Platelet Inventory Management: A Quality Improvement Initiative to Reduce Platelet Outdates
Authors: Jeff Kinney, ART, Dr Ziad Solh, MD London Health Sciences Centre
The shelf life of platelet products makes it challenging for both blood suppliers and hospitals to manage inventory and avoid platelet outdates and wastage. London Health Sciences Centre (LHSC) is a large tertiary care hospital in London, Ontario, Canada which includes two separate hospital sites, University Hospital (415 beds) and Victoria Hospital (565 beds). Annual transfusion rates for both sites combined are approximately 22,000 red blood cell (RBC) units and 4,000 platelets over the past 3 years. Prior to Canadian Blood Services (CBS) consolidating services to the Brampton site in 2012, a CBS facility was located just outside the front doors of Victoria Hospital which allowed for quick access to many of the blood components CBS provides. Today, the travel distance between CBS distribution facility and the London hospitals is greater than 170 km which presents new challenges for inventory management. At the time of CBS consolidation, the hospital and CBS worked together to ensure blood product availability while minimizing STAT transportation costs. These priorities sometimes lead to platelet outdate rates as high as 30% which was not acceptable, so a new outdate goal of below 15% was set.
Factors leading to platelet outdates were identified with the intent to implement interventions that would reduce outdates. Hospital-based factors were pre-existing high inventory goals, lack of adherence to inventory levels by technologists, platelets expiring more often on a specific weekday, and inconsistent product redistribution between sites. Interventions included 1) adhering to the department policy of platelet redistribution to the busier Victoria site when units at the University site were in last 24 hours of shelf life, 2) ensuring that daily platelet product requests were not a fixed standing order Monday to Friday but a flexible number based on historical data for outdate each day of the week, and 3) re-evaluation of the ratio of irradiated to non-irradiated platelets stocked.
After implementation of these interventions, the percentage of expired units dropped below 10% for both sites combined and continued below this level for several months. In August 2017 CBS introduced 7 day storage of platelets which saw a further reduction in outdates to below 5%. Hospital inventory management strategies including redistribution of product and changes to inventory ordering practices had a large impact on reducing platelet wastage at our large centre which was additive to extension of storage duration. For a period of greater than 2 years LHSC has been able to maintain a platelet outdate well below its intended goal and we will continue to monitor our performance to ensure a sustained low platelet outdate rate.
The Ontario Immune Globulin Screening Pilot (IGSP) for Neurology
Authors: Denise Evanovitch, ART, Wendy Owens, ART, Laurie McLeod, MLT, ORBCoN and Lois Shepherd, MD, Kingston Health Sciences Centre/ Queen’s University
In 2015, the Ontario Ministry of Health and Long-Term Care (MOHLTC) and Immune Globulin Advisory Panel (IGAP) examined different order/request screening methodologies for immune globulin (IG) for several reasons:
- IG utilization and costs continue to grow
- Concerns regarding the sustainability of this growth
- A 2015 compliance audit demonstrated a need for improvement in appropriate IG utilization
- The need for patient reassessment for those on long-term therapy to determine if the treatment and dosage continued to achieve the expected clinical response
- The expertise to screen IG requests across all specialties is not available at every hospital
- An IG audit conducted in 2012 indicated that 11.6% of Ontario’s IG use was for unapproved conditions
A pilot project to review requests for IG and provide screening by specialist physicians was proposed to determine if this approach could potentially improve appropriate IG utilization. Requests for neurology indications were selected for the IGSP because provincial clinical champions were identified and were willing to support it.
The Exceptional Access Program (EAP) model, currently in use for screening some drug requests, was selected due to its availability at all hospitals that issue IG and the fact that most physicians are already familiar with the EAP.
The objectives of the IGSP were to:
- reduce inappropriate use and wastage of IG
- ensure the minimum effective dose was administered
- improve patient outcomes by ensuring treatment was efficacious
- gain an understanding of the increased utilization of IG
- raise awareness of IG use and costs
- ensure dose correction for obese patients
- develop a screening model that may expand to requests from other specialties.
As the EAP electronic request technology was not available for this pilot, a paper-based, faxing system was developed to fill this gap. The pilot ran from May 30th, 2016 to January 31st, 2017.
All IG neurology requests were initially screened by an IGSP assessor (pharmacist). The order was approved within 24 hours if the order met established guidelines. The requests not meeting the guidelines were forwarded to an anonymous neurologist reviewer for approval or rejection. An urgent process was developed for critical patients and an appeal process was available.
All IG orders for renewal were required to have an Outcome Questionnaire completed and submitted with the new request form to ensure that the treatment continued to be effective and that a minimally effective dose had been applied.
Ninety-two (92) hospitals submitted 1,478 requests which represented 1,167 patients. Eleven (11) requests were rejected, 1,187 requests were approved and 187 requests had adjustments, either through dosing, frequency or duration of treatment.
When the baseline data were compared to the post-IGSP data, the pilot did not appear to affect physician IG ordering practices.
The pilot potentially conserved 72,848 g of IG at a cost saving of $4.5M (CAN). A compliance assessment determined that only 51% of cases had the IGSP-approved dose administered by the hospital. The final cost saving was $2.2M (CAN) when this compliance rate was applied along with factoring in EAP costs.
The pilot was a partial success as it provided:
- A uniform, expert screening process
- A mechanism to deny inappropriate requests or adjust frequency, duration or dose of IG
- Awareness of the extent of IG treatment and the cost
- A monitoring process for patient outcomes
- Cost savings were realized
- The means for all transfusion services to have access to neurology expertise
A limitation of the pilot was the manual nature of the process, which was tedious and unsustainable for the ordering clinicians, the IGSP screeners and reviewers, and the hospitals. An IG screening model can reduce inappropriate utilization and have a positive effect on patient outcomes, but the requisite technology must be available to support it.
The IGSP for Neurology Report
For those stakeholders who are interested in a copy of the IGSP for Neurology Report, it is available upon request, through the MOHLTC. Please click on this link ONBlood@ontario.ca to request one.