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 Table of Contents  
SHORT ARTICLE
Year : 2018  |  Volume : 3  |  Issue : 2  |  Page : 132-135

Salvage of red blood cell units using remote electronic blood issue system in operation theater: A pilot study from India


1 Department of Transfusion Medicine, Medanta-The Medicity, Gurgaon, Haryana, India
2 Department of Transfusion Medicine, IMS and Sum Hospital, Bhuvneshwar, Odisha, India
3 Department of Liver Transplant Anesthesia, Medanta-The Medicity, Gurgaon, Haryana, India
4 Department of Liver Transplant and Regenerative Medicine, Medanta-The Medicity, Gurgaon, Haryana, India

Date of Web Publication24-Oct-2018

Correspondence Address:
Dr. Aseem K Tiwari
Department of Transfusion Medicine, Liver Transplant and Regenerative Medicine Medanta-The Medicity, Gurgaon, Haryana
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/GJTM.GJTM_38_18

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  Abstract 


Introduction: Anesthetists procure pre-defined number of blood units in advance for surgical patients for ‘just-in-case’ scenarios. This often results in non-usage and discarding of blood units. Blood bank discards blood units returned from operation theatre due to disruption of cold chain. In an effort to reduce this wastage an intervention from transfusion medicine team was undertaken in collaboration with liver transplant team with help of an electronically controlled remote inventory and bedside transfusion management system called BloodTrack Courier. Effectiveness of BloodTrack® Courier in tracing and reducing red cell unit wastage was studied over a four-month period and compared with four-month historical control. Materials and Method: intervention was limited to red cell units issued in elective live-donor liver transplant cases through BloodTrack (Haemonetics Corporation, USA). Controlled access linked to hospital identity cards was provided to Transfusion Medicine Specialists and Liver Transplant anesthetists with different access levels. Pre-allocated RBC units were kept at OT refrigerator for a period of 24-36 hours after which unused units were retrieved by BTS and re-inventoried. Results: Transfusion of RBC units in 60 liver transplant recipients donor before installation was compared with similar 86 liver transplant recipient-donor after installation of BloodTrack. Mean number of RBC units transfused in recipient-donor decreased from 6.2 and 1.0 unit before installation to 5.9 and 0.76 units after installation, respectively. RBC units discarded due to breakage of cold-chain reduced to zero and RBC units successfully returned to blood bank increased 7.6 times. Conclusion: Blood inventory management and remote issue function of Blood Track was very effective in saving RBC units during four-month study period.

Keywords: BloodTrack, inventory management, liver transplant, red blood cell salvage


How to cite this article:
Tiwari AK, Aggarwal G, Acharya DP, Arora D, Bhardwaj G, Setya D, Vohra V, Soin AS. Salvage of red blood cell units using remote electronic blood issue system in operation theater: A pilot study from India. Glob J Transfus Med 2018;3:132-5

How to cite this URL:
Tiwari AK, Aggarwal G, Acharya DP, Arora D, Bhardwaj G, Setya D, Vohra V, Soin AS. Salvage of red blood cell units using remote electronic blood issue system in operation theater: A pilot study from India. Glob J Transfus Med [serial online] 2018 [cited 2018 Dec 16];3:132-5. Available from: http://www.gjtmonline.com/text.asp?2018/3/2/132/243929




  Introduction Top


Blood transfusion services (BTS) is responsible for providing right blood component to the right patient at the right time under right conditions.[1] A typical transfusion process in a hospital includes pretransfusion compatibility testing by blood bank followed by the transportation of red blood cell (RBC) unit, usually through a human courier; to patient bedside for transfusion.[2] However, as soon as any blood unit leaves the blood bank premises, blood bank has limited control over cold-chain maintenance and traceability.[3] The authors' center is primarily a surgery-oriented hospital and since blood center is located at a distance from operation theaters, anesthetists procure certain number of blood units in advance for all patients undergoing elective or emergency for “just-in-case” scenarios. This often results in overordering, nonusage of few units, and their discarding. Even after the implementation of minimum surgical blood ordering schedule (MS-BOS), the authors' blood center continued to discard unused blood units returned from operation theater due to the disruption of the cold chain.

In an effort to reduce this preventable wastage, an “intervention” from transfusion medicine team was undertaken in collaboration with the liver transplant team since liver transplantation is a major surgery and requires multiple number of blood components in the recipient,[4] and sometimes, this requirement can be unpredictable. The intervention entailed the transportation of precrossmatched compatible RBC units for storage in temperature-controlled refrigerator just outside the operation theater. This intervention was done with the help of an electronically controlled remote inventory and bedside transfusion management system called BloodTrack Courier. The effectiveness of BloodTrack Courier in tracing and reducing red cell unit wastage was studied over a 4-month period and compared with a 4-month historical control.


