Article

Original Article

Ann Lab Med 2022; 42(3): 342-351

Published online May 1, 2022 https://doi.org/10.3343/alm.2022.42.3.342

Copyright © Korean Society for Laboratory Medicine.

Questionnaire Survey on Current Red Blood Cell Transport and Storage in Korea for Reducing Wastage

Mikyoung Park, M.D., Ph.D.1 , Mina Hur, M.D., Ph.D.2 , Hahah Kim, M.D., Ph.D.2 , Kyungmi Oh, R.N., Ph.D.3 , Hyunmi Kim, R.N.4 , Young Hye Song, R.N., Ph.D.4 , Dae-Hyun Ko, M.D., Ph.D.5 , and Yousun Chung, M.D.6

1Department of Laboratory Medicine, Eunpyeong St. Mary’s Hospital, College of Medicine, The Catholic University of Korea, Seoul, Korea; 2Department of Laboratory Medicine, Konkuk University School of Medicine, Seoul, Korea; 3Department of Nursing, Kyungbok University, Namyangju, Korea; 4Department of Nursing, Konkuk University Medical Center, Seoul, Korea; 5Department of Laboratory Medicine, University of Ulsan College of Medicine and Asan Medical Center, Seoul, Korea; 6Department of Laboratory Medicine, Hallym University College of Medicine, Seoul, Korea

Correspondence to: Mina Hur, M.D., Ph.D.
Department of Laboratory Medicine, Konkuk University School of Medicine, Konkuk University Medical Center, 120-1 Neungdong-ro, Hwayang-dong, Gwangjin-gu, Seoul 05030, Korea
Tel: +82-2-2030-5581
E-mail: dearmina@hanmail.net

Received: August 10, 2021; Revised: October 13, 2021; Accepted: November 8, 2021

This is an Open Access article distributed under the terms of the Creative Commons Attribution Non-Commercial License (http://creativecommons.org/licenses/by-nc/4.0) which permits unrestricted non-commercial use, distribution, and reproduction in any medium, provided the original work is properly cited.

Background: To ensure safe red blood cell (RBC) transfusion practice, it is important to comply with storage and transport requirements of RBC units. We conducted a comprehensive survey on the practice of RBC transport and storage to explore the awareness of and compliance with the 30-minute rule, the current status of RBC unit transport, and possible utility of temperature indicators (TIs) to reduce RBC wastage.
Methods: From June to August of 2019, 64 blood bank physicians (14 questions) in 64 secondary- and tertiary-care hospitals and 673 nurses (13 questions) in 42 tertiary-care hospitals replied to a questionnaire survey. The results of the survey were analyzed with descriptive statistics.
Results: Among the physicians surveyed, 97.0% (N=62) of hospitals had transfusion guidelines in place. The RBC wastage in 2018 ranged from less than five units to more than 200 units. Among the nurses surveyed, 99.4% (N=669) were aware of and complied with the 30-minute rule; 13.5% (N=91) of the nurses had experience of RBC wastage due to violation of the 30-minute rule. Both physicians (67%, N=43) and nurses (83.1%, N=559) responded that TIs would help reduce RBC wastage.
Conclusions: This is the first survey on the practices related to RBC transport and storage in Korea. This study provides fundamental data on current practice for the blood cold chain, insights into RBC wastage, and highlights the utility of TIs.

Keywords: Red blood cells, Survey, Transport, Storage, 30-minute rule, Temperature-sensitive indicator, Wastage

Red blood cell (RBC) units are the most widely transfused component during patient care, including critically and non-critically ill patients [1, 2]. For safe RBC transfusion practice, it is important to comply with storage and transport requirements of RBC units [3-5]. RBC units should be kept at 1–6°C during storage in a blood bank refrigerator and at 1–10°C during transport, according to the American Association of Blood Banks [3]. The Korean transfusion guidelines state that RBC units exceeding a core temperature (CT) of 10°C should not be retrieved from the blood bank [4].

Based on a study performed in the early 1970s, the 30-minute rule has been used as a customary time limit; to ensure that the CT of RBC units does not exceed 10°C, in clinical practice, RBC transfusion should be initiated within 30 minutes after issue from the blood bank [4, 6-8]. The World Health Organization (WHO) states that RBC units kept out of the blood bank refrigerator for over 30 minutes should be discarded; if RBC units are not transfused immediately at wards or operating rooms (ORs) without blood refrigerators, RBC units should be issued from the blood bank just prior to transfusion [7]. To ensure that the temperature of RBC units remains below 10°C during transport, each transport container needs to be in a controlled temperature condition [8].

