Playing a Deadly Game of Match by David Wyld

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Playing

a deadly game of match How new efforts to use RFID in blood banking and transfusion can save patient lives and safeguard the blood supply chain

“A unit of blood that will save a patient ‒ or kill him ‒ looks exactly the same.” ‒ Dr. S. Gerald Sandler, Director of Transfusion Medicine, Georgetown University Hospital

by David C. Wyld, Southeastern Louisiana University

lood. Itʼs the foundation of all our lives. And when we or a family member need blood and blood products, whether it be due to an accident, surgery, or an ongoing medical condition, we must make a “leap of faith” that we are being given safe blood ‒ blood that has been donated by a thoroughly screened donor, blood that has been prop-

Global Identiﬁcation - March 2008

erly stored, transported and handled, and blood that is of the correct type. Each and every day, approximately 40,000 units of red blood are transfused, and each year, almost 30 million units of blood components ‒ red blood cells, plasma, platelets, and cryoprecipitated AHF (antihemophilic factor) ‒ are needed in all. The blood supply chain in

America is a donor-based system, rooted in the over 8 million people who donate blood annually. It is a time delimited system: donors can only donate once every 56 days, and blood products, unless they are frozen, must be used in a timely fashion. For instance, red blood cells have a shelf life in cold storage of just 42 days. Platelets ‒ used in the treatment of cancer and leukemia pa-

tients and in cases where doctors are attempting to control bleeding ‒ can be stored at room temperature, but they have only a 7 day maximum shelf life. Cryoprecipitated AHF, made from fresh frozen plasma, must be Granulocytes, which are sometimes used to ﬁght infections, must be transfused within 24 hours of donation, and likewise, fresh frozen plasma, must be used within 8 hours. The blood distribution system is largely regional in nature, with donated blood products being collected and held at local blood banks and hospitals. It is a cooperative system, in which the blood centers and hospitals can access each othersʼ blood product stock in cases of speciﬁc needs and emergencies. Due to the very nature of blood, the need to match the blood needed by patients with that provided by donors is a complex equation. As can be seen in Figure 1, blood types are not by any means evenly distributed across the population. According to the most recent national statistics available, over 70% of the US population is one of two blood types (O Rhpositive or A Rh-positive), while the remaining 28% is distributed across six less common blood types. This makes for a complex formula to determine the compatibility between different types of blood, other than for O Rh-positive, which can be universally received by persons of any blood type.

To complicate matters even further, the distribution of blood types across the entire population does not hold true in subpopulations. For instance, Hispanic-Americans have a much higher number of O Rh-positives (in

to donate blood. As can be seen in Table 2, the list of reasons for persons to be permanently or temporarily barred from donating blood has grown quite lengthy, with everything from illness, prescription drugs, and

Blood donors can only donate every 56 days and blood products, unless they are frozen, must be used in a timely fashion fact, over half are O+), while African and Asian-Americans have relatively much higher number of B Rhpositives (both groups are at least double that of the entire population). As we will see later, it is critical for correct matches to be made between blood types.

Donations

travel to certain countries disqualifying large numbers of Americans. In fact, according to a just-published article in the leading journal in the ﬁeld, Transfusion, the research team of William Riley, Matthew Schwei, Jeffrey McCullough found that only approximately one-third of the entire US population ‒ 111 million individuals ‒ are eligible to donate blood.

A ﬁnal complicating factor in the blood supply chain is the growing number of persons who are not eligible

Thus, the restrictions on the pool of eligible donors severely restrict the “ﬂow” of blood into the blood supply

Distribution of American blood types

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chain. Taken together, blood banks and medical facilities must play an intense game of match between their supply of blood products and the uncertainty of the exact needs. Even though bar coding has taken hold in blood bank management, staff must carefully monitor the storage and transport of blood products, which means time and labor intensive inventory and recordkeeping efforts.

