Compur. & Opr Res. Vol. 6, PP.

69-V
Pergamon Press Ltd.,1979.Printed inGreatBritain

COMPUTER-BASED REGIONAL BLOOD DISTRIBUTION

GREGORYP. PRASTACOS*
Department of Decision Sciences, The Wharton School, University of Pennsylvania, PA 19104,U.S.A.

and

ERIC BRODHEIM?
Operations Research Laboratory, The New York Blood Center, NY 10021,U.S.A.

(Received 15 November 1978)

Scope and purpose-Human blood is a product of unique medical value. It is perishable, having a usable
lifetime of 21 days, and its supply and demand are probabilistic. These factors make the efficient
management of the regional blood resources a very complex task. This paper describes a prototype blood
distribution system currently in effect in Long Island, New York. The system is based on a provedly
efficient analytical model, and is completely computerized, as part of a larger blood management network.
The system has been in operation for three years. It has introduced a routine operation in the management
of the blood region, and has drastically reduced the outdating and shortage incidents in the region.

Abstract-This paper describes the regional blood distribution system used in Long Island, New York. A
brief review of the theoretical model is given ftrst. Then the operational system is discussed, and the
automation support is described. Finally, results are presented and evaluated.

INTRODUCTION
One of the most important medical resources of a community is its blood management system.
Through this system blood is collected in units of one pint from volunteer donors at various
collection sites by the staff of a Regional Blood Center (RBC), and after a series of typing and
screening tests performed at the RBC it is shipped to the Hospital Blood Banks (HBBs) in the
region to be stored and be available for transfusion.
Efficient management of the regional blood resources is a complex task. Blood is a
perishable product: it has a legal lifetime of 21 days from collection, during which it can be used
for transfusion to a patient of the same type, and after which it has to be discarded. Its supply
and demand are probabilistic and partly seasonal. Finally, it must be inventoried under special
medical considerations at hospitals whose annual transfusion volumes range from several
hundred to tens of thousands of pints per year.
As a result of this complexity, most of the distribution systems that are in effect in blood
regions can be characterized as “reactive”[l] in nature: the HBBs of the region usually call
every morning and order such quantities of blood that will bring their inventories to what each
one considers “safe” levels. The RBC usually tries to fill these orders, and at the same time
keep some necessary buffer inventory at the RBC. In general, not all HBB’s orders can be filled
to the size they are requested. This creates a feeling of uncertainty and a tendency for
overordering, thus generating artificial shortage situations, and adding to the problems of the
regional system.
*Dr.Gregory P. Prastacos is Assistant Professor of Decision Sciences at the Wharton School of the University of
Pennsylvania, where he is teaching courses in Operations Research, Stochastic Decision Models, and ManagementInformation
Systems. He holds a B.S. and an M.S. in Computer Science, and an Sc.D. in Operations Research, all from Columbia
University. Dr. Prastacos has previously been an Adjunct Assistant Professor at Columbia, and a Research Fellow at the
Lindsley F. Kimball Research Institute of the New York Blood Center. Dr. Prastacos has worked extensively on perishable
inventory theory: he is a contributor to numerous Operations Research and Management Science journals, and he has been
awarded (together with E. Brodheim)the 1979International Management Science Achievement Award in the Tims competition
on the practice of Management Science. His current research interests are in stochastic optimization models, and the design
and evaluation of computer information systems.
tDr. Eric Brodheim is Investigator at the Operations Research Laboratory of the Lindsley F. Kimball Research Institute
of the New Blood Center. He holds a B.E.E. from the City University of New York, and an MS. and Sc.D. in Operations
Research from Columbia University. His past academic appointments include Senior Research Associate and Adjunct
Associate Professor at Columbia. Dr. Brodheim has been chairman of national and international committees on blood banking
automation, and is the recipient (together with G. P. Prastacos) of the 1979International Management Science Achievement
Award. His current research interests are in computer information systems, and the automation of blood processing.