An international survey showed that the overall wastage rate of issued RBC units ranged from 1.9% to 2.8% in the United States, Africa, Europe, and Australia; up to 1.4% of RBC units were discarded due to an improper transport container or violation of the transport temperature requirement [9]. The 30-minute rule was also suggested to cause increased RBC wastage [10, 11]. RBC wastage due to violation of the 30-minute rule or uncontrolled temperature ranged from 0.4% to 22.3% among all discarded RBC units [12, 13].

Temperature-sensitive indicators (TIs), which are adhesive labels with an irreversible color change at 10°C, were recently introduced to transfusion practice to monitor the surface temperature (ST) of RBC units and are expected to help maintain the blood cold chain and reduce RBC wastage [5, 14-18]. However, some practical issues surrounding the use of current TIs remain with regard to heterogeneity and lack of standardization, questioning whether TIs are indeed useful for reducing RBC wastage in transfusion practice [5, 17].

The blood cold chain is a process to store and transport blood safely from the site of donation to the site of transfusion [8]. Nurses take a frontline role in RBC transfusion practice at bedside [7, 19, 20]. Therefore, both blood bank physicians and nurses must be aware of and comply with storage and transport requirements of RBC units to guarantee adequate transfusion practice and reduce RBC wastage [20-22]. To the best of our knowledge, there has been no published survey on RBC transport and storage practice including blood bank physicians as well as nurses in a real hospital setting. We conducted a comprehensive survey on the RBC cold chain practice to explore the awareness of and compliance with the 30-minute rule, the current status of RBC unit transport, and possible utility of TIs to reduce RBC wastage.

Study population

This study was conducted as part of the 2019 Policy Research Service Project of the Korea Centers for Disease Control and Prevention, titled “The Efficient Management of Blood Resources using Temperature Indicators” (Number 2019E830400). The study protocol was approved by the Institutional Review Board of Konkuk University Medical Center (KUMC 2019-05-028). In June 2019, the survey and questionnaire were designed and critically reviewed by nine experts from three professional academic societies: Korean Society for Laboratory Medicine (KSLM), Korean Society of Blood Transfusion (KSBT), and Korean Nurses Association (KNA). The survey to blood bank physicians comprised a short questionnaire (with 13 questions) to assess the blood cold chain practice of RBC units in the blood bank. The survey was sent by e-mail or post to blood bank physicians who are certified members of KSLM or those of KSBT working at 93 secondary- or tertiary-care hospitals. A total of 64 blood bank physicians working at 64 hospitals (one physician per hospital) replied to the survey completely anonymously. Nurses working at 42 tertiary-care hospitals were sent a short questionnaire (with 15 questions) to assess nursing practice for the blood cold chain of RBC units; a total of 673 nurses replied to the survey completely anonymously. The surveys were conducted from June to August 2019, and the data were compiled in August 2019.

Questionnaire surveys

The questionnaire surveys consisted of basic demographic questions. For physicians, three questions on basic demographics were included: hospital size, geographic region in Korea, and status of certified members of KSLM. The 13 questions on blood bank practice were related to the existence and content of RBC transfusion guidelines at the hospital, criteria for discarding RBC units after issue or within the blood bank in the RBC transfusion guidelines, transport container to the ward after issue, ST monitoring of RBC units at transport after issue, total number of blood refrigerators at the ward or outpatient clinic, existence of a ward with a blood refrigerator, crossmatching tests in 2018, RBC units issued in 2018, RBC wastage in 2018, crossmatch to transfusion (C:T) ratio in 2018, expected utility of TIs to reduce RBC wastage, and reasons for the expected low utility of TIs to reduce RBC wastage. A blood refrigerator was defined as a refrigerator intended for only blood storage with an automated temperature monitoring system and an alarm when the temperature exceeds unacceptable levels [8]. RBC wastage was defined as discarded amounts of issued RBC units or those stored in the blood bank [9, 12].

For nurses, four questions on basic demographics were included: hospital size, geographic region in Korea, nursing department, and clinical experience as a nurse. The 15 questions on blood bank practice were related to the existence and content of nursing practice guidelines for RBC transfusion, criteria for discarding RBC units after issue in the nursing practice guidelines for RBC transfusion, use of a transport container to the ward after issue, types of transport containers to the ward after issue, ST monitoring of RBC units during transport after issue, blood refrigerator located at the ward or outpatient clinic, storage time limit of RBC units in the blood refrigerator at the ward, monitoring of temperature of the blood refrigerator at the ward, knowledge of the 30-minute rule, compliance with the 30-minute rule, experience of RBC unit discarding due to violation of the 30-minute rule, reasons for RBC unit discard due to violation of the 30-minute rule, expected utility of TIs to reduce RBC wastage, and reasons for the expected low utility of TIs to reduce RBC wastage.