  Materials and Methods Top


Settings

This study was conducted by the department of transfusion medicine in coordination with the liver transplant team at a tertiary health center in North India. This was a prospective pilot study conducted over 4-month period (April to July 2016), and the study data were compared with similar transfusion data from previous 4 months (December 2015 to March 2016). The intervention was limited to RBC units issued in elective living-donor liver transplantation (LDLT) cases through the BloodTrack Courier software.

BloodTrack

BloodTrack® Courier software (Haemonetics Corporation, USA) system tracks, monitors, and controls access to blood products outside the blood bank and verifies that the right blood unit is retrieved for the right patient. BloodTrack consisted of three components as follows:

Central server

This was located in the in-house IT department and was responsible for the intranet link between the “manager” software installed on the personal computer desktop at the blood bank and the “courier” kiosk connected to RBC refrigerator (R1) placed outside the liver transplant operation theater complex.

BloodTrack manager

The software was installed on a personal computer desktop at blood bank. The software enabled the transfusion medicine staff to allocate crossmatched compatible RBC units to intended patient. Unique Hospital Identification number, patients', and donor-units' blood group were entered in the software at the time of unit allocation. Allocated RBC units were then physically transferred to a standard 2°C–8°C blood bank refrigerator (R1; Helmer Scientific, Germany) located inside the liver transplant operation theater complex.

BloodTrack Courier

The kiosk was connected to the refrigerator (R1) located inside the liver transplant operation theater complex. Access control was provided to doctors from transfusion medicine team and liver transplant anesthetists through hospital identity cards with different access levels.

Protocol

Blood component requisition form was received at blood bank 1 day before an elective LDLT. Pretransfusion compatibility testing was carried out; compatible RBC units were first allocated through the BloodTrack manager in the blood bank and then physically transferred to the OT refrigerator (R1) using insulated boxes. At any given point of time, one rack in the OT refrigerator contained RBC units for one LDLT only, that is, one liver recipient and one liver donor. Post-LDLT preallocated RBC units were kept on hold at the OT refrigerator for a period of 24–36 h, after which the unused units were retrieved by the BTS and reinventoried [Figure 1]: Study protocol].
Figure 1: Study protocol

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Transportation of red blood cell units from blood center to R1

Labeled compatible blood units for both recipient and donor were transported to the R1 using insulated boxes making sure that cold chain was maintained throughout the transportation.

R1 refrigerator

A standard 2–8°C blood bank refrigerator was placed outside the liver OT complex. Access to R1 was through the kiosk connected to the refrigerator. Electronic access control was through the hospital identification (ID) card (an electronic chip embedded in it) and was password controlled. Access was granted to doctors from transfusion medicine and liver transplant anesthetist team.

Access and retrieval of red blood cell from R1

To retrieve an RBC unit, accessor had to scan the ID card and enter the password. This would open the refrigerator door. RBC unit was selected and then scanned for identification before retrieval. This maintained traceability at all times.

Data analysis and statistics

Data collection involved number of transplant procedures, RBC units stored, transfused, and retrieved from the BloodTrack. The “t-test” was applied to compare the RBC unit's wastage before and after the intervention.

Ethical clearance

The study was approved by the Institutional Ethics Committee, Medanta Institutional Ethics Committee.


  Results Top


Transfusion of RBC units in 60 liver transplant recipient donors before installation was compared with similar 86 liver transplant recipient donors after installation of BloodTrack. Mean number of RBC units transfused in recipient donor decreased from 6.2 and 1.0 units before installation to 5.9 and 0.76 units after installation, respectively. RBC units discarded due to breakage of cold chain reduced from 284 RBC units to zero and RBC units successfully returned to blood bank increased 7.6 times from 80 to 611 RBC units. The comparison in reduction in number of discarded units and number of returned RBC units, both in recipients and donors, in pre- and post-installation period of BloodTrack was statistically significant (P < 0.005). [Table 1] and [Table 2] depict demographic details of recipient donor and RBC units allocated, respectively.
Table 1: Demographic details of recipients and donors

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Table 2: Comparison of red blood cell unit demographics pre- and post-installation on BloodTrack software

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  Discussion Top


Salvaging red blood cell units

Implementation and use of blood inventory management and remote issue software of BloodTrack system was highly successful. As clearly evident by the results, a significant number of RBC units were successfully returned to the blood bank instead of being discarded. The intervention saved around 611 RBC units during the study period. This converts to approximately INR 19.5 lakh or $28.7k (this works out to be INR 58.5 lakhs [$86.2K] per annum). Apart from the financial savings, unnecessary transfusions were possibly prevented (data not provided). The anesthetists tend to overprocure RBC units for “just-in-case” scenarios and would end up transfusing such units.[5] The BloodTrack system prevents such transfusions by providing RBC units “just-in-time” and thus reduces cost (of unnecessary transfusions) and improves patient safety. Number of intraoperative RBC transfusion is an independent risk factor for hepatic artery thrombosis,[6] thus reduction in number of such transfusions also improves patient safety. Reduced number of transfusions also reduces the possible risk of immunological reactions and transfusion-transmitted infections. This is also echoed by Davies et al.[7] in their discussion “significant savings in blood use might realize sufficient cost savings to allow the implementation of electronically controlled blood transfusion procedures in hospitals with the prime aim of improving patient safety.” They used BloodTrack system for storage and retrieval of RBC units.

