A Proposed Managerial Model for Improvement of Blood Consumption in the Operating Rooms in Southern Iran

Blood transfusion is one of the most important health issues in the modern world. Despite extensive advances in various fields of medicine, scientists have not yet been able to find a viable alternative to human blood, so the only source of blood is the already donated blood (1). World Health Organization states that about 87.5% of developing countries supply less than half of the blood requirements for their populations (2). On the other hand, the demand for blood bags in hospitals depends on the number of daily admission of patients with accident-related injuries, which cannot be well forecasted; therefore, in most cases, forecasting the daily demand of hospitals might not exactly correspond to their real demand (3). Various studies mentioned excessive blood ordering as a major cause of blood wastage (4-6). The importance of demand forecasting in the blood supply chain process and the criteria for measuring blood utilization in health care settings have been investigated in many studies (7, 8). Different management models and targeted interventions, such as using trained personnel for blood product transportation (8) and managing as well as reducing excessive orders of blood (9, 10), have been proposed and established in different countries. In Iran, based on comprehensive research during 2005 - 2015, the two main causes of blood product wastage were stated as date expiry and returned/reserved units of operating rooms and wards (1). On the other hand, 34.7% and 93% of the red blood cells (RBCs) wastage have been reported in surgery units in different medical centers of Iran (11, 12). Lack of standard guidelines for proper blood ordering and consumption is stated as a major problem leading to blood wastage in Southern Iran, as well (13). Enormous costs of preparing blood products, as well as relative costs of wasting blood, have received considerable attention from researchers worldwide (14, 15). Taken together, implementing efficient interventions for promoting blood product consumption is considered as one of the major health issues, especially in developing countries that are facing limitations in blood supply.

Therefore, this study was designed to suggest an effective blood consumption management model based on determining the most influential initiatives using stakeholders’ opinions in the operating rooms of the largest tertiary referral hospital in Southern Iran.

In this cross-sectional study, 185 participants, consisting of 10 anesthesiologists, 33 surgeons, 75 anesthesiology technicians, and 67 surgical technicians, were enrolled during September and November 2019 in the Nemazee Hospital, the largest tertiary referral center in Southern Iran. Inclusion criteria were all anesthesiologists, surgeons, anesthesiology technicians, and surgical technicians working in the operating rooms during the study period who were willing to cooperate with us. Based on Mundfrom et al.’s study (16), the suggested minimums for the sample size are 3 to 20 times the number of variables. Therefore, our sample size is enough for confirmatory factor analysis (8 samples per item). The study protocol was approved by the Ethical Committee of the Islamic Azad University (ethics code: IR.IAU.SRB.REC.1398.078, approval code = 15899).

In the first step, a comprehensive literature search was done to determine the effective factors and initiatives previously reported for improvement of blood consumption management and decreasing blood wastage (Table 1).

Data of 185 participants (60 (32.5%) females and 125 (67.5%) males), with a mean age of 40.63 ± 12.31 years were analyzed. The CFA model is depicted in Figure 1. Five dimensions influencing blood consumption management in descending order were as follows: Resource allocation, control, and leadership, planning, and organization process.

Figure 1.

General model of CFA

Factor loading values of each factor are shown in Table 2. The standardized coefficients and a significant number of items are demonstrated in Table 3. Model fit indices had acceptable values, indicating the appropriateness of the proposed model (P = 0.032) (Table 4).

Table 5 demonstrates the most impressive interventions for improving blood consumption management in operating rooms based on the calculated coefficients in the suggested model. Interventions with less impact on blood consumption management in each dimension were as follow:

Resource Allocation: Q5: Considering full-time specific blood bank experts in the operating rooms for supervising blood consumption process (0.69).

Control: Q19: Monitoring and tracing electronic data of blood bag consumption (0.61); Q1: Annual supervision of blood products use by blood supply institutions and hospitals (0.57).