Supply chain breaking

Reasons why people may be denied or deferred from donating blood

The need for this “blood supply chain” to work properly is absolute for the over ﬁve million Americans who receive blood and blood products annually, but unfortunately, sometimes that supply chain breaks down ‒ most notably in the form of human error. According to the US Food and Drug Administration

Global Identiﬁcation - March 2008

(FDA), the chance that a patient will receive the wrong blood due to a mismatch of the patientʼs blood type and the donor blood is estimated to occur in one out of every 14,000 transfusions ‒ a rate that has not improved over the past two decades. Fortunately, the odds of a patient actually dying from such a blood transfusion error are far greater ‒ ofﬁcially estimated to be approximately one in 600,000. This is due to the fact that some mismatches are harmless, while in severe cases, aggressive medical treatment can counteract the ill effects. Still, in the medical community, there is a general sentiment that the true number of blood mismatches is far greater, due to the fact that many cases go unreported or even unnoticed. And, recent research in the United Kingdom has in fact found far higher rates of transfu-

sion errors. In fact, the national, ongoing Serious Hazards of Transfusion (SHOT) study has found over 100 likely deaths and 300 cases of serious complications resulting from patients being transfused with the wrong blood. The precise number of adverse events is indeed difficult to determine. For instance, if an extremely ill patient who has received blood products later dies, the cause will more than likely be due to the original condition. Likewise, if an accident victim who has been transfused multiple units of blood in surgery develops complications or dies, it may be difficult, if not impossible to determine that mismatched blood may have been the principal causal factor. How do blood mistransfusions occur? The critical point in the entire blood delivery chain is at the point of delivery ‒ at the patientʼs bedside or in the operating room. Most blood handling protocols call for positive matches between the patientʼs ID and the unit bag of blood being ‒ most with positive identification required by two nurses, doctors, and aides. While bar coding labeling has taken hold in the area of blood banking, bar-coded wristbands have proven to be especially problematic for inpatients, especially the longer they are worn. While new wristbands can be easily read by the PDA scanners typically used both in hospitals and outpatient surgery centers, wristbands that become crinkled, smudged,

faded, or torn can be difﬁcult or even impossible to be read. The longer a patient wears a wristband, the higher the odds that the band may simply be made unreadable due to the surface being stained by ﬂuids or food or being damaged by water from bathing.

RFID and the blood supply chain There is signiﬁcant interest in the health care community to introducing RFID technology into the handling and administration of blood products. This is evidenced by the number of pilots and small implementations that have taken place to date worldwide, which include the following identiﬁed in the United States and abroad: • Jackson, MS USA (Mississippi Blood Services) • Pittsburgh, PA USA (St. Clair Hospital) • Washington, DC (Georgetown University Medical Center) • Saarbrücken, Germany (Saarbrücken Clinic Winterberg, Internal Medicine Division) • Bologna, Italy (Ospedale Maggiore) • Malaysia (The University Malaya Medical Centre, Penang Adventist Hospital, National Blood Bank). These trials are using passive RFID as a supplement to the traditional labeling and bar coding of blood units. RFID over barcodes is the fact that you can read an entire blood container without opening

Source Data: Southern Californian Red Cross, 2006

it and that you donʼt have to reposition every bag in a tray in order to read the contents as described on the RFID label. With RFID, it is possible to inventory an entire tray or cooler of blood bags in seconds, rather than having to scan each unitʼs bar code individually. Early reports show that RFID has improved the inventory management of blood products and helped to alleviate concerns over mistransfusions at the last step of the chain. The reaction to these efforts has been largely positive across medical staff and clinicians. The ROI comes from the labor and time savings involved in the process, along with the vast potential savings that come from the potential large costs that would be associated with an adverse event stemming from a blood mistransfusion. The expectation is that such installations will accelerate over the next few years. Presently, the International Society of Blood Transfusion (ISBT) is currently at work to develop global standards for the use of RFID in blood

banking and transfusions. These are expected to be released by early 2008. The American Blood Commission is funding a study being carried out by the Blood Center of Wisconsin and the University of Wisconsin RFID Lab to determine if sustained exposure to RF energy might have any adverse effects on blood products.

RFID has improved the inventory management of blood products and helped to alleviate concerns over mistransfusions at the last step of the chain

The blood supply chain will likely thus be one of the fastest emerging areas for RFID applications to develop and take hold in the health care area. When paired with RFIDbased patient identiﬁcation wristbands, which have numerous advantages over the former bar code and handwritten-based systems, “smart” blood banking and transfusion protocols can improve patient safety, produce ROI, heighten productivity and morale, and reduce liability exposure for blood banks and hospitals worldwide. RFID can thus make this all-important game of match work far better for all, producing signiﬁcant market opportunities on a global scale for RFID vendors.