Statistical analysis

Data are presented as number (percentage). Descriptive statistics were used to summarize survey data. Statistical analysis was performed using the MedCalc software version 19.7.4 (MedCalc Software Bvba, Ostend, Belgium) and Microsoft Excel 2019 (Microsoft Corporation, Redmond, WA, USA).

Basic demographics of the total respondents are summarized in Table 1. The majority of respondents were from hospitals with 500–999 beds, accounting for 54.7% (N=35) of blood bank physicians and 67.5% (N=454) of nurses. Most of the respondents’ affiliated hospitals were located in a metropolitan area (Seoul, Inchon, and Gyeonggi-do). The majority of physicians were certified blood bank physicians (96.9%, N=62). Most of the nurses’ affiliated departments of nursing were the general ward (GW) and intensive care unit (ICU), and 47.5% (N=320) of the nurses had more than 10 years of nursing experience.

Table 1 . Basic demographics of the survey respondents (N=737)

VariablesN of respondents (%)

Blood bank physicians (N = 64)Nurses (N = 673)
Hospital size
< 100 beds0 (0.0)1 (0.1)
100–499 beds18 (28.1)9 (1.3)
500–999 beds35 (54.7)454 (67.5)
1,000–1,999 beds8 (12.5)126 (18.7)
2,000–2,999 beds2 (3.1)16 (2.4)
≥ 3,000 beds1 (1.6)67 (10.0)
Geographic region in Korea
Seoul22 (34.4)304 (45.2)
Incheon, Gyeonggi-do14 (21.9)183 (27.2)
Busan, Daegu, Gryengsang region9 (14.1)67 (10.0)
Sejong, Daejeon, Chungcheong region8 (12.5)34 (5.1)
Gwangju, Jeolla region6 (9.4)82 (12.2)
Gangwon-do, Jeju-do5 (7.8)3 (0.4)
Certified members of KSLM62 (96.9)N/A
Nursing department
GWN/A439 (65.2)
ICU114 (16.9)
OR37 (5.5)
ED28 (4.2)
OC26 (3.9)
Others29 (4.3)
Clinical experience of as a nurse
< 1 yrN/A57 (8.5)
1–2.9 yr92 (13.7)
3–4.9 yr89 (13.2)
5–9.9 yr115 (17.1)
≥ 10 yr320 (47.5)

Abbreviations: KSLM, Korean Society of Laboratory Medicine; GW, general ward; ICU, intensive care unit; OR, operating room; ED, emergency department; OC, outpatient clinic; N/A, not available; yr, year.



The survey results of blood bank physicians are summarized in Table 2. The majority (96.9%) indicated the existence of transfusion guidelines at their hospitals, including the 30-minute rule; 85.9% (N=55) of physicians stated that blood refrigerators are equipped at hospital wards. The number of RBC units issued in 2018 ranged from <500 units to >50,000 units. Regarding the C:T ratio, 44.4% (N=28) and 14.3% (N=9) were below 1.1 and above 1.4, respectively. Regarding the expected utility of TIs to reduce RBC wastage, 67% (N=43) and 33% (N=21) of blood bank physicians stated that TIs would have high and low utility, respectively. Reasons for the expected low utility of TIs were as follows: low RBC wastage due to violation of the 30-minute rule (81.0%, N=17), possibility of increasing RBC wastage due to the fast color change of TIs (52.4%, N=11), intra- or inter-observer variability in reading the color change of TIs (33.3%, N=7).

Table 2 . Summary of the survey to blood bank physicians (N=64)

