Introduction:
Transfusion of blood and blood components play an important role in the management of patients, they are a lifesaving intervention. The evaluation of wastage of blood products represents an important element in the appropriate use of blood components, a critical control point in the system of blood administration. (1) Blood centres the world over work with the main aim of providing safe and sufficient blood and blood components. Implementation of rigorous protocol on blood reserves and proper and timely use of blood products is needed, this can be overcome by accurately describing a protocol and creating more coordination, preventing the loss of blood products and energy, human, and financial resources. (2) Improvement of blood transfusion services performance by analyzing the data and the reason for the discards can help develop plans thereafter to train staff and introduce measures in order to minimize the discarded blood to a reasonable rate. (3)
Discarding or wastage of blood can be attributed to several reasons namely time expiry, wasted import, non-usage of ordered blood, broken bags and seal with leakage, hemolytic reasons, clotted blood, returned after 30 min, and miscellaneous others. (4) Wasting of blood and 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. To deal with the ever-increasing demand and supply of blood and its components in resource-limited settings like ours, stringent criteria need to be applied for donations and proper utilization of blood. The “wastage rate” or rate of discarded blood components is one of those indicators and has been listed third among the ten quality indicators recommended by National Accreditation Board for Hospitals and Healthcare providers. (5) To overcome demand and supply gap, increasing the level of resources used in the collection and production of blood components or by efficiently utilizing existing resources, is needed. (6) Each unit of blood is precious and should be utilized judiciously with minimal wasting.
The present study was undertaken with aim of primarily to determine the frequency of blood products wasting and secondarily to determine the factors that affect blood products wastage at our institute.
Material and Methods:
The present study is a retrospective cross sectional descriptive study conducted in a tertiary teaching hospital located in South Delhi catering to low socioeconomic population, study was conducted in the Blood bank of Department of Pathology from January 2012 to December 2018. The required data from clinical units and blood bank were collected and analyzed. The total number of patients whose transfusion requests were made, units cross matched, issued, transfused, and not utilized were evaluated. Data on blood and its component usage and wastage were collected from laboratory blood banking information system. Blood component wastage was defined as components that did not meet the required standards of hospitals or fractionation centres during collection, processing and storage. The main reasons included expiry date, inappropriate volume, haemolysis of red blood cells (RBCs), contamination of plasma or platelets with RBCs, blood bag leakage, reactive infectious disease tests and inappropriate temperature during storage or transportation. The requisition forms were analyzed for relevant details. Implied consent was obtained while collecting the blood sample.
Results:
A total of 13728 blood units were received during the specified period which included whole blood 11.7%, red cell concentrate 41.5%, fresh frozen plasma 41.6%, platelet concentrate 4.4%, single donor plasma 0.6%. Wastage factor was calculated component wise depicted in Table 1, overall wasted factor was of 18.5% with maximum wastage of platelet concentrate units (53.7%).
| Table 1: Wastage Factor of Blood Bank: Component Wise |
|
All Units |
Whole Blood |
Red Cell Concentrate |
Fresh Frozen Plasma |
Platelet Concentrate |
Single Donor Platelet |
Total Collection(T) |
13728 |
1617 |
5699 |
5723 |
605 |
84 |
Wastage(Total wasted Units, W) |
2541 |
378 |
678 |
1158 |
323 |
2 |
% Wasted Units T/W |
18.5% |
23.4% |
11.9% |
20.2% |
53.7% |
2.4% |
 |
Figure 1: Distribution of cases according to collection and wastage |
Analyzing the discarding of units over those collected at six monthly interval, depicted in Figure 2 shows maximum discarding I the period extending March 2017 to February 2018.
 |
Figure 2: Comparative Depiction of Discarding Units to Collected Units |
We analyzed the wastage factor on a six-monthly basis depicted in Table 2. Total wastage along with component wise discarded blood is shown Table 2.