69
70 G. P. PRAS~ACOSand E. BRODHEIM

The blood distribution system described in this paper can be considered as “predictive” in
nature: according to it, most of the blood needs are satisfied by prescheduled periodic
shipments from the RBC to each of the HBBs based upon the demonstrated need of each
individual HBB. The system, called Programmed Blood Distribution System (PBDS), has been
in effect in Long Island, New York during the last three years: it has established a smooth and
routine operation in the management of the blood region, and has drastically reduced the
outdating and shortage incidents.
PBDS is based on an analytical distribution model where close to optimal stationary policies
have been derived and evaluated. It is an automated system in itself, and also is part of a larger
automated blood bank network of The New York Blood Program. Finally, its successful
operation has been the result of a careful and continuous cooperation between the technical and
the medical staff in all phases of design, implementation and monitoring of the system.
The theoretical basis for the model, and the algorithm used have been described in[2]. Here
we will discuss the operational aspects of the system, especially the ones related to the
automation aspects of it, and will present certain performance results. We will first briefly
review the model to develop a blood distribution rationale. We will then describe the opera-
tional system and the automation support. Finally, we will evaluate the performance of the
system in light of the set objectives.

A REVIEW OF THE MODEL

Assume that every ten days, blood is collected and is immediately distributed among the n
HBBs of the region. We define this ten-day-interval as one period. We use Q(‘) to denote the
total quantity of fresh blood that is available for distribution at the beginning of period t. Any of
the fresh blood that has not been transfused after one period is returned to the RBC and is
redistributed. Blood that has not been used by the end of its second period is outdated and has
to be discarded. We will use R(‘) and W@)to denote the one-period-old returns to the RBC and
the outdates, respectively, at the end of period t. Thus, at the beginning of every period t, HBB
k receives quantities Qp) and RI,(I) of fresh (rotation) and one-period-old (retention) blood,
respectively, to keep in inventory for one period.
Let Fk( ) denote the probability distribution of demand for blood at HBB k. If the demand
during one period exceeds the HBB’s inventory, the excess is satisfied through a shortage
delivery, either from the RBC’s buffer inventory, or from special calls to registered donors. We
will use S@)to denote the total quantity short in the region during period t.
We will assume that unit penalties s and w are associated respectively for every unit short
and for every unit outdated in the region. Obviously, the quantities R(‘), Set) and W(‘) depend on
the distribution policy 7~used by the RBC. Letting C(T) denote the expected average total cost,
we have
C(n) = s . ES(P) + w . EW(r) (la)
where

(W

If we assume that oldest blood is transfused first at each HBB (FIFO issuing policy?), then it
can be shown[4] that the shipments which minimize next period’s expected cost (i.e. myopically
optimal) satisfy the equations

Fk(RkcL))
= 1 - A, ; k=l,2,...,n (2a)
Fk(Rk(‘)+ Qk”‘)= 1 - A2,. k=l,2,...,n (2b)

where hi and A2 are the lowest possible outdate and shortage rates, respectively, and are
defined such that

2 Rp) = R(l), $, Qk(f)= Q. (2c)

k=l

*It has been shown in[31that FIFO minimizes outdates.

 Computer-based regional blood distribution 71

These results imply that the optimal blood distribution policy can be computed by the following
procedure:
(1) Allocate the one-period-old returns so that the outdate rates (1 - Fk(Rk)) at each HBB
are equalized to a common outdate level Ai.
(2) Allocate the fresh quantity so that the shortage rates (1 - Fk(Rk + Q)) at each HBB are
equalized to a common shortage level AZ.
The results also imply that the shipments computed above minimize both the expected
shortage cost and the expected outdate cost of next period, and not just the sum of the two. We
will denote the policy derived from equations (2) by M. We must note here the shipments
{Qk,Rk} of M can be easily computed in closed form for most of the common demand
distributions [4].
Looking into the infinite horizon problem, it can be shown[5] that the myopically optimal
policy described above is, in fact, better over a large number of policies in the long-run, too,
and its achieved expected average cost is very close to a lower bound.
We now formulate our model: Given “target” values A, and A2 for the outdate rates and
shortage rates, respectively, of each HBB, we wish to determine the minimum rotational supply
needed, and the distribution policy to be used to achieve these targets. We also have to consider
some operational constraints:
(1) For most practical cases the interval between shipments is too long; in practice it is
desirable for this interval to vary between 1 day for the larger HBBs and 4 days for the smallest
HBBs. A computer sensitivity analysis was undertaken to determine the effect of the interval
between shipments on the achieved shortage and outdate rates. It was determined that the new
rates are not significantly different from the previous ones.
(2) It is desirable to pre-schedule the periodic shipments to each HBB, every period. An
analysis of the available statistical data indicated that if a reasonable number of HBBs exist in
the region (of the order of ten or more) each of which is subject to independent demand
patterns, the total returns to the RBC every period can be considered as constant and equal to
their mean value under policy M, ER(M). Therefore, an approximation of the form