QuestionnaireN of respondents (%)
Presence of RBC transfusion guidelines
Yes63 (98.4)
No1 (1.6)
Contents of RBC transfusion guidelines*
Shipping and receiving RBC units from the blood center51 (79.7)
Storage temperature of RBC unit in the blood bank62 (96.9)
Transport of RBC units to the ward after issue56 (87.5)
RBC transfusion51 (81.3)
Standards for discard of RBC unit after issue*63 (98.4)
Criteria for discard of RBC units after issue or within the blood bank in RBC transfusion guidelines*63 (98.4)
Exposure to RT for over 30 minutes62 (96.9)
ST of RBC units to reach 10°C34 (53.1)
Damaged RBC units56 (87.5)
Contaminated RBC units53 (82.8)
Withdrawal of RBC transfusion due to the change of patient’s condition39 (60.9)
Transfusion-related adverse reactions48 (75.0)
Transport container to ward after issue
Cooler only22 (34.4)
Cooler with refrigerant31 (48.4)
Cooler with refrigerant and TI1 (1.6)
Others (e.g., cool bag, plastic box, plastic bag)10 (15.6)
ST monitoring of RBC units at transport after issue1 (1.6)
Total numbers of blood refrigerators at ward or outpatient clinic55 (85.9)
126 (47.3)
212 (21.8)
33 (5.5)
≥414 (25.4)
Ward with blood refrigerator*55 (85.9)
GW3 (5.5)
ICU21 (38.2)
OR52 (94.5)
ED20 (36.4)
OC1 (1.8)
Crossmatching tests in 2018
< 1,0002 (3.2)
1,000–4,99910 (15.9)
5,000–9,99913 (20.6)
10,000–49,99932 (50.8)
50,000–99,9995 (7.9)
≥ 100,0001 (1.6)
RBC units issued in 2018
< 5001 (1.6)
500–9993 (4.8)
1,000–4,9999 (41.3)
5,000–9,99921 (33.3)
10,000–49,99926 (41.3)
≥ 50,0003 (4.8)
RBC wastage in 2018
<56 (9.5)
5–910 (15.9)
10–1911 (17.5)
20–4916 (25.4)
50–9915 (23.8)
100–1994 (6.3)
≥ 2001 (1.6)
C:T ratio in 2018
1.0 to < 1.128 (44.4)
1.1 to < 1.216 (25.4)
1.2 to < 1.37 (11.1)
1.3 to < 1.43 (4.8)
≥ 1.49 (14.3)
Expected utility of TIs to reduce RBC wastage
High utility43 (67.2)
Low utility21 (32.8)
Reasons of expected low utility of TIs to reduce RBC wastage*21 (32.8)
Low RBC wastage due to violation of the 30-minute rule17 (81.0)
Possibility to increase RBC wastage due to a too-fast color change of TIs11 (52.4)
Intra- or inter-observer variability in reading a color change of TIs7 (33.3)

*Multiple choice; The number of respondents was 63, excluding one from a newly opened hospital (<1 year).

Abbreviations: RBC, red blood cell; RT, room temperature; TI, temperature-sensitive indicator; ST, surface temperature; GW, general ward; ICU, intensive care unit; OR, operating room; ED, emergency department; OC, outpatient clinic; C:T ratio, crossmatch to transfusion ratio.



The survey results of nurses are summarized in Table 3. The majority of nurses indicated that their hospitals had existing nursing practice guidelines for RBC transfusion, which included the 30-minute rule as a standard for RBC unit discard, and they were aware of and complied with the 30-minute rule. Some nurses (13.7%, N=92) indicated experience of RBC unit discard due to violation of the 30-minute rule. Regarding the expected utility of TIs to reduce RBC wastage, 83.1% (N=559) and 16.9% (N=114) of nurses answered that TIs would have high and low utility, respectively. Reasons for the expected low utility of TIs were as follows: difficulty of reading a color change of TIs (76.3%, N=87), low RBC wastage due to violation of the 30-minute rule (62.3%, N=71); possibility of delayed transfusion due to reading the color change of TIs (62.3%, N=71), insufficient time to read the color change of TIs due to nursing tasks (46.5%, N=53); and possibility to increase RBC wastage due to the fast color change of TIs (1.8%, N=2).

Table 3 . Summary of the survey to nurses (N=673)