Leadership: Q8: Preparing and implementing problem-based guidelines for blood consumption in each ward such as Maximum Surgical Blood Ordering Schedule (MSBOS) (0.51);

Q9 1-3: Developing an educational program on blood consumption management via electronic program (0.46), sessions, lectures, and workshops (0.49), or pamphlets and books (0.47);

Q10: The possibility of transportation of the unused blood bags between hospitals in one city (0.54);

Q14 1-2: Correcting anemia before operation in outpatient clinics and hospitals (0.49) or specific stations of blood transfusion organization in each city (0.42).

Planning: Q18: Convincing the hospital management to establish a coherent electronic system for recording blood data (0.51);

Q2 1-2: Annual reporting of blood utilization indices via the website (0.49) or quarterly blood product bulletin (0.45).

Organization process: Q13: Careful review of electronic medical records of surgical patients before surgery by the responsible physician (0.58),

Q4: Designing an Intranet website to better transfer blood consumption data between hospital wards (0.46).

In the present study, factors and initiatives affecting the management of blood consumption in operating rooms were studied in a large tertiary referral hospital in southern Iran. The most impressive and practical interventions were determined based on the viewpoints of the surgeons, anesthesiologists, and technicians of the operating rooms and proposed as an effective model.

In the suggested model, resource allocation was determined as the most impressive managerial dimension, which its most effective factor was using trained and oriented personnel to inventory management principles and blood bag handling, storage, and transportation rules, followed by providing in-hospital safe and standard blood transportation equipment. Therefore, providing the required efficient and appropriate transportation equipment, such as monitoring temperature devices and specific protective boxes for different types of blood products, as well as suitable allocation of skilled personnel, not only can substantially reduce blood wastage but also improve blood bag consumption management in the hospital. In the same vein, Javadzadeh Shahshahani et al. (31) and Heitmiller et al. (8) showed that the use of trained personnel for transporting blood bags reduced the wastage of blood bags. Also, inappropriate transportation equipment has been recognized as one of the important factors causing RBC wastage in previously reported articles (8, 9). Moreover, Bots et al. (32) showed that straightforward interventions, particularly improving transport conditions, had a clear impact on the level of RBC wastage.

The second most influential dimension was "control". In this facet, the most impressive subject was evaluating and reporting reasons for the expiry date of blood products, such as excessive orders of blood bags in operating rooms. In accordance with our results, excessive order of blood was suggested as one of the major causes of blood wastage in several studies (9, 27, 33). Another important problem in our center that leads to a high amount of blood wastage is a high frequency of canceled transfusion injections, mainly due to canceled surgeries. It seems that implementing a designed control program can be highly efficient in this regard. Generally, managing the inventory by careful assessment of blood product supply and demand is one of the crucial issues in blood consumption management (34).

Concerning leadership, prioritizing consumption of older blood bags, rather than newer ones (FIFO: first in/first out), by blood banks was the most important factor influencing the management of blood usage in operating rooms. Our finding was similar to those of Stanger et al.’s (35) study, which showed that FIFO was one of the most important disciplines in reducing wastage. Likewise, Soleymani et al. (21) detected a 75% reduction rate in the loss of blood bags after implementing the FIFO law. The use of national and international blood management guidelines was recognized as another important factor improving blood consumption management, which should be taken into account with more caution.

In the planning dimension, creating responsibility for those ordering blood bags by signing and recording the details seems to be effective in increasing attention towards the appropriate ordering of blood products and decreasing the rate of wastage. In the last dimension, designing a systematic and user-friendly electronic software for registration of all data related to blood products was identified as the most important factor that can decrease blood wastage at the hospital. It seems that in developing countries, including Iran, this important issue has been neglected due to the shortage of financial resources; however, establishing a systematic electronic system for data registry translates into improved monitoring and tracking of inventories, resulting in better management and will be highly cost-effective in the field of blood consumption.

From less important influencing factors, implementation of problem-based guidelines for blood consumption in each ward, such as MSBOS, and establishment of a regular educational program with different teaching methods for related staff should be taken into consideration as well.

Our study was limited due to using data from a single center; however, as mentioned above this center was the largest referral tertiary center in Southern Iran.