Best Practice in Platelet Inventory Management
facilitated by Craig Taylor and Rachel Moss                            

Background 
While red cell use in the UK has fallen considerably over the last few years platelet use has continued to rise. The National Blood Service issued 217 270 units of platelets in 2005-06 (NIBTS 7236) representing a rise of 0.8 over the previous year (NIBTS 3.6%).
Wastage levels for platelets are high compared to red cells, both within the blood services and within the hospitals. In 2005-06 the NBS wasted 12.2%, while the NIBTS wasted 21.1%. Over the same period hospitals supplied by 6.9% and those supplied by the NIBTS wasted  10%.
A relatively high wastage of platelets both at the blood centres and the hospitals is inevitable given the short shelf life. There has however been relatively little emphasis on the appropriate usage of platelets and inventory management recently and it is possible that considerable savings can be made in this area.
Groups were asked to identify important issues/problems and to suggest possible solutions/best practice

The Workshops
The workshop was run twice during the day, in the morning and in the afternoon. Most participants were biomedical scientists though a few transfusion practitioners and consultants also attended. Participants were given a brief introduction by Craig Taylor before being split into 5 groups to discuss the following broad topics:

• Stock holding of platelets
• Ordering and delivery of platelets
• Crossing ABO/D groups and “robbing Peter to pay Paul”
• Influence of near patient testing and TEG on platelet use and management
• Special requirements (CMV, HLA etc) and predicting usage

For each topic participants were asked to consider important issues and problems, and to suggest possible solutions and best practice.

Outcome of Discussions
The themes of discussion in each group often overlapped.

1. Stock holding of platelets
Factors affecting whether a blood bank was likely to hold stock platelets included the size and workload of the hospital, the distance/time from the blood centre and the number of deliveries each day. There were a number of concerns raised around the practicalities of holding stock platelets and the purchase, validation and monitoring of storage facilities may be an issue for those wanting to start keeping.
The ideal stock platelet was felt to be an A neg, CMV neg, irradiated, HT neg unit, and there was some concern about the ability of the blood services to maintain a supply if all hospitals were to take stock. It was felt that wastage would inevitably increase at the hospital end if stock were held, and this represents a major disincentive to holding stock in many units.
An interesting poster was presented at the meeting that suggested that although stock holding increases wastage, the overall cost to the blood bank may go down when the ad hoc charges are taken into account. In addition the crossing of ABO/D groups would need to be more widely accepted and this would require further education of staff involved in the clinical areas as well as the blood banks.
There was also felt to be the potential for some confusion in identifying which platelets were stock and which were for named patients prior to labelling.
While the decision to hold stock must be made on an individual basis, several suggestions were made that might make this more attractive and workable:

• Pre-planning orders benefits both the hospital and the blood centres
• Extending the shelf life of all platelets would reduce the hospital and blood centre wastage, and make stock holding more attractive
• Supply of short dated platelets on a sale or return basis might encourage stock holding
• Inter-hospital transfer of stock would reduce wastage

Monitoring and audit is important and it was suggested that this might be facilitated by the blood services identifying those units that had been supplied as stock.

 2. Ordering and delivery of platelets
Many of the problems experienced by blood banks arise because of the behaviour of clinicians, and not necessarily because of genuinely unforeseen circumstances. In particular, it was suggested that clinicians created problems by putting in late requests, and failing to understand the issues with regard to the supply and availability of platelets. Clinicians were felt to have unrealistic expectations of the delivery times achievable.
Platelets that are requested and not used create waste, and one participant reported that 80% of pre-ordered platelets were wasted.
The solution to this is partly education though this is difficult to keep up with given the rapid rotation of junior doctors. A common approach is to set a strict ordering cut off time, and some reported success in using this approach though many continue to have difficulties. Putting the patient first makes it difficult to enforce such strategies.
The response time for hospitals was a problem when ordering, and there were considerable issues around short dated stock, and stock levels on Mondays and Tuesdays and over Bank holidays/Christmas/New Year. This situation is from time to time exacerbated by delays in obtaining NAT results, and this was felt to occur frequently enough to be an issue.
Many of the problems in this area could be avoided by holding stock of platelets.
It was suggested that the Blood Service should fund facilities to allow stock holding and the idea of stock rotation/sharing was raised. Problems with the MHRA were envisaged in setting this up however.
It was suggested that platelet only deliveries might be introduced, or routine rounds might carry extra platelets that can be supplied to those that need them, avoiding some ad hoc deliveries. Again, an extension of the shelf life may alleviate some of the problems, and sale or return of stock was suggested.
It was suggested that the Blood Services could consider the 7 day production of pooled platelets to address the problems at weekends and at holidays
Finally, it was suggested that hospitals must accept some wastage.