QuestionnaireN of respondents (%)
Presence of nursing practice guidelines for RBC transfusion
Yes616 (91.5)
No4 (0.6)
Unknown53 (7.9)
Contents of nursing practice guidelines for RBC transfusion*
Preparation for RBC transfusion614 (99.7)
Storage of RBC units until transfusion571 (92.7)
Storage temperature for RBC units558 (90.6)
Transport temperature for RBC units355 (57.6)
Nursing practice during intra-transfusion600 (97.4)
Standard and procedure for return and discard of RBC units615 (99.8)
Criteria for discard of RBC units after issue in nursing practice guidelines for RBC transfusion*615 (99.8)
Exposure to RT for over 30 minutes570 (92.7)
ST of RBC unit to reach 10°C251 (40.8)
Damaged RBC units555 (90.2)
Contaminated RBC units547 (88.9)
Withdrawal of RBC transfusion due to the change of patient’s condition468 (76.1)
Transfusion-related adverse reactions528 (85.9)
Use of transport container to ward after issue
Yes666 (99.0)
No1 (0.1)
Unknown6 (0.9)
Types of transport container to ward after issue
Cooler only278 (41.7)
Cooler with refrigerant361 (54.2)
Cooler with refrigerant and TI8 (1.2)
Others (e.g., cool bag, plastic box, plastic bag)19 (2.8)
ST monitoring of RBC units at transport after issue8 (1.2)
Blood refrigerator equipped in ward or outpatient clinic200 (29.7)
GW83 (41.5)
ICU51 (25.5)
OR36 (18.0)
ED20 (10.0)
OC10 (5.0)
Storage time limit of RBC units in blood refrigerator at ward
≤ 30 min6 (3.0)
≤ 12 hr9 (4.5)
≤ 24 hr170 (85.0)
> 24 hr5 (2.5)
No standard2 (1.0)
Unknown8 (4.0)
Monitoring of temperature of blood refrigerator at ward
Electronic monitoring only40 (20.0)
Electronic monitoring with regular check by clinical nurses148 (74.0)
Unknown12 (6.0)
Knowledge about the 30-minute rule669 (99.4)
Compliance of the 30-minute rule666 (99.0)
Experience of discard of RBC units due to violation of the 30-minute rule92 (13.7)
Reasons of discard of RBC units due to violation of the 30-minute rule*
Withdrawal of transfusion due to change of patient’s condition77 (11.4)
Delayed transfusion due to other nursing tasks12 (1.8)
Delayed transport of RBC units2 (0.3)
Exposure to RT over 30 minutes after issue1 (0.2)
Failed blood refrigerator in ward1 (0.2)
Patient’s absence1 (0.2)
Expected utility of TIs to reduce RBC wastage
High utility559 (83.1)
Low utility114 (16.9)
Reasons of expected low utility of TIs to reduce RBC wastage*114 (16.9)
Difficulty of reading a color change of TIs87 (76.3)
Low RBC wastage due to violation of the 30-minute rule71 (62.3)
Possibility of delayed transfusion due to reading a color change of TIs71 (62.3)
Insufficient time to read a color change of TIs due to nursing tasks53 (46.5)
Possibility to increase RBC wastage due to a too fast color change of TIs2 (1.8)

*Multiple choice.

Abbreviations: RBC, red blood cells; OC, outpatient clinic; RT, room temperature; ST, surface temperature; TI, temperature-sensitive indicator; GW, general ward; ICU, intensive care unit; OR, operating room; ED, emergency department.


This questionnaire survey of blood bank physicians and nurses focused on the practice for the blood cold chain of RBC units at a blood bank and bedside, and their awareness and expected utility of TIs. In particular, our survey focused on the awareness and compliance of the 30-minute rule, the practical situation of RBC transport, and possible utility of TIs to reduce RBC wastage. Most of the blood bank physicians answered that their hospitals have RBC transfusion guidelines that include standards for RBC unit discard after issue. Although most of the guidelines include details about RBC unit transport to the ward after issue, this is generally not accompanied by detailed protocols defining transport conditions, including the transport container and/or temperature monitoring. Most of the nurses also answered that their hospitals have nursing practice guidelines for RBC transfusion that include the standard for RBC unit discard. However, only slightly more than a half (57.6%) answered that the content of transport temperature for RBC unit was included in the guidelines.

The majority of the RBC transfusion guidelines in the blood bank and nursing practice guidelines for RBC transfusion included the 30-minute rule as the standard for discard of RBC units after issue. However, the content of ST monitoring of RBC units during transport was rarely included in either guideline type. Approximately half of the blood bank physicians answered that they do not use a refrigerant during transport of RBC units to maintain transport temperature. Although most nurses were aware of and complied with the 30-minute rule, one veteran nurse with clinical experience of more than 10 years and three nurses with clinical experience <5 years were not aware of the 30-minute rule. Among them, only two nurses answered that they have nursing practice guidelines for RBC transfusion including the 30-minute rule. Taken together, it seems that both blood bank physicians and nurses are aware of the importance of the blood cold chain, are familiar with the 30-minute rule and 10°C rule, and follow the 30-minute rule. In actual practice, little attention has been paid to RBC transport compared with RBC storage, and no detailed protocols and/or guidance have been prepared for the same. National guidelines and/or guidelines from professional societies are needed for the safe transport of RBC units.

