Platelet inventory management CSTM Education Day Kathryn Webert Medical Director, Utilization Canadian Blood Services September, 2016

Platelet outdates and rates—National Background Platelet outdates and rates—National Last year, 22.6% of all donated platelets expired without being transfused Last year, 22.6% of all donated platelets expired without being transfused Check these numbers…why not the same as the previous graph

Platelet wastage 26,328 platelet doses! Background Platelet wastage Within the Canadian blood system (excluding the province of Quebec), the rate of platelet outdates in the most recent fiscal year was: Apheresis platelet units: 16.7% (1.8% at CBS, 14.9% at hospitals) Whole blood-derived platelet doses: 21.5% (4.2% at CBS, 17.3% at hospitals) Overall, 20.1% of all platelets that were collected were wasted 26,328 platelet doses!

Background Platelet wastage The cost to the healthcare system is high Apheresis platelets: 6674 units X $502/unit = $3,350,340 Pooled platelets: 19645 doses X $197/dose = $3,870,065 Total cost to the healthcare system was over $7.2 million

What have we done about it?

Work done so far Surveys: Hospital CBS distribution sites What have we done about it? Work done so far Surveys: Hospital CBS distribution sites Hospital customer letter (best practices)

Surveys To gain insights: What have we done about it? Surveys To gain insights: Identification of factors that may contribute to the outdating of platelet units within the blood system Share best practices that have been implemented to avoid or decrease platelet discards

What have we done about it? A System View Management of platelet inventory is a complicated topic, but working together within the blood system, we may be able to identify ways to decrease the number of platelet units that are collected but are ultimately wasted.

Hospitals and Canadian Blood Services What have we done about it? Surveys Hospitals and Canadian Blood Services 53 hospitals (top 50 per number of platelet in-date and outdate discards, plus 3 additional hospitals) 9 distribution sites (Vancouver, Calgary, Edmonton, Regina, Winnipeg, Brampton, Ottawa, Dartmouth, St. John’s) Two distinct surveys with 100% participation and response rate

Hospital survey: results What have we done about it? Surveys Hospital survey: results Hospitals were extremely helpful in their responses provided to CBS. Many things were learned We are still looking at responses Here is a preliminary look at some of the interesting responses…

14. What are your impressions of reasons why platelets outdate at your hospital? Demand Distance from CBS Shelf life ‘Just in case’ inventory Clinical policy /Order Unpredictable Distance and time for delivery Short Oncology No policy to give ABO incompatible without MD approval Routinely get platelets that are 3-4 days old MTP requirements No policy to give Rh Pos and automatically issue WinRhO with unit Taking short-dated platelets from CBS MD requests platelets be on hand for procedure Order for platelets canceled or procedure cancelled, patient doesn’t require platelets Standard daily inventory level Redistribution not an option Emergency stock Poor transportation routes or lack of funding for redistribution Geographic trauma centre Contingency plan to support potential clinical procedures

15. Please describe any “best practices” to avoid or decrease the frequency of platelet outdates that you have implemented or that could be implemented. Blood Groups Redistribution Standing Order / Inventory Review Clinical Give oldest first over ABO compatible Share inventory with other hospitals Implement a min/max inventory Constant follow-up with MDs/nursing units to review daily HLA matched requirements/utilization Stock only O and A and give to all patients Canvas other hospitals for product before ordering from CBS Abandoned standing order of platelets to decrease expiry rate; order as required to keep a minimal stock Keep a roster of all SCT patients. Platelet counts reviewed daily to assess current and future needs. MLT able to release and reassign platelets according to patient needs. Use O with titre less then 1:100 Use Provincial Platelet Web Application Routinely review data and revise standing orders Review patient platelet counts (to predict need) Group compatible platelets are issued and RHIG is given to Rh Neg who receive Rh Pos platelets Adjust inventory based on utilization trend Dashboard used to predict patient demand Audit utilization by patient group Increase irradiated stock Require MD to order transfusion before requesting platelet product from CBS Educate and reinforce with staff Implement CMV-safe policy for all patients except neonates Attend cardiac rounds to emphasize the need for better communication between surgeon, anesthetists and TM Lab

16. Is there anything that Canadian Blood Services or the Provincial Blood Offices (if your province has one) could do to help to decrease the frequency of platelet outdates? Shelf Life Transportation/ Redistribution Communication / Support Collection/ Production Extend >5 days Fund improvements for routes Greater feedback to hospitals on expected production numbers Evenly spread out collection (address outdates at first of week) Release platelets to hospitals sooner Increase routine delivery options (weigh against cost of outdating) Use better inventory management tools Produce more group AB platelets Faster response time for stat orders Hold consensus meeting (CBS & hospitals) to deep dive issue Redistribute platelets using CBS drivers Locate distribution site closer to hospitals BPCO could expand use of platelet inventory web app.

What have we done about it? Hospital customer letter: Platelet utilization and inventory management best practices

https://www.blood.ca/en/hospital/customer-letters

Ongoing and future initiatives

Ongoing and Future initiatives Still much work to do: Working groups with CBS Medical and Supply Chain to look at Areas for improvement highlighted within customer survey Best practices identified within CBS sites Identification of customer best practices, helping with dissemination Engagement of hospital/PBCO colleagues to develop novel solutions

Ongoing and future initiatives 7 day platelets

Proposal: Buffy coat platelets Ongoing and future initiatives: 7 day platelets Proposal: Buffy coat platelets Delay sampling to ≥ 36 hours post-collection, with a ≥ 6 hour post-inoculation hold net gain: 30 hours Increase sampling volume to 20 ml Inoculate 1 aerobic and 1 anaerobic bottle Slide from Dr. Mindy Goldman

Proposal: Apheresis platelets Ongoing and future initiatives: 7 day platelets Proposal: Apheresis platelets Delay sampling to ≥ 36 hours post-collection, with a ≥ 6 hour post-inoculation hold For a single apheresis collection, increase sampling volume to 20 ml, and inoculate 1 aerobic and 1 anaerobic bottle For a double apheresis collection, increase sampling volume to 40 ml, and inoculate 3 aerobic and 1 anaerobic bottle This would enhance the sensitivity of detection for double apheresis collections, but reduce the probability of machine false positives which are most common with anaerobic bottle Slide from Dr. Mindy Goldman

CSB proposal More to come on this!!! Ongoing and future initiatives: 7 day platelets CSB proposal This is in the proposal stage only Requires submission to Health Canada If approved, the project targets to go live by Spring or Summer 2017 More to come on this!!!