Blood component therapy supplanted whole blood transfusion in industrialized countries in the middle of the twentieth century and remains the standard of care for the majority of patients receiving a transfusion. Ensuring that these products are of high quality and that they deliver their intended benefits to patients throughout their shelf-life is a complex task. Wastage of all blood components is an important issue for hospitals worldwide. Blood wastage has been recorded for a number of reasons: time expiry (the expiry date on the unit has passed), broken seal, broken bag, broken cold chain, clotted blood, blood returned after 30 min [1]. The objectives of this study were to find out the rate and causes of wastage of blood and blood products (packed red cells, plasma, platelets, and cryoprecipitate), to take interventions and assess the blood component wastage post intervention.

Experimental Section

The study was carried out, after taking necessary institutional approval. Retrospective data was analyzed for the period of 34 months from Jan2018 to October 2020. Indicators monitored by our quality dept routinely are percentage (%) of blood component usage, percentage (%) of transfusion reactions, percentage (%) of wastage of blood and blood components, and average turnaround time for issue of blood and blood components.

In our institute, blood donors, fulfilling World Health Organization criteria for donor selection, are selected for blood donation, after medical history, brief clinical examination by the medical officer. The donors are either voluntary or replacement. Replacement donors are either relatives or friends of the patients. The present study includes blood unit discarded for different reasons which include transfusion transmitted infection (TTI) seroreactivity, expired component, less quantity (LQ), leakage/ breakage, clotted bag, unit sent for quality checks (QC), and DCT positive. Blood components such as red blood cells (RBCs), platelet concentrate (PLT), fresh frozen plasma (FFP), cryoprecipitate (CRYO), normal human plasma (cryo-poor plasma [CPP]), and single donor platelet (SDP) were prepared regularly from 450/350 ml blood bag under all aseptic condition as advised by Food and Drug Administration guideline and NABH 3rd edition, International Organization for Standardization (ISO) 9001: 2015, National AIDS Control Society (NACO) as demand and workforce available in blood bank.

We also compiled the data collected for blood component wastage. We used Fishbone analysis for root cause analysis and key driver diagrams, illustrating factors contributing use and decrease blood component wastage. The data collection form includes details like type of component, blood group, reasons for discard, date of discard & date of autoclave.

In this study The Plan-Do-Check-Act model was used throughout the Quality Improvement process to reduce wastage. In the pre interventional phase mainly in 2018 all the bottlenecks was observed at various level not only in blood bank but also in OT, ICU, staff awareness and from patient perspective. Then from 2019 to 2020 active interventions were taken. Limited number of platelet preparation was insisted based on the everyday requirement to avoid excess component wastage. It was ensured that consumption of prepared platelets must be optimum before expiry, for that purpose staff was sensitized accordingly to place request judiciously. Data calculation methodology was started on monthly basis to check the accuracy of data. Data calculation methodology was followed as recommend by NABH Blood Bank standards i.e [Number of blood and blood components units wasted in a month/ Number of blood and blood components units issued from the blood bank in a month  x100]. This includes blood products found unfit for use, importantly it also captures the number of blood and blood components used and not just the number of transfusions carried out. At times more than one blood bag or components may have been given in a single transfusion it was also being considered.]. Nurses, technicians training and education was rigorously provided by Quality Team and Blood Bank Incharge during the intervention period. The data were analyzed in MS Excel, SPSS 26.0 and graph pad prism 8.0. 

Blood bags included during this period, were screened for transfusion transmissible infections (TTIs). The blood bags, which were seroreactive (Seropositive), were discarded. The blood bags, which were expired because of non-utilization, were discarded. Less amount of blood collected from the donors because of any reasons, including donor’s reactions was discarded. Blood showing any changes of either hemolysis or turbidity were also discarded.

In December 2018, a multidisciplinary team was created to reduce hospital blood component wastage. This team included representatives from the five departments involved predominantly in blood transfusion activities: emergency department, operation theatre, anesthesiology, intensive care unit, and blood bank. The team formed a blood utilization committee, which began holding weekly meetings to discuss all blood bag issue, transport, storage, activations that occurred during the previous week with a specific focus on blood component usage and wastage. Three primary quality improvement interventions resulted from these meetings. 

First, a communication channel between all five departments was implemented by establishing quarterly meetings to discuss potential improvement areas. In addition, reciprocal agreements found the need for closed-loop communications, especially during blood request activations and deactivations. To reduce wastage due to delayed communication between the clinical and blood bank teams, the personnel were asked to start giving verbal confirmation feedback of verbal message reception to avoid misunderstandings. 

Second, the blood bank created specific digital timelines for every blood bag activation detailing when and how many units of each blood component were prepared, issued, transfused, returned, and discarded. These timelines were made available to all involved personnel. 

Third and finally, all concerned personnel received additional education on proper blood component preparation, issue, transport, storage, discard. During departmental meetings, these training sessions occurred and emphasized the concepts of blood component handling and cold chain preservation. These last two interventions were designed to increase awareness of blood component wastage among staff.

