Thalassemia Clinic at the McGill University Health Centre1 Cordelia Gray, Director of Operations for Central Laboratories at the McGill University Health Centre (MUHC, a group of several Montreal hospitals), headed up a quality improvement team that was trying to improve the service delivery for thalassemia transfusion patients. The thalassemia clinic served a high-demand population who had suffered from the genetic blood illness their entire life, and now had to fit frequent blood transfusions into their adult life of jobs and family responsibilities. Patients came to the clinic every three weeks for 2 units and sometimes for 3-4 units of blood, each unit taking approximately 3 hours to administer (a total of 6-12 hours). However, prior to receiving the transfusion, the patient's blood had to be sampled and matched, a process that took several hours. The quality improvement team had surveyed its customers (a response rate of 57 out of 59). The results pointed to patient dissatisfaction with the speed with which they received their blood for transfusion - wait times were critical. The process involved the following steps: The patient books appointments. (The several patients that were treated on a given day were scheduled to arrive in the morning, staggered every 20 minutes starting at 9 AM.) The patient comes to clinic and registers. The patient sees doctors, thalassemia coordinator and may have other tests. A nurse in the clinic collects a sample from the patient. The sample is sent by porter to the centralized lab. The sample is tested in the lab for antibodies and samples of donated blood are tested to cross-match. The compatible blood products are retrieved from storage in the blood bank. The blood products are sent by the porter from the blood bank to the clinic. Nurses hang the blood and administer it to the patient. The total process time (prior to the nurse hanging the blood) depended on how quickly the lab was able to cross-match the blood - according to a benchmark with Children's Hospital, the matching process should be done in 2 hours, including travel time. In practice the average time was 2.5 hours with a standard deviation of 2 hours. Those patients whose blood did not test positive for a number of antibodies were served in 2 hours on average, but those patients who did test positive took longer on average 3 hours, as sourcing appropriate blood products was more difficult.2 For these patients, the lab would need to test more samples from donated blood to find one with appropriate characteristics that would not conflict with patient's blood. In fact, patients exhibiting a number of antibodies often required \"washed blood,\" that was generally in short supply and great efforts were made to source matching blood products so washed blood would 1 This case was based on \"UHN: Lindsay Campbell and Thalassemia Quality\" by Joseph D'Cruz 2003. Antibodies affect the typical A, B, O and Rh positive/negative designation. There are a myriad of other antibodies as well. The number of different antibodies a person presents increases as they are exposed through transfusions to more antibodies. Once exposed, the antibodies do not go away. 2 Page 1 of 3 not be used and would be available for other patients. In a typical week, 40% of the thalassemia patients required washed-blood. Also, the later in the day a sample was received by the laboratory, the greater the delay in processing it as demands from other clinics and departments grew. Thalassemia patients were very knowledgeable about their disease and formed a political advocacy group. The clinic served 59 patients, treating 3 to 8 patients a day, 3 days a week (Monday, Wednesday and Friday). When they were unhappy, the group was known to be vocal. Many of the patients had experienced short waits (under 2 hours) for the start of transfusion when served by the Children's Hospital, before graduating into the general population served by MUHC, across the street. At the Children's Hospital, the children's thalassemia clinic, the laboratory and blood bank were located in the same building and parents were able to carry samples to the lab and blood products back to the clinic. The short waits occurred even though the children's thalassemia clinic was only open on Tuesday and Thursday. The clinic, the lab and the blood bank were each located on different buildings and a dedicated porter constantly transported patient samples to the lab and blood products from the bank to the clinic (a walk of 10 minutes between each). Because of the distance, the porter would often wait to carry several samples at once. Unless there was an emergency, the thalassemia clinic was the porter's highest priority. Canadian Blood Services (CBS) typically delivered blood to the blood bank by 8 AM and then samples of the blood to the lab for testing. The testing would be done once a patient's blood sample was present and was needed to be cross-matched for antibodies. Approximately once a week the delivery would be delayed until 10 AM. Normally, blood had a 42-hour shelf life after receipt, but washed red cells had a shelf life of only 24 hours. The blood would be used by patients from all clinics and departments across MUHC. The clinic was served by 3 nurses working 8 hour shifts, two starting work at 8 AM to prepare for the patient's arrivals and the third beginning work at 4 PM to serve clients who had been delayed. This late nurse was also needed in case patients (especially the teenagers) changed their appointments and when patients came in the day before their appointment to get a sample taken early so they would not need to wait the following day. Each nurse was capable of sampling a patient in 10 minutes. Administering each unit of blood, once it arrived, would require 20 minutes of work (including paper work). Thus patients were scheduled to arrive every 20 minutes in the morning. Cordelia Gray recognized that improving the process would require the participation of everyone (doctors, nurses, the lab, patients, CBS) Page 2 of 3 The patients' political advocacy group is claiming that the clinic is understaffed and should be staffed to meet the maximum number (8) of patients every day. Further, they claim that the CBS is not stocking enough blood to satisfy the needs of all the patients and they need to hold more inventory to address any possible demand that will arise from the clinic. Page 3 of 3