| Table 2: Wastage Factor Of Blood And Blood Components (6 Monthly): Analysis Of Discarded Blood – Component Wise |
|
Tot prep |
Tot dis |
W% |
Tot WB |
Dis WB |
W% WB |
Tot RCC |
Dis RCC |
W% RCC |
Tot FFP |
Dis FFP |
W% FFP |
Tot PC |
Dis PC |
W% PC |
M12-A12 |
489 |
65 |
13.3% |
68 |
15 |
22.1% |
203 |
24 |
11.8% |
203 |
11 |
5.4% |
15 |
15 |
100% |
S12-F13 |
656 |
107 |
16.3% |
137 |
30 |
21.9% |
219 |
28 |
12.8% |
219 |
6 |
2.7% |
74 |
43 |
58.1% |
M13-A13 |
611 |
116 |
19% |
152 |
25 |
16.5% |
192 |
41 |
21.3% |
192 |
50 |
26.%5 |
74 |
0 |
0% |
S13-F14 |
805 |
170 |
21.1% |
163 |
19 |
11.7% |
261 |
25 |
9.6% |
284 |
98 |
34.5% |
75 |
27 |
36% |
M14-A14 |
812 |
111 |
13.7% |
161 |
28 |
17.4% |
319 |
35 |
11% |
319 |
43 |
13.5% |
8 |
5 |
62.5% |
S14-F15 |
719 |
172 |
23.9% |
98 |
12 |
12.3% |
304 |
21 |
6.9% |
304 |
137 |
45.1% |
5 |
1 |
20% |
M15-A15 |
785 |
217 |
27.6% |
130 |
28 |
21.5% |
325 |
34 |
10.5% |
325 |
151 |
46.5% |
1 |
1 |
100% |
S15-F16 |
905 |
274 |
30.3% |
213 |
47 |
22.1% |
302 |
25 |
8.3% |
302 |
165 |
54.6% |
80 |
37 |
46.3% |
M16-A16 |
1073 |
226 |
21.1% |
234 |
75 |
32.1% |
383 |
32 |
8.4% |
383 |
79 |
20.6% |
69 |
40 |
58% |
S16-F17 |
1117 |
138 |
12.4% |
131 |
27 |
20.6% |
464 |
43 |
9.3% |
464 |
31 |
6.7% |
45 |
37 |
82.2% |
M17-A17 |
1267 |
225 |
17.8% |
43 |
39 |
90.7% |
574 |
85 |
14.8% |
574 |
49 |
8.5% |
70 |
52 |
74.3% |
S17-F18 |
1324 |
208 |
15.7% |
20 |
10 |
50% |
626 |
95 |
15.2% |
626 |
60 |
9.6% |
48 |
44 |
91.7% |
M18-A18 |
1033 |
239 |
23.1% |
25 |
13 |
52% |
503 |
81 |
16.1% |
504 |
145 |
28.8% |
0 |
0 |
0% |
S18-F19 |
871 |
188 |
21.6% |
21 |
5 |
23.8% |
408 |
74 |
18.1% |
408 |
92 |
22.6% |
30 |
17 |
56.7% |
M19-A19 |
1261 |
85 |
6.7% |
21 |
5 |
23.85 |
616 |
35 |
5.7% |
616 |
41 |
6.7% |
8 |
4 |
50% |
The Wastage rate = Number of blood or components discarded/Number of blood or components issued x 100. 1
Out of total 13728 blood bags which were collected from donors during the study period, 12111 units were separated into components and rest 1617 units were kept as whole blood units. Total 2541 (18.5%%) blood bags were discarded, of which 378 were whole blood bags and 2163 were components. The total number of whole blood units issued during this period was 1289 and components issued during this period were 8214. Therefore, the wastage rate of whole blood units and components can be:
Wastage rate of whole blood = 378/1289 x100 = 29.3%
Wastage rate of components = 2163/8214 x100 = 26.3%
A graphic representation of total percent wastage over time, Figure 3, shows a maximum of 30.3% in the Months September 2015 to February 2016 followed by 27.6% in the previous six months.
 |
Figure 3: Graph Showing Total Percent Wastage Over Time |
 |
Figure 4: Comparative Analysis Of Percent Wastage Of Blood Components
(Dark Green: PC, Yellow: FFP, Blue: RCC, Light green: WB) |
However, a decline in overall wastage was seen over the next few six months with the minimum wastage of 6.7% in the period March 2019 to August 2019.