Transfusion safety

This system of securely tracking and managing RBC inventory (verifies the right blood is removed for the right patient) remotely with real-time information and traceability (Compliant with AABB and the Food and Drug Administration regulations) streamlined from the point of issue to the point of care resulted in safe blood transfusion. Since the primary objective of the present study was salvaging RBC units, only blood inventory management and remote issue function were used. However, the BloodTrack system is also capable of bedside transfusion verification. If and when we install and use BloodTrack system routinely, we also propose to use the patient verification function which would further enhance the transfusion safety.[7] Murphy et al.[8] suggest that “hospitals must improve information technology systems to facilitate better bloodstock management, ensure traceability from donor to recipient.”

Challenges

There were a few challenges during the course of the study: (1) Rh(D) incompatible units could not be issued through the BloodTrack and (2) personnel withdrew RBC units without scanning at point-of-care leading to disparity in electronic and physical RBC counts. The first challenge came in the form of issuing Rh(D)-positive units to Rh(D)-negative patients (liver recipients), as the present hospital information system (HIS) does not have such a provision. Since HIS and BloodTrack® were interfaced, the challenge can be overcome by upgradation of HIS software. The second challenge was detected when the physical count did not match the BloodTrack counts and was resolved by corrective action in the form of issuing the “missing” units through BloodTrack and conducting retraining of personnel involved.

Radio frequency identification for inventory management

Radio frequency identification (RFID) device can also be used for tracking a blood unit from collection to infusion. It uses small chips with an antenna that communicate over short distances with a transponder. They do not require “line-of-sight” and thus have an advantage over the use of barcodes.[8] It appears that the majority of health-care organizations have been hesitant to adopt RFID technology as part of their inventory management operations because of high start-up and maintenance costs, interoperability issues, and data security standards.[9]


  Conclusion Top


Blood inventory management and remote issue functions of BloodTrack are very effective in saving RBC units.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

1.
Letowska M. Patient-specific component requirements: Right blood, right patient, right time, right place. ISBT Sci Ser 2009;4:52-5.  Back to cited text no. 1
    
2.
White J. Pre-transfusion testing. ISBT Sci Ser 2009;4:37-44.  Back to cited text no. 2
    
3.
Pagliaro P, Turdo R, Capuzzo E. Patients' positive identification systems. Blood Transfus 2009;7:313-8.  Back to cited text no. 3
    
4.
Pandey P, Tiwari AK, Sharma J, Srivastava D, Dixit S, Raina V, et al. Perioperative use of allogenic blood components in live-related donor orthotopic liver transplantation: A cross sectional study. Asian J Transfus Sci 2013;7:68-72.  Back to cited text no. 4
[PUBMED]  [Full text]  
5.
Mahar FK, Moiz B, Khurshid M, Chawla T. Implementation of maximum surgical blood ordering schedule and an improvement in transfusion practices of surgeons subsequent to intervention. Indian J Hematol Blood Transfus 2013;29:129-33.  Back to cited text no. 5
    
6.
Yang Y, Zhao JC, Yan LN, Ma YK, Huang B, Yuan D, et al. Risk factors associated with early and late HAT after adult liver transplantation. World J Gastroenterol 2014;20:10545-52.  Back to cited text no. 6
    
7.
Davies A, Staves J, Kay J, Casbard A, Murphy MF. End-to-end electronic control of the hospital transfusion process to increase the safety of blood transfusion: Strengths and weaknesses. Transfusion 2006;46:352-64.  Back to cited text no. 7
    
8.
Murphy MF, Stanworth SJ, Yazer M. Transfusion practice and safety: Current status and possibilities for improvement. Vox Sang 2011;100:46-59.  Back to cited text no. 8
    
9.
Coustasse A, Cunningham B, Deslich S, Willson E, Meadows P. Benefits and barriers of implementation and utilization of radio-frequency identification (RFID) systems in transfusion medicine. Perspect Health Inf Manag 2015;12:1d.  Back to cited text no. 9
    


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    Tables

  [Table 1], [Table 2]



 

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