Blood Inventory Management During COVID-19 Pandemic Using a Simple Mathematical Tool: A Two-Year Study from a Tertiary Care Hospital in North India

Utilizing the Safety Stock Tool for Blood Centre Inventory Management

Efficient blood inventory management depends upon trained staff, effective implementation of standard operating protocols and effective inventory management tools [7]. A blood inventory management tool should be simple to understand and apply in order for it to be implemented in a blood centre. COVID-19 outbreak presented as a rapidly changing scenario which affected health care services around the world [16]. In the present study, the lockdown period of the first wave of the COVID-19 outbreak (period B) resulted in a drastic reduction in blood collection because of: (i) cancellation of voluntary blood donation camps; (ii) fear of contracting COVID-19 infection among the potential blood donors. The red cell collection during this period decreased to 30 ± 12 units per week which were 28.5% less as compared to the pre COVID period (period A). Similar findings were seen in other studies [12, 17, 18]. Hence period B presented the hardest challenge in terms of maintaining the average red cell stock inventory above the calculated red cell safety stock of 40 units. Various strategies were adopted to mitigate this decrease in blood collection. Firstly, an in-house blood donation camp was organized in collaboration with a local social organization following COVID appropriate behaviour. Secondly, regular repeat blood donors were counselled and informed about various measures taken by the blood centre to ensure social distancing and enhanced infection control measures. The donors who agreed to donate blood were issued a blood donation appointment letter which could be utilized as a movement pass.

In addition, all the blood centre staff was counselled to strictly follow the first in first out (FIFO) policy [19]. Interestingly, the red cell demand also decreased during period B as the average red cell issued during this period was 39 ± 2 units per week which were 35.8% less as compared to the pre-COVID period (period A). This was because the elective surgeries were postponed and more beds and hospital manpower were reserved for the management of COVID-19 patients. Due to the abovementioned interventions, the decrease in red cell collection was less as compared to the decrease in red cell utilization (28.5% vs 35.8%) and the blood centre was able to maintain the average daily red cell stock more than the calculated safety stock levels at all times during period B.

During period C, majority of the restrictions were gradually removed by the government. There was an increase in the average weekly red cell collection (51 ± 12 units) as well as the average weekly red cell issued (51 ± 4 units). The increase in red cell utilization was more than the collection during this period (104% vs. 70%). This can be attributed to the fact that a lot more information became available about COVID-19 and the hospitals were able to create mechanisms for providing both COVID and non-COVID health care services at the same time [20]. The total capacity of the hospital was also expanded from 500 to 700 beds. At the same time, the fear of COVID-19 also decreased among the general public [21]. However, the blood centre was successful in maintaining the average daily red cell stock above the calculated safety stock level by (i) strict implementation of the FIFO policy; (ii) increasing the number of voluntary blood donation camps; (iii) increased communication with the end-user clinicians for following restrictive strategy for blood transfusion [22].

Period D was the intervening period between the 1st and 2nd waves of the COVID-19 pandemic. The blood centre was able to maintain average daily red cell stock and remained above the calculated safety stock level at all times during this period without any special measures. Period E corresponded to the lockdown period of the 2nd wave of the COVID-19 pandemic which resulted in an overwhelming of health care facilities and the return of the lockdown measures to control the spread of the COVID-19 infection. Having learnt the lessons from the lockdown period of 1st wave of the pandemic, the blood centre was better prepared for period E. The blood collection only decreased by 16.6% compared to period D. However, the red cell demand decreased by 26.4% as compared to period D. This is again attributed to increased allocation of beds and manpower for COVID-19 management and postponement of elective surgeries. Since the % decrease in red cell demand was greater than the percentage decrease in blood collection, the average daily red cell stock reached 73 ± 6 units which was much higher than the calculated safety stock of 32 units for period E. This resulted in an increase in the total number of “near expiry date red cell units”. Some of the red cell units were transferred to the blood centre of a government hospital in another district of the state. However, eventually, the increased DBSI (2.3) resulted in increased wastage of blood due to the OB units during period E.

As seen in period C (the unlock period of the 1st wave of COVID-19), period F (the unlock period of the 2nd wave of COVID-19) also witnessed an increase in red cell demand by 52% as compared to period E as a result of reopening of non-COVID services in hospitals. Similarly, the blood collection also increased (↑ 43.3%) but efforts were made to decrease the gap between the average daily red cell stock and the calculated safety stock to decrease blood wastage. Finally, during period G (the endemic stage of COVID-19), the red cell demand increased by 28.9%, while blood collection was increased only by 9.3% to achieve further correction in the average daily bloodstock in line with the calculated safety stock to decrease blood wastage.

COVID-19 pandemic is a learning lesson that blood centres should be prepared for periodic health crises [16]. In the present study, by keeping the average daily blood stock above the calculated safety stock levels, the blood centre was able to meet the red cell requirements of the tertiary care hospital at all times.

Validity of OB as a Quality Indicator of Blood Wastage and the Relationship Between DBSI and OB

Blood stocks management scheme, which was established in United Kingdom in 2001, uses wastage as percentage of issue (WAPI) as an indicator of blood wastage [8]. WAPI is inversely proportional to blood utilization. In contrast, OB is inversely proportional to blood collection. Blood centres are in a much better position to control or optimize blood collection as it is the direct control of blood centre. Blood issued on the other end is related to blood demand and is dependent upon the end user clinical department. In 2016, WAPI was replaced by OB as a measure of blood wastage and also as a quality indicator of BTS by NABH, India [15]. Ideally, blood centres should try to achieve an OB of less than 7% for PRBC [23].

In the present study, upon simple linear regression, a strong direct relationship was seen between OB (dependent variable) and DBSI (predictor variable) [R = 0.79; p = 0.03]. The maximum DBSI of 2.3 was seen in period E (the lockdown period of the 2nd wave of the COVID-19 pandemic) which resulted in an increase in the “near expiry date units” and was directly responsible for high OB during period E as well as period F. Hence, based on the results of present study, it is suggested that to achieve minimum OB, the blood collection should be adjusted so that DBSI should be kept in the range of 1.4–1.7. If a blood centre is supporting more trauma patients and obstetric emergencies, then the DBSI should be kept near the upper range and for blood centre supporting more of routine surgery and medicine cases, the DBSI should be kept near to the lower range.

A limitation of the present study was that it was performed in blood centre of a tertiary care teaching hospital situated in a remote hilly location with relatively low demand/ consumption of PRBC and hence it was easier to manage blood collection accordingly. Therefore, whether these indices can be applied in blood centres of hospitals with large demand/consumption needs to be ascertained.

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