3. Crossing ABO/D groups & “Robbing Peter to pay Paul”
The crossing of ABO barriers, and using of platelets that are held for a different patient is common practice, and often undertaken when supplies of the correct group are not available or to avoid wastage or ad hoc deliveries. However, some laboratory systems will not easily allow the issue of the wrong group and require a ‘cheat’ to work around the problem.
It is not desirable to issue the wrong group to neonates and children, and it is not good practice to give Dpos to women who are Dneg and of childbearing age. In addition it was pointed out that sticking to the same group resulted in better increments.
It was suggested that education of both clinical and laboratory staff may be needed in this area.

4. Influence of near patient testing and TEG on platelet use & management
The use of near patient testing has become more prevalent in recent years and the use of TEG may now be having an effect on the use of platelets. There were concerns that treatment on the basis of these technologies may not always be based on good clinical studies, and that the rapidly available results may result in the immediate treatment of results rather than the patient.
It was suggested that the consultant haematologists and the HTC need to take a greater role in agreeing guidelines and protocols for treatment based on the results of NPT and TEG. A particular concern was that the laboratory may not be aware of the reason that components are being ordered, and may not have a record of the NPT results in the lab.
It was suggested that transmission of results to the lab is essential, and this may be achievable electronically with some systems. The maintenance and QA/QC of near patient testing equipment was a concern and it was agreed that this should have laboratory input. This is not always the case at present.
There was no consensus as to whether the use of NPT reduced or increased the use of platelets and participants reported both experiences.
The issue of stock holding was again raised and felt to be desirable if the results of NPT results are to be acting on promptly.

5. Special requirements (CMV, HLA etc) & predicting usage
Special requirements cause issues with both specially ordered and stock platelets. There are problems with availability and concerns were raised around who authorises the request for special components, and when the requirements are reviewed, and who by.
Wastage was identified as a particular concern where HLA typed platelets were needed to cover surgery and not in the end needed. The need to occasionally cross groups to meet special requirements was discussed, and the occasional need for anti D to be administered.
The dilemma of whether to use an HLA typed unit for someone else in urgent need was discussed and it was felt that on occasions this may be appropriate but that knowledge of how easily the unit can be replaced would aid in making the decision.
Again it was suggested that the inter-hospital transfer of platelets may ease some of the problems of supply, as would an extended shelf life.

Conclusion and Comment
There were several common themes that ran through the discussions. It was recognised that wastage is not always the most important issue in the platelet supply chain, and that there will always be a high wastage on a product with such a short shelf life.
There is an obvious benefit of having stock closer to the patients, but this shifts a larger portion of the cost of the inevitable wastage to the hospitals, and there is an understandable reluctance to take this on.
The recently increased cost of ad-hoc deliveries has to be set against this and many hospitals may find it worthwhile looking at this issue again. Many of the suggestions made relate to bringing stock closer to the patients, either as stock holding in blood bank, sharing of stock between hospitals or carrying stock on the rounds.

It was felt that there was a need for the whole supply chain to be examined, from vein to vein, to establish the most efficient and cost effective model (for the NHS as a whole) for the supply of platelets.