The committee also brought in policy changes that included: A properly conducted donor interview, notification of permanently deferred donors, frequent audits, improving communication between departments through hospital information system, properly implementation of blood transfusion policies helped in discarding less number of blood bags due to expiry.

Among 11,432 total donors in the blood bank, 98.95% were male. 1979 were voluntary donors, and 9453 were replacement donors.

The figure 1 shows the fishbone diagram for root cause analysis of blood component wastage. Primary underlying causes included lack of awareness on blood component handling, lack of awareness on placing appropriate request, improper assessment of proper volume requirement in OT, leakage, expiry and erroneous stock calculation.

Figure 1: Ishikawa Diagram for Root Cause Analysis

Figure 2: Key Driver Diagram Illustrating Factors Contributing to Use & Decreased Wastage of Blood Components.

This image has evolved with the project; interventions that were implemented during this study were previously not initiated or established and are now established, supported and effective. Four key reasons for high rate of blood component wastage, referred to as key drivers, are staff knowledge & education; ICU & OT related factors where blood unit requirement is high and lastly blood bank factors. The key driver breaks down further into primary and secondary drivers. Predominant reasons identified were nurses’ communication with physician, handover communication, placing improper request, component expiry mainly platelet and its interrelationship was also projected in this diagram. 

Out of total 11,432 blood bags which were collected from donors during the study period, 97 of whole blood bags were discarded. Amongst whole blood bags discarded, seropositivity for TTIs were the most common cause (60.83%) followed by expiry of date due to non-utilization (32.98%), other causes include less volume (4.12%), yellowish discoloration of plasma, signs of hemolysis noted in blood bags, issued blood bags to the patients not being used. A total of 59 seropositive bags were discarded of which 38.98% were hepatitis B, 15% HCV,11% HIV, and 10% VDRL positive. Table 1 shows the analysis of discarded units of blood components against total prepared components.

Table 1 shows analysis of discarded units against total prepared components.

Table 1: Analysis of Discarded Units of Blood Components against Total Prepared Components

In our study, the discard rate was highest for platelets (32.94%). Other components’ discard rate was packed red cells (2.15%), fresh frozen plasma (1.9%). Out total discard rate for all blood products was 7.6%.

The major reasons for blood wastage include expired blood unit, leakage, broken cold chain, returned after 30 min, clotted blood and the least being component with red cells, discrepancy in handover process, lack of communication & documentation. On reviewing with blood bank staff, it was noted that the major reason for wastage of different components might be due to how it was handled after collection from the blood bank and from nurses’ point of view it was identified that placing appropriate request and prioritization of component to be infused was a major concern. In post interventional phase 2020 it was recommended that there is always larger shortage of blood and a need of awareness is important among blood bank staffs, nurses and physicians on handling blood products.

Figure 3 shows the monthly wastage of blood and components wastage, pre and post intervention.

Figure 3: Percentage Monthly Wastage of Blood Products a. Pre Intervention & b. Post Intervention Phase

The mean percentage of wastage of blood products are 11.62, 6.67 and 3.58 of years 2018, 2019 and 2020 respectively. Ordinary one-way anova test was performed and the p-value obtained was <0.0001, which shows the percentage of wastage blood product has gradually and significantly decreased in the year 2019 and 2020 compared to 2018 and it is statistically significant. After successful intervention of the above-mentioned methodologies discard rate has been reduced from 19.5% to 2.75% gradually within span of two years.

According to National Blood Transfusion Council (NBTC) norms for discard of blood and blood components, for upper middle income group country like India, median percentage of total donation discarded should be 6.7%, median parentage discards due to seroreactivity 3.9% and median percentage of discard due to outdate/expiry 4.7%. According NACO Blood Bank QMS Training Manual, seroreactivity bench mark limits for various TTI are defined as follows HIV 0.28%, HBV 2-3%, HCV 0.4-2%, Syphilis 0.11% and malaria 0.03% According to the WHO status report, in upper middle income group countries, total blood donation discards the median range 6.7% (0.5–21.7), total reactivity rate 3.9 (0.01–16.0), and donation discarded due to outdates/expiry is 4.7% (0.04–25.8) [2]

Wastage of blood components will continue to be an issue at all hospitals therefore inexpensive and easy interventions such as educational outreach, print and digital messaging, and improved transportation and component identification modalities can have a prompt and dramatic impact on reducing blood wastage with regard to both cost and resource savings . Awareness is important among laboratory staffs, nurses and physicians on handling blood products.

