification of emergency group O red cells held in hospitals should reflect the age, sex, and clinical speciality likely to use the emergency supply, i.e. follow and adhere to BSH guidance.

• Hospital labs should be able to provide safe and timely blood for patients in emergencies without compromising overall blood stocks.

• Revisit recommendations for emergency use of O D Neg and make amendments.

Using VANESA to peer review your stockholding

Hospital daily stock equates to just over 4 days worth of O Neg

Cluster daily stock equates to just nearly 7 days worth of O Neg

Green SD bars ± 1 SD around cluster average, covers 67%

of possible entries

VANESA peer review of Wastage 1

Same hospital as used for the peer

review of ISI

VANESA peer review of Wastage 2

VANESA peer review Wastage 3

Same graph as previous slide but with MISC and

FF wastage removed.

O D Neg Wastage – Financial Realities• Cost of RBC unit around £124

• Worst Green

• ABO 48 units = £5,952 per quarter

• O D Neg 10 units = £1,240 per quarter

• Middle Amber

• ABO 82 units = £10,168 per quarter

• O D Neg 26 units = £3,224 per quarter

• Best Red

• ABO 115 units = £14,260 per quarter

• O D Neg 41 units = £5,084 per quarter

National Picture

• If we take the O D Neg wastage figures from the quarterly report shown in slide 6

• Then £124.46 x 2108 units (Total Wasted) = £262,362 for 1 Quarter

• Multiply by 4 gives a cost of £1,049,448 per year

• Looking just at TIMEX £124.46 x 1388 = £172,750 for 1 Quarter

• Multiply by 4 give a cost of approx £691,000 per year

• Remember TIMEX is linked to stock holding and ISI !!!!!!!!!

Stock Summary•Know how much O D Neg you actually use (Nominal

Stock)

•Know how your stock levels fluctuate in any month (min and max levels)

•Know how long that stock will last (days worth of Stock, ISI)

•Count those emergency O D Neg’s as stock that you can get your hands on (i.e. in the Lab, or close to the lab)

Actions• Audit and peer review your stock levels in the light of falling

demand.

• Audit use – is the use of emergency O D Neg blood justifiable and appropriate in each instance that it is used.

• Ensure your risk analysis is appropriate and realistic.

• Actively manage emergency O D Neg units rotate them weekly at least.

• Look into whether a stock share across a network or trust may be beneficial, moving older units to a larger site where they are more likely to be used appropriately.

Thank you for your attention

Any questions