On analyzing the wastage pattern over time of whole blood, red cell concentrate, fresh frozen plasma and platelet concentrate, maximum wastage was seen in the platelet concentrate in all the time group, followed closely by whole blood and FFP.
| Table 3: Distribution of Units According to Causes of Wastage |
| Causes |
Total Units |
WB |
RCC |
FFP |
PC |
Expiry |
1757 (69.2%) |
291 (76.9%) |
410 (60.5%) |
730 (63%) |
313 (96.3%) |
Seropositive |
347 (13.7%) |
46(12.2%) |
147 (21.7%) |
146 (12.6%) |
8 (2.5%) |
Quantity not sufficient |
73 (2.9%) |
22 (3.2%) |
26 (3.8%) |
25 (2.2%) |
0 (0%) |
Quality Control units |
234 (9.2%) |
14 (3.7%) |
94 (13.9%) |
122 (10.5%) |
4 (1.23%) |
Teaching |
1 (0.04%) |
0 (0%) |
1 (0.2%) |
0 (0%) |
0 (0%) |
Not issued (thawed) |
0 (0%) |
0 (0%) |
0(0%) |
11(0.9%) |
0(0%) |
Leakage |
62 (2.4%) |
0 (0%) |
0(0%) |
62 (5.4%) |
0(0%) |
Lipemia |
48 (1.9%) |
0 (0%) |
0(0%) |
48 (4.2%) |
0(0%) |
RBC Contamination |
12 (0.5%) |
0 (0%) |
0(0%) |
12 (1%) |
0(0%) |
ICT positive |
1 (0.04%) |
0 (0%) |
0(0%) |
1 (0.1%) |
0(0%) |
Clot |
6 (0.24%) |
5 (1.3%) |
0(0%) |
1 (0.1%) |
0(0%) |
Total |
2541 |
378 |
678 |
1158 |
325 |
One of the aims of this study was to find out the causes for discarding blood bags so that they could be utilized rationally with minimal wastage. Analyzing the causes of blood and blood product wastage in the hospital for this study showed that blood and blood product wastage were associated with many causes (Table 3) of which the common causes, included the expiration of the usability period (69.2%), sero-reactivity for infectious diseases (13.7%) and Quality Control units (9.2%). (Table 3).
Transfusion transmitted Infections are an important cause of discarding and in the present study they comprised of 13.7% of the expired units. Table 4 shows distribution of Sero-reactive blood units.
| Table 4: Distribution of Sero-Reactive Blood Units |
| Test |
Total units |
WB |
RCC |
FFP |
PC |
HIV |
50 |
7 |
22 |
21 |
0 |
HBV |
219 |
28 |
94 |
92 |
5 |
HCV |
63 |
8 |
25 |
27 |
3 |
VDRL |
15 |
3 |
6 |
6 |
0 |
Total |
347 |
46 |
147 |
146 |
8 |
Among sero-reactive units, hepatitis B surface Ag positivity was the most common. None of the units tested were detected positive for malaria parasite. The overall positivity in the sero-reactive units for various TTI of HIV, HBV, HCV, and syphilis for WB as well as components was 14.4%, 63.1%, 18.1%, and 4.3%, respectively.
Discussion
The present study attempts to analyse blood wastage at our hospital, a tertiary teaching hospital located in South Delhi catering to low socioeconomic population. A review of the practices would help us to focus on the areas of frequent wastage and also enable us to understand the main cause/causes of blood wastage at our centre. It also provides an insight into how to design an outline or measures to prevent such wastage in the future.
A total of 13728 units were collected with a wastage of 2541 units, percent wastage of 18.5 was seen in the present study. Variation in blood wastage rates is reported from 0.1% to 25% in various regional and international studies. Sultan et al (7) reported a wastage rate of 10.9% which was lower as compared to our observation, however their period of study was of 2 years whilst ours was of 6years. Lower blood wastage rates of 2.3%, 4.3%, 14.6% have been reported by Morish et al, (2) Kora et al, (8) Kumar et al (9) respectively.
