A Team Approach To Decrease Wasted Blood Products

QUALITY IMPROVEMENT Leigh Jefferies, MD M. Elizabeth Smith, MT(ASCP)SBB Deborah Magee, MT(ASCP)SBB Patricia Wallace, MSN, RN, CCRN Meg Horgan, MSN, RN A Team Approach To Decrease Wasted Blood Products Team approaches to problem solving are being used increasingly in health care delivery.1'2 Our institution used a multidisciplinary quality improvement team to determine what factors contribute to blood product waste in a tertiary care hospital and to implement initiatives to decrease waste. Evaluation of Blood Product Waste The delivery of quality, cost-effective transfusion services depends on many factors that affect the system of blood administration. When viewed in the context of the total institutional quality plan, the system of blood administration, one of several key operational systems, may be broken down into critical control points. Each critical control point represents a major process, the correct performance of which is necessary to ensure the quality and safety of blood given to patients. Each critical control point may be associated with key elements steps that must be managed or monitored to ensure optimal function of the critical control point. As shown in Fig 1, our transfusion service views the evaluation of blood product waste as a key element in the appropriate use of blood components. This key element represents one of four critical control points in the system of blood administration. 3 Other key elements focus on establishment of guidelines for blood component transfusion, review of preoperative blood order schedules, use of a peer review process to monitor appropriateness of transfusions, and a mechanism to tally blood component use.4-6 A blood component that is ordered for a patient but that never results in a transfusion represents a wasted component. The outdate rate is the proportion of blood components that is stored in inventory until the original dating period expires. The discard rate is similar, but repre- ABSTRACT The evaluation of blood product waste represents a key element of the appropriate use of blood components, a critical control point in the system of blood administration. A multidisciplinary team approach, depending on contributions from laboratory personnel, may be used to analyze and reduce the problem of blood product waste. Process improvement steps include the creation offlowcharts for each step in the process of blood delivery, case analysis to determine factors that contribute to waste, and implementation of new procedures and education of hospital staff to reduce waste. In our analysis, key factors contributing to blood product waste included failure to communicate canceled orders to the transfusion service, failure to return unused blood products to the transfusion service in a timely manner, miscommunication of requests for blood products, o and problems in assessing patients' readiness for transfusion. e 3 The team took steps to address these problems and E subsequently reduced blood product waste. o sents those components that were removed from inventory owing to an abnormal appearance suggesting possible bacterial contamination, breakage of a component bag, or another reason that prohibits safe use of the component.4 Of these categories of unused blood, wasted blood components are an inefficient use of resources and may be avoided. Such wasted components may result in significant loss of money and loss of a precious resource for patients. Opportunity for Improvement During a 2-year period, our transfusion service manager and supervisor presented data about blood product waste to the blood usage review committee. Data included the types of products wasted, location of waste (specific patient care unit), and the number of products wasted compared with the number of products received in VOLU ME 27, N UM BER 1 2 From the Transfusion Service, Department of Pathology and Laboratory Medicine (Dr Jefferies, Ms Smith, Ms Magee); and Quality Improvement (Ms Wallace, Ms Horgan); University of Pennsylvania Medical Center, Philadelphia. Reprint requests to Dr Jefferies, Blood Bank, 6th Floor, Founders Pavilion, University of Pennsylvania Medical Center, 3400 Spruce St, Philadelphia, PA 19104. LABOR ATORY MEDICINE 833 0 I

and clinical laboratory staff viewed this level of waste to be unacceptable, however, and decided to address the problem. The initial verification or definition of a problem, in this case a high rate of blood product waste, represents the first step toward improving a process. Process improvement by itself may be viewed as a critical control point, applicable to analyzing and upgrading any process or addressing any system problem. Key steps for process improvement, summarized from the quality SYSTEM: BLOOD PRODUCT ADMINISTRATION program prepared by the American Association of Blood Banks and other publications, are shown Critical Control Points in Table 1. For each step, Dispensing blood Recipient Appropriate blood Blood component we list activities we used components for identification prior component use transfusion transfusion to transfusion to analyze and reduce blood product waste. inventory. For example, from July 1992 through June 1993, more than 56,000 components were received in inventory, while 1,600 (3%) of these products were wasted. This represents approximately $107,000 worth of wasted blood products. Published guidelines that suggest acceptable rates of blood product waste, analogous to a target crossmatch-to-transfusion ratio, or a target inventory outdate rate, are not available. 7 Members of the blood usage review committee Fig 1. Outline of quality plan approach for system of blood product administration. Key Elements Guidelines ordering and blood compo Mechanism to review preoperative blood order schedules Team Organizes To Analyze Problem Mechanism to tally blood component use Peer review process to monitor appropriateness of transfusion After we identified the problem of blood product waste, we organized a team to study how blood is administered to patients. We selected team members from several areas of hospital services, because we believe that many steps and TABLE 1. PROCESS IMPROVEMENT STEPS TO DECREASE BLOOD PRODUCT WASTE Step 1 Problem Identification Blood bank managersupervisor monitor blood product waste and present data to blood usage review committee. Step 2, A Self-Assessment Multidisciplinary team is organized to analyze entire process of blood product administration by creating flowcharts and brainstorming. 2, B Self-Assessment Case waste report forms are developed. Individual cases are analyzed to determine factors contributing to waste and relative significance. Step 3 Proposed Solutions Initiatives developed include new policies, procedures, training, and continuing education of hospital staff. Progress reports to hospital quality improvement committees facilitate project. Step 4 Monitoring and Feedback Monitoring of waste indicates improvement. Timely feedback to hospital staff is key factor in continuing process. Realistic goals are established for future. 834 LABORATORY MEDICINE VOLUME 27, NUMBER 12