Q(‘) = EQ; R(‘) = ER(M)

is valid, and fixed shipments can be implemented. Furthermore, since these fixed shipments are
pre-scheduled, rotation units that are due to return to the RBC on a given day might be kept at
the HBB’s inventory as part of the next retention shipment.
(3) A minimal fraction fk of fresh blood is need to each HBB k for certain medical
procedures. To satisfy this requirement, a constraint is imposed on the model:

Qkzfk; k=l,2 ,..., n. (4)

This completes the model: to solve it, a mathematical program is formulated and solved using a
“grid” algorithm [2].

THE OPERATIONALSYSTEM
The above model has been implemented in Long Island, New York. It was first experiment-
ally tested on a group of 5 HBBs. Upon demonstration it was expanded gradually, until all
38 HBBs in the region were included. Currently, each HBB receives at specified days and times,
fixed, prescheduled quantities of blood, according to a distribution schedule.
The retention units are to stay at the HBB’s inventory until used or outdated. The rotation
units are to return to the RBC after 4 working days (each HBB receives a new shipment at least
that often) unless needed to maintain the HBB’s inventory to the desired level[7]. The resulting
inventory policy for each HBB, and the overall regional blood distribution flow are illustrated in
Figs. 1 and 2. It is seen that smaller HBBs received a higher proportion of rotation (long-dated).
blood, a significant percentage of which is returned to the RBC four days later. Instead, the
larger HBBs receive a higher proportion of retention (stock-dated) blood.
 G. P. PRASTACOSand E. BRODHEIM

MEDIUM-
WALL SIZED LARGE
BLOOD BmD
BANKS BANKS tii2
-. . - -

FOR DESIRED

Fig. 1. Illustration of inventory policies.

SIMPLIFIED REGIONAL
BLOOD DISTRIBUTION FLOWCHART

REGIONAL
BLOOD CENTER

REGIONAL
BLOODCENTER

Fig. 2. Illustration of the regional blood flow.

For PBDS to operate correctly, each HBB is responsible to observe the following important
management rules:
(1) To request supplemental delivery only when the available inventory cannot satisfy the
demands;
(2) To use the oldest units first, whenever possible; and
(3) To return all unused rotation units in excess of the prescribed inventory level back to
the RBC on the due date.
Failure to observe these rules will result in an increase in the outdate rate and/or in the
shortage rate at that HBB.
In order to detect any changes that might occur with time in the usage of an HBB, a control
procedure based on a 5% level Hypothesis Testing is run by the RBC every 2 weeks. On the
basis of the number of rotational units that were returned and of the number of units requested
 Computer-based regional blood distribution 13

on supplemental delivery, the RBC computes a test-statistic related to the recent usage of each
HBB, and checks if the computed value falls within the statisticalfy permitted range. If the
statistic falls in this range, it is concluded that the usage pattern has not changed. Otherwise, it
is concluded that the pattern has changed; it is estimated again using the updated information,
and new shipments are computed.
Figure 3 shows the control charts of the Whole Blood (WB) and Packed Cells (PC) usage of
an HBB over a period of 27 weeks. The s~tistic~y permitted range is the area between the two
outside lines (action limits) of each graph. The charts clearly indicate that the usage of PC is
increasing, with a corresponding decrease in the usage of WB.

