Implications of CBS New Shipping Containers September 2016

Current State Canadian Blood Services (CBS) currently uses containers known as J82s for deliveries CBS does not directly ship to all sites in BC Containers are used for 3 streams of activities: Provincial redistribution Intra-health authority distribution Transfer of blood with critically ill patients to higher acuity care CBS plans to implement new shipping containers (Dec 2016/Jan 2017) which will not be available for any redistribution or distribution activities* *CBS presentation July 20, 2016

Provincial Redistribution 2015/16 – redistributed ~11,000 RBC units From 56 shipping sites to 8 receiver sites Average 5 RBC units per shipment ~2200 shipments/year 2015/16 RBC Expiry Rate – 1.3% (lowest ever) What if… “Let It Go”…Project Elsa From 12.5-14.5% back in the day…as high as 30% in smaller hospitals

Red Blood Cells – Provincial Redistribution Map 2014/15 The thicker and oranger the line, the higher the redistribution. You can see that there are two high redistribution sites in the north. There is high redistribution taking place on the Island and even in the Fraser Health Region……..

Project Elsa – Problem Breakdown

Life Cycle of a Redistributed RBC 7-14 days before expiry date Shipping Site redistributes to the Receiving Site CBS distributes supply to Hospital A Transfused, Discarded or Expired at the Receiving Site Expiry Date Let’s review the life cycle of a red blood cell unit that is redistributed.

Methodology 7-14 days before expiry date RBC Units stay at original site CBS distributes supply to Hospital A Estimate number of units that may now expire Look at actual utilization, 7, 10, 14 days before expiry, in this period of hospital A to determine whether this unit may have been used or not. CTR has historical data on all units of red cells that were distributed from each site. The analysts looked at the actual utilization that occurred at that site, ie units of blood transfused and the blood groups of the recipients to determine whether the blood would have been used or expired if it had stayed at the site and not redistributed. The analysts looked at the activity at 7, 10 and 14 days before the expiry of each unit to predict what would have happened. Also, we know that certain blood groups can be used as a substitution for example O Neg as we know can be transfused to any blood type but A Neg for example can go to A Pos or A Neg only. We also know that not every small site is comfortable in substituting blood groups so we looked at those scenarios as well. All these scenarios are presented to validate the numbers and satisfy your curiosity but I will focus on what happened at 10 days before expiry to move the presentation along. You will be able to study the slides in more detail if you like afterwards.

Scenarios: Actual utilization at 7/10/14 days from expiry of each redistributed unit The Exact ABO/Rh Match transfusion: Was there a recipient transfused with the exact same blood group? Acceptable ABO/Rh Substitution transfusion: Was there a recipient transfused that could’ve received a blood group substitution? Three years of data for validation Actual utilization at the original site or “shipping site” what actually happened at that site after that unit was redistributed. We can look at the data and see if the unit had stayed and not redistributed what would have happened to that unit. Would that unit actually have expired or can we predict that the unit would have been transfused.

Scenario 1- The Exact Match The number of units estimated to expire if RBC units had stayed at the shipping sites Scenario 1- The Exact Match Year Using 7 days before expiry as shipping date Using 10 days before expiry as shipping date Using 14 days before expiry as shipping date 2012/13 6, 031 units 5, 536 units 5, 064 units 2013/14 6, 301 units 5, 698 units 5, 164 units 2014/15 6, 223 units 5, 699 units 5, 156 units Average 6, 185 units 5, 644 units 5, 128 units Average of the three years, at the bottom of the slide; with 7 and 14 days as the “extremes” but actually not really extreme, so we can use 10 days for the purpose of this presentation. It provides a fari indication

Scenario 2 – Allow Substitution The number of units estimated to expire if the RBC units had stayed at the shipping sites Scenario 2 – Allow Substitution Year Using 7 days before expiry as shipping date Using 10 days before expiry as shipping date Using 14 days before expiry as shipping date 2012/13 3,434 units 2,773 units 2,250 units 2013/14 3,297 units 2,514 units 1,976 units 2014/15 3,379 units 2,611 units 2,010 units Average 3,370 units 2, 632units 2,078 units

Impact on Expiry Rate and Cost Year Actual Expiry Rate Actual Expiry Cost Scenario Days Before Expiry Estimated Expiry Rate Estimated Expired Cost Additional Expired Cost 14/15 1.5% $ 979,000 Exact Match 7 5.7% $3,931,500 $2,952,500 10 5.3% $3,669,500 $2,690,500 14 5.0% $3,398,000 $2,419,000 Subs Allowed 3.7% $2,509,500 $1,530,500 3.1% $2,125,500 $1,146,500 2.7% $1,825,000 $ 846,000 Expired = Historical expired + additional expired – redis expired at receiving site. Expiry cost plus Additional supply cost….. Total = Historical Trans + Discard + new expired New Expiry rate = new total expired/new total Additional Cost = ( New total – Actual total ) * unit cost(422) - Cost Calculation based on $500 per unit

Impact on Total Supply 14/15 130, 987 Exact Match 7 5,531 $2,765,500 Year Actual Total Supply (Units) Scenario Days Before Expiry Additional Supply From CBS Additional Supply Cost to CBS ($) 14/15 130, 987 Exact Match 7 5,531 $2,765,500 10 5,007 $2,503,500 14 4,464 $2,232,000 Subs Allowed 2,687 $1,343,500 1,919 $ 959,500 1,318 $ 659,000 Expired = Historical expired + additional expired – redis expired at receiving site Total = Historical Trans + Discard + new expired New Expiry rate = new total expired/new total Additional Cost = ( New total – Actual total ) * unit cost(422) We show subs allowed because CBS does not like the substitution that happens at the receiving site in redistribution. There will still be substitution but at the original shipping site instead to maintain a reasonable expiry rate. - Cost Calculation based on $500 per unit

Conclusion of Project Elsa Hospital demand would increase by estimated 2,000 – 5,000 units Expiry rate would increase Between 3 – 5% Depending on ABO substitution policy: Additional Expiry cost $1.2 – 2.7 M Additional supply cost $1.0 – 3.0 M Increase the number of donors needed If RBC Redistribution Program Stops: stopping redistribution based on today’s numbers could lead to > 5% expiry Increase the number of donors needed

Intra- Health Authority Distribution Hub-and-Spoke Model CBS does not directly ship to all sites in BC Estimated over 3500 blood components and 6000 blood products distributed were from hub sites to smaller sites

Transfers with Patients Manual count of available paper records provided to CTR by hospitals 194 transfers (455 blood products) Excludes one HA and does not include numerous transfers within HA…understated

Impact, Issues & Concerns Physical impact: VCH OH&S identified concerns re: staff risk due to weight and size of new containers Process impact: Hub & spoke models established to streamline process and reduced tech time and training CBS does not currently deliver to all sites in province Training & Education: Training and competency assessments is a requirement per HC Regs for anyone involved with handling and receiving blood (approx 900 ppl) Financial: Short term: Continue using existing J82s (provided by CBS); costs include box transport (shipping) and labour Long term: New shipping containers (J82s or other) for entire province

Long–term plan – J82 boxes and supplies, logistics & transportation Decision Long–term plan – J82 boxes and supplies, logistics & transportation