Various components such as red cell concentrate, FFP and platelet concentrates were prepared, total of 12111units were separated into components. 2541 units were discarded of which 378 were whole blood with a wastage rate of 29.3% and 2163 were components with wastage rate of 26.3%. Whole blood wastage rate was high as compared to other studies where the wastage rate was19.6% (10) and much lower 3.1% (11). Most common reason for discarding whole blood units was expiry.
On analyzing the wastage pattern over time of components such as red cell concentrate, fresh frozen plasma and platelet concentrate, maximum wastage was seen in the platelet concentrate in all the time group, followed closely by whole blood and FFP. A wastage rate of 20.8% was noted for FFP which was considerably higher as compared to 5.5%11, (11) 6.2%, (12) 7.6%. (13) The most common reason for the discarding of FFP units was expiry followed by seropositivity, leakage was seen in only 5.4% this finding was non-concordant with other studies where leakage was the main cause of wastage. (10,11) Other causes of wastage of FFP in our study were attributed to insufficient quantity, not issued (thawed) leakage, lipemia and quality control units. Similar causes of wastage have been reported by other authors. (9-11) In order to minimize the wastage of FFP excess units can be given to fractionating whereas leakage can be reduced by adopting methods that minimize the risk of breakage of product during storage, handling, and transportation. The lipemic discards can be minimized by proper donor history regarding donation and time of the last meal.
The shelf life of platelet is 5 days, therefore their chance of expiry due to non- utilization is highest among blood components. In the present study 96.3% wastage of platelet concentrate was due to expiry similar to Simon et al (10) with 95.6% wastage due to non -utilization and expiry. High wastage rates in platelet counts have been reported by many authors. (7,11,12,14,15) The most common cause of platelet wastage in these studies has been attributed to expiration and technical problems at the time of preparation. This was in concordance to our study. Various remedies have been put forward to minimize this loss of platelet concentrates such as using platelet additive solutions, special type of storage bag and cryopreservation techniques can minimize the expiry of PC. (10) Red cells contamination although not seen in the present study is another cause of wastage that can be reduced by continuous training and monitoring of component separation and using automated cell separator. Red cells contaminated platelet can be used to same blood group individuals within 24 h of separation. (10) Studies have been conducted to manage PC inventory designed a model to reduce wastage from 15%–20% to less than 0.1%, with regards to the fact that platelet units have short expiry dates. (16,17) The model aimed to balance between platelet production and hospital demands, prevent expiration, and prevent the inventory shortage. However, a certain amount of platelet wastage is unavoidable to ensure its availability when it is needed. (16,17)
Red cell concentrate was the other component prepared at our blood centre. The most common reason for discard of red cells concentrate was expiry followed by transfusion transmitted infection positive, this was in concordance with findings of other authors. (4,10) However in other study the main reason for wastage was suboptimal volume followed by seropositivity for transfusion transmitted infection. (11) One of the reasons for expiry was collecting whole blood for making random donor platelets. Whole blood units wastage was mostly due to expiry followed by seropositivity and insufficient quantity in the present study, similar trend was noted by Kanani et al. (11) Reasons for insufficient quantity of blood have often been attributed to phlebotomy failure such as collapse of vein or acute donor reaction such as uneasiness, vomiting, perspiration, hematoma formation, and fainting during donation.(7,10,11) This can be resolved by the selection of healthy donors with training and motivation of blood bank staff. Another reason may be due to using uncalibrated blood collection monitor and spring balance, thus making it unable to measure accurately the volume of blood in the bag.
Transfusion transmitted Infections are an important cause of discarding and in the present study they comprised of 13.7% of the expired units. Hepatitis B surface Ag positivity was the most common cause as was noted by other authors.(11,18) Blood safety still depends highly on honest answering of the screening questions by donors, counselling, identifying transfusion transmitted positive donors, deferring suspected professional donors who have been screened previously, appropriate usage of antiseptics solutions and proper serological testing reduces the wastage of blood and blood components due to TTI and lipemic plasma.
Blood transfusion and supplying of healthy blood are among the expensive medical services this takes relevance especially in developing countries. Developing the proper culture for the optimum use of blood products in such countries is therefore of utmost importance.