COMPUTER SUPPORT
The PBDS system described above has been coded in a series of progranis that run on a
PDPllFlO minicomputer of Digital Equipment Coloration (DEC). The system is using 3
floppy disks: one for the data files, one for the progams, and one for the operating system.
Every two weeks the computer prints packing slips for the periodic shipments to 38 HBBs,
maintains updated files for the demand and usage activity of each Hospital, computes the
control statistics and recomputes the distribution schedule for each HBB whose activity has not
been within the statistically expected range. Figure 4 shows the operations performed at the
RBC every 2 weeks.
PBDS is one element of a larger blood banking network that is being established at the New
York Blood Center. This network also handles automated sample testing at a central location
with test results being transmitted to each location by phone lines[8]. In order to minimize
errors in the recording or processing of transactions, to achieve a cost-effective flexible
computer connation that can be efficiently utilized by non-speci~ists and to accommodate for
increasing or varying needs, the system’s development and use is based on four principles:
(1) bar codes are used to completely identify each blood product,
(2) hod-held light pens are used to enter the ~ansactions, and to operate the computer,
(3) small and relatively inexpensive minicomputers, tied together through communication
lines, are the basic building blocks of the larger network, and
(4) a modular design has been used for the development of the hardware and the software
system.

I BLOOD DISTRIBUTION CONTROL GRAPHS I

central Polii No.: started on:

I Nan of Hospital:
Page:-
I

-6
-6
-10
2 4 6 6 IO I2 14 16 16 20 22 24 26 26 30

WEEK NuMER

Fig. 3. Control chart.

CAOR Vol. 6. No. 2-R
 G. P. PRASTACOS
and E. BRODHEIM

OurPuts OPERATIONS INPUTS

IN0 I I

Decision model
---
program
c

__ _

-23 STOP

Fig. 4. Biweekly operation at the RBC.

According to the standards developed by the American Blood Commission’s Committee for
Commonality in Blood Banking Automation[9], all sample tubes and blood bags are identified
by standard labels which are both eye-readable and machine-readable. In any automated
environment, the scanning of the symbol by a light pen identifies the product uniquely. In a
non-automated environment the symbol is ignored, and the item is identified by the eye-readable
description at the top of the product label.
Since the computers are used in a medical environment, it is essential that their use be made
as simple as possible, and does not require computer-trained personnel. For this reason, the
computer is viewed as a black box which the operator controls solely with the use of a light
pen. The RTll operating system, which is provided by DEC, has been modified so that a
monitor which controls all computer operations assumes control as soon as the computer is
turned on. The operator is prompted to enter identification number, select the program to be
run, and verify or cancel the monitor’s messages by scanning the appropriate bar codes of an
“identification card”. In addition, in almost all cases, transactions are entered by scanning the
appropriate bar codes on the blood bag labels.
Figure 5 shows the configuration of the overall blood management network implemented at
The New York Blood Center. The minicomputer system which is used as a basic building block
 Computer-based regional blood distribution 7s

CENTRAL DATA ACOUISITION

LOCAL UNITS

GLOWSERVICES

LA35 REMOTE

&.Jggtq

Fig. 5. Blood management network.

in the network is the PDPllV03; it is of size to fit under most normal work tables, and can be
wheeled from location to location. Despite its small size and low cost, it has substantial
computing and storage power. A maximal configuration of such a system involves two
partitions (foreground and background), and costs approximately $20,000.
A central PDP11/70 computer switches data between all computer systems, and ac-
cumulates data from all minicomputers for centralized management functions and for further
processing. This computer provides phone lines for communication with the remote units, and
is also connected to local PDPllFlO computers used for blood testing, as well as program
development.

EVALUATION
The implementation of PBDS in Long Island introduced a routine operation in the
management of blood in the region. Each participating HIBB, as well as the Regional Blood
Center, know the times and the sizes of the periodic supplies. This way the logistics of all
transactions are facilitated, and a careful planning of the utilization of resources, personnel and
facilities can be achieved.
The major result of PBDS has been the reduction in the outdating and shortage incidents of
the region. When the previous system was in effect it was estimated that 23% of the regional
blood supply was outdating, and that each HBB would, on an average, call for 8 supplemental
deliveries per month (shortage rate of 27%). Under PBDS, in 1976-1977, reported outdating has
been reduced to 4% with an average of approximately 3 supplemental deliveries per HBB per
month (shortage rate of 9%). Furthermore, the lowest possible outdate and shortage rates that
can be achieved in this region, under assumptions of perfect management, can be shown, using
the results of[.5], to be greater than 2% and 6%, respectively. The achieved results, together
with the lowest bounds are shown in Fig. 6. For a more detailed analysis of the shortage and
outdating performance by blood type or by hospital, the reader is referred to[lO].
It is also of interest to examine the effectiveness of the Control procedure. It is obvious that
tight control bounds would trigger frequent changes in the distribution plans, and could thus be
inefficient in their use. On the other hand, loose bounds would be insensitive to changes in the
demand and usage needs of the HBBs, and would only suggest changes in the distribution
schedules at rare intervals. An analysis of the interval lengths between two successive changes
in distribution for the participating HBBs indicated that the mean time between distribution
76 G. P. PRAS~ACOS
and E. BRODHEIM