Criteria which determined when blood or blood component should be discarded are broken bag, broken seal, broken cold seal, expiration and contamination. Major cause of blood wastage in this study was due to expiration followed by broken seals, broken cold chain, broken bag and the least being component with red cells. In a study in Iran, [3] wastes were in the form of packed red cells (59.4%), plasma (22%), platelets (16%), and cryoprecipitate (2.4%) and 77.9% packed red cell units were wasted due to the expiration of their usability period . Pack cell wastage in hospitals is reported to range from 1.93% to 30.7% [3]. According to another author, wastage rates were as follows: Cryoprecipitate (7%-33%)., RBCs (0%-9%),  plasma (0%-7%), and PLTs (0%-7%) [4]. The United Kingdom has a wastage rate ranging from 0.26% to 6.7%, while the United States has a 4.4% rate. Iran 9.8%, where Temperature of storage & transport of blood bags is one of the main factors that can greatly affect blood quality and packed red cells are one of the commonest discard [5]

[4] report following discard rate among blood and blood component: whole blood 0.99%, red blood cells 2.28%, FFP 1.88%, PLT 4.66%, CRYO 3.88%, CPP 1.25%, and SDP 0.47%, respectively and major reasons for discard are: seroreactivity of blood donor (1.11%), expiry (0.67%), quality checks (0.29%), clotted bag (0.03%), Direct antiglobulin test (DAT/DCT) positivity (0.00%), and other causes (0.06%).

The prevalence of HIV, HBV, HCV, and VDRL was higher i.e. 0.32, 2.26, 0.23, and 0.45%, respectively, in Kolkata in the year 2002 than 0.35, 1.78, 0.32 and 0%, respectively, in Aurangabad in the year 2007. [6] They discarded 3.58% blood bags, 68.86% of which were positive for different transmissible diseases (TTIs). Among the units discarded, 49.82% were positive for hepatitis B surface antigen (HBs Ag), 10% for human immunodeficiency virus (HIV) and 8.97% for hepatitis C virus (HCV) while no unit was positive for Venereal Disease Research Laboratory. 

In another study in Kuala Lampur, the total number of discarded whole blood units and its components was 8968 (2.3%). Platelet concentrate recorded the highest of discard at 6% (3909) followed by whole blood at 3.7% (647), fresh frozen plasma (FFP) at 2.5% (2839), and cryoprecipitate at 2% (620). The rate of discarded packed red blood cells RBCs, plasma aphaeresis, and PLT aphaeresis was less than 1% at 0.6% (902), 0.6% (37), and 0.29% (14), respectively. RBC contamination of PLT and plasma were the major cause of discard at 40% (3558). Other causes include leakage (26% - 2306), lipemia (25% - 2208), and underweight (4% - 353). [7]

In a study, it was observed that an average 14.61% bags and of the 292 units discarded, 242 units were due to non-utilization. [8]

Our study being a retrospective one, only information’s available in the records was collected for the study. Due to this limitation it was not possible to determine the rate of wastage by in-hospital location. Data were retrospectively collected, potentially resulting in unknown confounders and gaps in data collection. Further prospective studies on outcomes based on larger patient samples will throw more light on this topic. 

The current study recommends the implementation of  policies for supervision and management of blood use and reduction of blood wastes, including monitoring consumers’ access to the supply of products, supervising the quality of new guidelines, investigating the feedback received from hospitals regarding issues related to blood transfusion, inspecting the method of use of blood or its products in hospital wards, controlling the method of shipping from delivery to the hospitals until distribution among wards, and checking the hospital’s stock of blood and plasma in terms of numbers, dates, method of storage, and the time of keeping blood for cross-matching.

Developing the proper culture for the optimum use of blood products is of utmost importance. Our study has shown us that relatively inexpensive interventions have a prompt and dramatic impact on reducing blood wastage with regard to both cost and resource savings. To reduce waste, hospitals should collaborate with blood banks to track the release and return of blood components, facilitate periodic re-training of involved personnel, and ameliorate communications between blood bank and between clinical departments and encourage programs for blood donation.

A number of reasons are responsible for blood wastage including TTIs seroreactivity, leakage, RBCs contamination, LQ, time expiry, hemolysis, or miscellaneous reasons. Over a period of time, BTS has observed significant advancements in various areas including donor management, storage of blood, newer blood components, cross-matching techniques, use of blood components, and distribution. To improve the standards of BTS, comprehensive standards have been formulated to ensure better quality control in collection, storage, testing, and distribution of blood and its components. Stringent donor screening criteria have also been into existence. Process improvement at various steps in BTS can prevent wastage of blood component such as technical expertise advocated in phlebotomy to prevent collection of LQ, expert hand in component separation to prevent RBC contamination during platelet and FFP preparation, precaution while thawing of FFP to prevent leakage/breakage, and increased use of apheresis technique. Continued medical education and more hands on training for technical staff to maintain self-audit, tracking quality indicator of processing, and preparation of the blood components have been advised to minimize the discard rate and ultimately save scarce resource. The transfusion committee should conduct regular audits (prospective audit, concurrent review or retrospective review), in order to achieve utmost efficiency and numerous benefits, in terms of workload, cost, errors, risks of transfusion, reduced wastage of blood components and ultimately increased customer satisfaction.

Source of Support: Nil.

Conflict of Interest: None declared.

Acknowledgements: Authors would like to thank the staffs at the hospital for their cooperation during the study.

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