Fig 2. Case analysis of blood waste during a 3-month period. Forty individual cases of blood product waste were analyzed. Ten key reasons for waste were identified and indicated in order of frequency on the x a x i s. The y axis represents percentage of cases analyzed. Blood Wastage 3-Month Analysis 30 a o N.>< n c < IS O j*>* ft f ff 4$ <f 7 X o 1 & Patient Readiness Issues Reason for Return processes in the overall system affect waste. The team initially consisted of members from hospital quality improvement, nursing, and the clinical laboratory transfusion service (eg, physician, manager, and supervisor). The team created a flowchart of each step in the process of blood delivery: from the time a patient sample is drawn for type and screen until the unit of blood is administered to a patient. This process encompassed the four critical control points for blood product administration shown in Fig 1. A surprising number of steps and communications are involved in the process of blood administration. As the team analyzed steps in the process of blood administration, the team grew to include members from hospital transportation, perioperative nursing, and operating room pharmacy; a patient care unit secretary; and physicians from high transfusion areas (eg, hematology and anesthesiology). Monthly meetings during a 4-month period focused on brainstorming and creating flowcharts. Team members identified problems with key steps that likely affected blood waste. On patient care units, these problems involved communicating that a blood product be released, and assessing the readiness of a patient for transfusion. Team members cited problems with verbal communication between nursing staff and transfusion service staff that suggested a need for simultaneous written communication for the release of blood products. Team members also suspected that nursing procedures used on patient care units to assess a patient's readiness for transfusion were inconsistent. In the operating room, the key problem involved temporary storage of blood products in portable coolers and failure to return blood components to the transfusion service within appropriate time limits. Team members who analyzed these issues later would be instrumental in making changes to address the problems. The Diagnostic Journey Next, the team performed a case-by-case analysis to determine what factors resulted in waste of blood products and to establish their relative significance. To track and investigate each case, the transfusion service manager and supervisor designed a wasted product case report form to record pertinent information, such as the date and time an unused blood product was issued DECEMBER 1996 V O L U M E 27, NUMBER 12 LABORATORY MEDICINE 835

regarding the timing of transfusion. Other issues related to the evaluation of patients' readiness for transfusion, because many products were issued to patient care units without complete preparation of the patient. Solutions for Reduction of Waste Fig 3. Rate of blood product waste by 6month period. The rate (percentage) of blood product waste declined following the process improvement project. and was returned, the name and location of the patient for whom the blood product was ordered, and the condition of the blood product upon return. When completed by transfusion service technologists, each case report was forwarded to nursing quality management staff who investigated why the blood product was not used. Results of a focused 3-month analysis of 40 cases are shown in Fig 2. The single most common reason for blood waste was failure to communicate that a blood order had been cancelled. For example, the medical team changed its decision to transfuse after the request was made for release of the product. In these cases, the blood product was prepared, delivered to the patient care unit, but not transfused nor returned in a timely fashion for reentry into inventory. The second most common category involved physical mishandling of blood products. Waste resulted from failure to return blood that was transported temporarily in coolers from operating rooms or intensive care units, or bag breakage due to improper spiking of blood products. As predicted from earlier flowchart sessions, problems also involved miscommunication between the patient care unit and transfusion service at the time a blood product was requested, particularly 836 LABORATORY MEDICINE VOLUME 27, NUMBER 12 To address the factors contributing to blood product waste, the team revised existing policies, established new policies, offered continuing education for hospital staff, and provided timely feedback about performance in cases of blood product waste. The team updated the adult transfusion policy by requiring nurses to assess a patient's readiness for transfusion before requesting blood to be issued. The team reviewed issues about the blood delivery process with hospital staff emphasizing time limits to return unused blood and proper handling of blood products. The nursing and anesthesia operative reports in patients' charts were amended to include notation of blood transported in coolers. Alarms were attached to blood coolers to alert staff to return unused blood to the transfusion service. A new fax blood request form was developed for blood issued from the transfusion service and piloted in highuse areas such as hematologyoncology. When a blood product is wasted, anesthesiologists and nurse managers in patient care areas are notified within 24 hours to provide quick feedback and investigation. To facilitate these initiatives at each step in the analytic and remedial processes, blood waste data are reported periodically to quality improvement committees in departments of nursing and anesthesia, in the clinical laboratory, and to hospital administration. Holding the Gain Ongoing monitoring of blood product waste has shown reduced rates of blood waste compared with wastage rates prior to interventions. Key initiatives were instituted in the fourth quarter of 1993 and in the first quarter of 1994. The rate of blood product waste decreased to 1.9% for the first half of 1995 (Fig 3). As a result of this success, the multidisciplinary committee established a target of 1.0% waste for the next fiscal year. Administration plans to follow-up on certain initiatives to determine their relative success in targeted areas of the hospital (eg, use of cooler alarms to decrease waste in the operating room and implementation of the fax request form on a hospitalwide basis).