I I I I I I

0 IO 20
OUTDATING (7’. of bbod s&y)

Fig. 6. Performance of alternative policies.

changes that are due to demand changes is 5 months. This interval is significantly large to
provide stability in planning operations. In addition, a questionnaire on HBB’s usage that was
recently distributed to the HBBs after two and a half years of operation indicated that the
updated usage estimates for each HBB are within at most a 7% deviation from the reported
figures. This leads us to believe that the control procedure is effectively keeping up with
changes in hospital demand patterns. This aspect of the program is still under investigation.

EXTENSIONS
In this paper we have described the operational aspects of the computer-based blood
distribution system currently in effect in Long Island, New York. The system, together with its
decision making model, can be implemented in other regions in the country, with appropriate
changes of the parameter values, and several RBCs have already demonstrated interest in
testing it.
There are two extensions of the system that we would like to discuss. The fist is the
unification of the distribution system with a blood collections forecasting system to form a
complete blood management system. At present it is assumed that collections can be controlled
to a great extent, and can be considered constant over a reasonable planning horizon. ‘Even
though this is approximately true, the random fluctuations create deviations, and therefore the
Todel can benefit by more accurate forecasting techniques, and larger planning horizons.
The second extengion that is being designed at this time is to tie the receiving hospitals into
the blood center computer to make an entirely automated distribution network. Small micro-
processors at each of the hospitals will record the receipt of blood units by scanning the bar
coded labels on these units. In a similar manner, the reservation of units for possible
transfusion to specific patients are recorded as well as the subsequent transfusion to specific
patients and/or their return to the regional blood center. The microprocessor will maintain a
running inventory of alI units at the hospital with their status. A periodic dial-up of the main
computer at the regional blood center will convey the status information and will perform
various verification operations (e.g. that the units received correspond to those shipped). In this
manner, the regional blood center will be able to adjust its shipments to reflect the actual
inventory situation and will be able to designate the specific unit to be returned. This scheme,
once implemented, is expected to further reduce the requked movement of blood in the region.

REFERENCES
1. DHEW Publication no. (NIH)73-147: Supply and Usage of the Nation’s Blood Resource. p. 38 (1972).
2. G. P. Prastacos and E. Brodheim. A model for reaional .blood distribution. Tech. Reo. No. 14. Ooerations
_ Research
Laboratory, The New York Blood Center, New Y&k (1978).
3. W. Pierskalla and C. Roach, Optimal Issuing Policies for Perishable Inventory, MgmtSci.18,603-614 (1972).
4. G. P. Prastacos, Optimal myopic allocation of a product with fixed lifetime, J. Op. Res. Sot. 29.905-913 (1978).
5. G. P. Prastacos, Allocation of perishable inventory, Tech. Rep. No. 70, Operations Research Group, Columbia
University, New York (1977).
 Computer-based regional blood distribution 77

6. E. Brodheim, C. Derman and G. P. Prastacos, On the evaluation of a class of inventory policies for perishable products
such as blood. hfgmt Sci. 21,132~1326 (1975).
7. E. Brodheim, R. Hirsch and G. P. Prastacos, Setting inventory levels for hospital blood banks. Transfusion 16,63-70
(1976).
8. E. Brodheim, Regional blood center automation, Tm~sfusion 18,298-303(1978).
9. E. Brodheim, G. Gerrick, T. Miier and R. Thatcher, B&rcoding for blood services, Code ond Symbol 3, l-6.
10. E. Brodheim and G. P. Prastacos, A blood management system with prescheduled deliveries. Transfusion. In press
(1979).