Regarding the wastage rate of RBC units, in the three of the participating hospitals, the RBC wastage rate ranged from 0.02% to 0.26%. In one of the three hospitals, 2.4% (N=2) of the RBC wastage was due to violation of the 30-minute rule (83 RBC units discarded in 2018). Among nurses with experience of RBC unit discard due to violation of the 30-minute rule, 0.5% (N=3) answered that an RBC unit was discarded due to delayed transport or exposure to room temperature (RT) for over 30 minutes. Kim, et al. [23] reported that 0.6% (N=1) of blood units were discarded due violation of the 30-minute rule among 162 discarded blood units. Only 5.5% (N=3) of blood bank physicians answered that the GW was equipped with a blood refrigerator; however, 41.5% (N=83) of nurses answered that their GW was equipped with a blood refrigerator. Since the survey to nurses was conducted anonymously, it is possible that this response referred to the same specific GWs.

In nursing practice, the storage time limit of RBC units in blood refrigerators at the ward varied, with the highest response of 24 hours. One nurse replied that the storage time limit of RBC units was set at 24 hours in the blood refrigerator at ward, but that the majority of RBC transfusions were performed within 30 minutes after issue. The WHO stated that it takes at least 30 minutes for a blood bank refrigerator with a full load of blood units set to 4°C to reach up to 6°C; however, no statement is provided on the time limit for storage in a blood refrigerator at the ward after issue regarding the 30-minute rule [8]. A time limit up to 60 minutes is acceptable for RBC units outside of controlled temperature [8, 11, 24]. RBC units exposed to uncontrolled temperature conditions for 60 minutes should be cooled down below 6°C for over 6 hours prior to reissue [2]. No significant change in RBC quality was found at temperatures higher than 10°C or with storage times longer than 30 minutes [25, 26]. Thus, the 30-minute rule has been amended to the 60-minute rule in the United Kingdom and Canada [24, 27, 28], resulting in significantly reduced RBC wastage [28]. Although we did not survey the actual wastage rate of RBC units and the overall rate of RBC wastage due to violation of the 30-minute rule nationwide, it is expected that the RBC shortage would increase. Blood donations could decrease under certain circumstances, including outbreaks of infectious diseases, such as COVID-19, and a decrease of eligible blood donors due to demographic changes given the declining birth rate and aging society [29, 30]; the increase in elderly people may also be associated with an increased demand of RBC usage [31]. Taken together, the customary 30-minute rule should be reconsidered in the face of contemporary society; extending or changing this time rule should also be considered in other countries.

The majority of blood bank physicians (67.2%) and nurses (83.1%) answered that TIs would have high utility to reduce RBC wastage; however, the distribution of reasons for the expected low utility of TIs to reduce RBC wastage varied between blood bank physicians and nurses. Most blood bank physicians and nurses who indicated that TIs would not be helpful answered like that because of the current low rate of RBC discard due to violation of the 30-minute rule. Moreover, more than a half of the blood bank physicians who selected the expected low utility of TIs answered that TIs could potentially increase RBC wastage due to the too-fast color change. Most of the nurses (76.3%, N=87) who selected the expected low utility of TIs answered that the interpretation of a color change of TIs would be difficult.

The time for a color change indicating 10°C varies across different TIs; in one study, more than 90% of TIs already showed a color change indicating 10°C within 30 minutes under RT [5, 1517]. Various factors affect the color change of TIs [5]. Reportedly, 87.4% of RBC units were discarded due to violation of the 30-minute rule after issue or color change of TIs among total discarded RBC units [32]. Intra- or inter-observer variability is also a concern in interpretation of the color change [5, 15]; in a recent study, time–temperature indicators (TTIs) showed better performance than TIs [17]. Although TIs could serve as a supplementary tool to reduce RBC wastage, several limitations, including performance, should first be overcome [5, 17, 32]. Although not included in the survey, the cost concerns and cost-effectiveness of TIs might have also resulted in selecting the “low utility” option.

This study has several limitations. First, the survey subjects were limited to blood bank physicians and nurses working at secondary- or tertiary-care hospitals in Korea, which were concentrated in Seoul, Incheon, and Gyeonggi-do. Although transfusion is conducted in approximately 2,500 medical institutions, our survey focused on blood bank physicians and nurses in hospitals where RBC transfusions are expected to be performed frequently [33]. Since the survey to nurses was conducted anonymously, we could not further analyze the results according to hospitals and wards; accordingly, there is a possibility that some survey results may have been derived from a few specific hospitals, leading to bias. Second, this survey did not include questions about the status of RBC transfusion within 30 minutes after issue, the wastage rate of an RBC unit due to delayed transfusion, regular education on RBC transfusion guidelines for nurses, and nursing practice at the ward, including the method of storage and discard of an RBC unit after issue. Further surveys with a larger study population and more detailed questions are needed to more accurately reflect the status of blood cold chain nationwide.