Role of the Clinical Laboratory Laboratory professionals are becoming increasingly involved in hospitalwide process improvement projects. Issues include patient sample collection, sample labeling, test request reporting, and billing. Process improvement may be used to analyze and improve operations between the clinical laboratory and direct patient care. Clinical laboratory personnel may be instrumental in many steps of the process of analyzing blood product waste in a large tertiary-care hospital. As pivotal team members, the manager and supervisor of the transfusion service helped clarify the problem by tracking blood product waste statistics, contributed to the team's creation of a flowchart of the blood product delivery system, and developed the means to track and analyze individual case waste for follow-up by nurse managers. Transfusion service technologists were instrumental in documenting individual case waste for analysis. Conclusion Clinical laboratories have many opportunities for improving the delivery of health are services. For some issues, such as that of blood product waste, provision of the service and delivery of the product involve staff from many hospital services. The overall success of this project was attributed to the m u l t i d i s c i p l i n a r y team a p p r o a c h, which incorporated brainstorming and the flowchart process to analyze the problem. Success also relied on shared responsibility a m o n g team members to design effective remedial strategies. 1 ' 2 Support from hospital administration and team members' knowledge of process improvement steps also were key contributing factors. Quality improvement teams do not necessarily provide u n i q u e s o l u t i o n s to p r o b l e m s. O u r a p p r o a c h, however, illustrates t h a t process improvement problem-solving tools may be used to address diffuse system problems. References 1. The Quality Letter for Healthcare Leaders. Rockville, Md: Bader and Associates; February 1992:4(1 );2-7. 2. Scholtes PR, ed. The Team Handbook, How to Use Teams to Improve Quality. Madison, Wis: Joiner Associates; 1992:1-10. 3. American Association of Blood Banks, Quality Program Quality-Plan Manual. 1994:2.1-2.4. 4. Hoeltge GA. Peer review of transfusion practices. In: Summers SH, Smith DM, Agranenko VA, eds. Transfusion Therapy: Guidelines for Practice. Arlington, Va: American Association of Blood Banks; 1990:157-175. 5. Silberstein LE, Kruskall MS, Stehling LC, et al. Strategies for the review of transfusion practices. fama. 1989; 262:1993-1997. 6. The JCAHO Accreditation Manual. Chicago, 111: Joint Commission on Accreditation of Health Care Organizations; 1996:255-256. 7. Clark JA, Ayoub MM. Blood and component wastage report: a quality assurance function of the hospital transfusion committee. Transfusion. 1989;29:139-142. Almost Tech Sample -The Perfect P r a c t i c a l % CMLE Program " Easy* Convenient^ Free? Self-study with Tech Sample is the nearly perfect way to earn CMLE credit hours and prepare yourself for the changing demands of laboratory medicine. Tech Sample's exercises address the sort of problems you encounter everyday, complete with 35mm color transparencies or other laboratory data. Ten different sections-including a new Phlebotomy series-cover each major area of the clinical laboratory. So it's easy to review in your area of responsibility or gain new skills. The self-study format lets you learn at your convenience, wherever and whenever you choose, and while Tech Sample isn't free, it's remarkably economical. You can earn your CMLE credit hours for as little as $5.83 each, with no additional costs. It's the ideal way to pursue professional perfection! For more information, call ASCP Customer Services 8 0 0-6 2 1-4 1 4 2 (press l, t h en ext. 260) (In Illinois and outside the US, call 312-738-4890) Or visit our Web Site at http:www.ascp.org ASCP PRESS