Conclusions:
Blood is an irreplaceable precious resource which needs to be properly utilized with minimal wastage. Although present study was limited due to its retrospective nature but it still outlines the importance to emphasize that measures should be taken into account for formulating guidelines, effective policies, and training efforts for personnel. Further it would also help us to design intervention programs or measures to prevent wastage as well as increased awareness of the wastage throughout the hospital in general.
References:
- Roy AD, Pal A. Evaluation of ‘Wastage Rate’ of Blood and Components – An Important Quality Indicator in Blood Banks. BJMMR. 2015; 8: 348-352.
- National AIDS Control Organisation. Standards For Blood Banks & Blood Transfusion Services. New Delhi, Ministry of Health and Family Welfare, Government of India, 2007.
- Morish M, Ayob Y, Naim N, Salman H, Muhamad NA, Yusoff NM. Quality indicators for discarding blood in the National Blood Center, Kuala Lumpur. Asian J Transfus Sci. 2012;6:19-23.
- Mohebbi Far R, Samiee Rad F, Abdolazimi Z, Kohan MMD. Determination of Rate and Causes of Wastage of Blood and Blood Products in Iranian Hospitals.Turk J Hematol 2014;31:161-167
- Accreditation Standards on Blood Banks/Blood Centers and Transfusion Services. National Accreditation Board for Hospitals and Healthcare Providers. 2nd ed. New Delhi: Quality Council of India; 2013. p. 51-2.
- Pitocco C, Sexton TR. Alleviating blood shortages in a resource-constrained environment. Transfusion 2005;45:1118-26.
- Sultan S, Jaffri S A, Irfan S M, Usman S M, Nadeem S, Waheed U, Zaheer HA. n Insight into Donor Blood Unit’s Wastage in a Hospital-Based Blood Bank from Pakistan. International Journal of Medical Research & Health Sciences. 2021;10: 91-95.
- Kora SA, Kulkarni K. Blood wastage in a blood bank in an analysis of donor rural Karnataka. J Clin Diagn Res 2011;5:1393-6.
- Kumar A, Sharma SM, Ingole NS, Gangane N. Analysis of reasons for discarding blood and blood components in a blood bank of tertiary care hospital in central India: A prospective study. Int J Med Public Health 2014;4:72-4
- Simon K, Ambroise MM, Ramdas A. Analysis of blood and blood components wastage in a tertiary care hospital in South India. J Curr Res Sci Med 2020;6:39-44.
- Kanani AN, Vachhani JH, Dholakiya SK, Upadhyay SB. Analysis on discard of blood and its products with suggested possible strategies to reduce its occurrence in a blood bank of tertiary care hospital in Western India. Glob J Transfus Med 2017;2:130-6.
- Sharma DN, Kaushik DS, Kumar DR, Azad DS, Acharya DS, Kudesia S. Causes of wastage of blood and blood components: A retrospective analysis, IOSR Journal of Dental and Medical Sciences. 2014:13:59-61.
- Bobde V, Parate S, Kumbhalkar D. Analysis of discard of whole blood and blood components in government hospital blood bank in central India. J Evid Based Med Healthcare March 2015;2:1215-20.
- Shahshahani H J, Taghvai N. Blood wastage management in a regional blood transfusion centre. Transfusion Medicine. 2017:1-6 doi: 10.1111/tme.12433
- Ghaflez MB, Omeir KH, Far JM, Saki N, Maatoghi TJ, Naderpour M. Study of rate and causes of blood components discard among Ahwaz’s hospital. Sci J Iran Blood Transfus Organ 2014;11:197-206.
- Gomez AT, Quinn JG, Doiron DJ, Watson S, Crocker BD, Cheng CK. Implementation of a novel real-time platelet inventory management system at a multi-site transfusion service. Transfusion 2015;55:2070-5.
- van Dijk N, Haijema R, van der Wal J, Sibinga CS. Blood platelet production: A novel approach for practical optimization. Transfusion 2009;49:411-20.
- Thakare MM, Dixit JV, Goel NK. Reasons for discarding blood from blood bank of government medical college, Aurangabad. Asian J Transfus Sci 2011;5:59-60
|