In conclusion, we conducted a survey of both blood bank physicians and nurses on RBC transport and storage in real hospital settings. This study provides fundamental data on the current practice for blood cold chain, and understanding about RBC wastage and the expected utility of TIs. Based on our survey results, to maintain the blood cold chain and guarantee safe transfusion practice, it is necessary to prepare detailed consensus guidelines and/or protocols on RBC transport and storage steps. It should also be mandatory to educate and guide medical personnel in these guidelines adequately.


Park M conducted the study, analyzed the data, and wrote the draft; Hur M conceived the study, analyzed the data, and finalized the draft; Kim H, Oh KM, Kim H, and Song YH discussed the data and reviewed the manuscript; Ko DH and Chung YS participated in the data analysis. All authors critically reviewed the manuscript and approved the final version.


No potential conflicts of interest relevant to this article are reported.


This study was supported by Division of Blood Safety Surveillance, Korea Centers for Disease Control and Prevention (No. 2019E830400).

  1. Lelubre C and Vincent JL. Red blood cell transfusion in the critically ill patient. Ann Intensive Care 2011;1:43.
    Pubmed KoreaMed CrossRef
  2. de Bruin S, Scheeren TWL, Bakker J, van Bruggen R, Vlaar APJ; Cardiovascular Dynamics Section and Transfusion Guideline Task Force of the ESICM. Transfusion practice in the non-bleeding critically ill: an international online survey-the TRACE survey. Crit Care 2019;23:309.
    Pubmed KoreaMed CrossRef
  3. Alquist CR and Harm S. Transfusion service-related activities: pretransfusion testing and storage, monitoring, processing, distribution, and inventory management of blood Components. In: Cohn CS. ed. Technical manual. 20th ed. Bethesda: American Association of Blood Banks, 2020:503-35.
  4. Korea Centers for Disease Control & Prevention. Transfusion guideline. http://www.transfusion.or.kr/KOR/images/file/4_file01.pdf (Last accessed: 16 March 2021).
  5. Park M, Hur M, Yi A, Kim H, Lee HK, Jeon EY, et al. Utility of temperature-sensitive indicators for temperature monitoring of red-blood-cell units. Vox Sang 2019;114:487-94.
    Pubmed CrossRef
  6. Pick P and Fabijanic J. Temperature changes in donor blood under different storage conditions. Transfusion 1971;11:213-5.
    Pubmed CrossRef
  7. World Health Organization. Clinical transfusion practice. https://www.who.int/bloodsafety/transfusion_services/ClinicalTransfusionPracticeGuidelinesforMedicalInternsBangladesh.pdf (Last accessed: 16 March 2021).
  8. World Health Organization. The blood cold chain. https://www.who.int/bloodsafety/testing_processing/components/en/BloodColdChain.pdf?ua=1 (Last accessed: 16 March 2021).
  9. Yazer MH, Abraham S, Beckman N, Folléa G. International Society for Blood Transfusion international survey on blood product wastage in hospitals. ISBT Sci Ser 2016;11:24-31.
    CrossRef
  10. Hamill TR. The 30-minute rule for reissuing blood: are we needlessly discarding units? Transfusion 1990;30:58-62.
    Pubmed CrossRef
  11. Dumani D, Goldfinger D, Ziman A. Is the 30-minute rule still applicable in the 21st century? Transfusion 2013;53:1150-2.
    Pubmed CrossRef
  12. Kurup R, Anderson A, Boston C, Burns L, George M, Frank M. A study on blood product usage and wastage at the public hospital, Guyana. BMC Res Notes 2016;9:307.
    Pubmed KoreaMed CrossRef
  13. NHS blood stocks management scheme. NHS Blood and Transplant/hospital report 2017-18. https://nhsbtdbe.blob.core.windows.net/umbraco-assets-corp/15951/nhsbt-annual-report-2017-18.pdf (Last accessed: 16 March 2021).
  14. Johnson V, Langeberg A, Taye-Makuria A, Sandler SG. Temperature-sensitive labels for containers of RBCs. Am J Clin Pathol 2006;126:406-10.
    Pubmed CrossRef
  15. Sigle JP, Holbro A, Lehmann T, Infanti L, Gerull S, Stern M, et al. Temperature-sensitive indicators for monitoring RBC concentrates out of controlled temperature storage. Am J Clin Pathol 2015;144:145-50.
    Pubmed CrossRef
  16. Tiwari AK, Sharma P, Pandey PK, Rawat GS, Dixit S, Raina V, et al. A cost effective model for appropriate administration of red cell units and salvaging un-transfused red cell units by using temperature sensitive indicators for blood component transportation in a hospital setting. Asian J Transfus Sci 2015;9:36-40.
    Pubmed KoreaMed CrossRef
  17. Park M, Hur M, Kim H, Oh K, Ko DH, Chung Y. Time-temperature indicators versus temperature indicators for transfusion practice: application in the real hospital setting. Vox Sang 2021 July 28. doi: 10.1111/vox.13182. Online ahead of print.
    Pubmed CrossRef
  18. Bots M, de Grouw EP, van Rooyen-Schreurs IH, van den Akker GJ, Sturk A, Klinkspoor JH, et al. Strategies to reduce wastage of red blood cell units. Vox Sang 2016;110:143-9.
    Pubmed CrossRef
  19. Gallagher T, Darby S, Vodanovich M, Campbell L, Tovey J. Patient blood management nurse vs transfusion nurse: is it time to merge? Br J Nurs 2015;24:492-5.
    Pubmed CrossRef
  20. Nakamura Y, Furuta Y, Tokida M, Ichikawa K, Shirahata M, Uzawa K, et al. A survey of nurses to assess transfusion practice at the bedside using an electronic identification system: experience at a university hospital. Transfus Med 2021;31:5-10.
    Pubmed CrossRef
  21. Ddungu H, Krantz EM, Phipps W, Naluzze S, Orem J, Kiwanuka N, et al. Survey to assess knowledge and reported practices regarding blood transfusion among cancer physicians in Uganda. J Glob Oncol 2018;4:1-12.
    Pubmed KoreaMed CrossRef
  22. Islami Vaghar M. The impact of an educational program on blood and blood products transfusion on nurses' level of knowledge and performance. J Med Life 2018;11:238-42.
    Pubmed KoreaMed CrossRef
  23. Kim BS, Seo YI, Chai GR, Shin JW, Choi TY. Analysis of discarded blood components at a university hospital in Korea. Korean J Blood Transfus 2011;22:120-6.
  24. SPECIFICATION SPN223/10 NHSBT portfolio of blood components and guidance for their clinical use. https://nhsbtdbe.blob.core.windows.net/umbraco-assets-corp/16494/spn223v10.pdf (Last accessed: 16 March 2021).
  25. Thomas S, Hancock V, Cardigan R. The 30 minute rule for red blood cells: in vitro quality assessment after repeated exposure to 30°C. Transfusion 2013;53:1169-77.
    Pubmed CrossRef
  26. Ramirez-Arcos S, Mastronardi C, Perkins H, Kou Y, Turner T, Mastronardi E, et al. Evaluating the 4-hour and 30-minute rules: effects of room temperature exposure on red blood cell quality and bacterial growth. Transfusion 2013;53:851-9.
    Pubmed CrossRef
  27. Ramirez-Arcos S, Kou Y, Ducas É, Thibault L. Changing the 30-min rule in Canada: the effect of room temperature on bacterial growth in red blood cells. Transfus Med Hemother 2016;43:396-9.
    Pubmed KoreaMed CrossRef
  28. Aplin K, Pitt T, Allen J, Roy A, Tidey K, Ball J, et al. Extending the 30-minute rule for red cell units-investigation of the bacterial risk of 60-minute exposures to ambient temperature. Vox Sang 2019;114:189-97.
    Pubmed CrossRef
  29. Stanworth SJ, New HV, Apelseth TO, Brunskill S, Cardigan R, Doree C, et al. Effects of the COVID-19 pandemic on supply and use of blood for transfusion. Lancet Haematol 2020;7:e756-64.
    Pubmed KoreaMed CrossRef
  30. Müller-Steinhardt M, Müller-Kuller T, Weiss C, Menzel D, Wiesneth M, Seifried E, et al. Safety and frequency of whole blood donations from elderly donors. Vox Sang 2012;102:134-9.
    Pubmed CrossRef
  31. Ali A, Auvinen MK, Rautonen J. The aging population poses a global challenge for blood services. Transfusion 2010;50:584-8.
    Pubmed CrossRef
  32. Heitmiller ES, Hill RB, Marshall CE, Parsons BJ, Berkow LC, Barrasso CA, et al. Blood wastage reduction using Lean Sigma methodology. Transfusion 2010;50:1887-96.
    Pubmed CrossRef
  33. Chun S, Choi JS, Jung YZ, Shin JW, Jeong KE, Oh JA, et al. Survey on the preparation status of medical institutions regarding the full revision of the Korean Blood Inventory Monitoring System. Korean J Blood Transfus 2020;31:211-21.
    CrossRef