As blood supply tightens, so too does mitigation

Anne Paxton

September 2022—Picture a performer juggling tenpins while walking a high wire, knowing that a hurricane looms. Add a safety net that could disappear at any time. That’s a sense of what hospital transfusion services experience in maintaining enough blood products to meet patients’ needs.

The challenges that the pandemic threw into the mix have made the balancing act even trickier. While the extreme shortages hospitals experienced last December and January are gone, many report they have had to adjust from a typical five-day supply pre-pandemic to a two- or three-day supply of blood units, so they’ve become far more vulnerable to emergency surges in blood needs.

But hospitals are deploying an array of tactics to contain blood shortages and to mitigate their effects when they do occur, transfusion medicine experts report. Alyssa Ziman, MD, medical director for Ronald Reagan UCLA Medical Center clinical laboratories and medical director of transfusion medicine and professor of pathology and laboratory medicine at UCLA, sees the strategies or action plans of most hospitals as having three main components: following data-driven guidelines, ensuring the right product goes to the right patient, and ensuring that patients are not unnecessarily transfused. “It’s looking at addressing blood shortages with a patient-centered focus,” she says.

At the University of California San Diego Medical Center, advance planning and communication about transfusion practices, aided by a strong working relationship with the chief medical officer’s office, have helped stave off the worst effects of blood shortages, says Patricia Kopko, MD, professor of pathology and director of transfusion medicine. When the recent shortages took on alarming proportions, the hospital responded by organizing a group of ICU physicians, hospitalists, and the chair of the transfusion committee (and including Dr. Kopko) with a mission to address fundamental questions like “What do we do when we have x units on the shelf and somebody is going to use 3x?”

The team agreed on procedures to fend off shortages by making some transfusions avoidable. “We developed a system where, when we sent blood out for a massive transfusion protocol, as soon as the second refrigerator of units went out, the blood bank alerted one of the surgeons to come up with plans” to control the need for transfusions, such as by encouraging early sending of people to interventional radiology to embolize vessels.

Dr. Kopko also set limits on certain orders. “If you want more than one red cell for an outpatient, you’re going to have to talk to one of the blood bank physicians. If you want more than one for an inpatient, you’re going to have to repeat a hemoglobin and hematocrit if they’re not bleeding, and you’re going to have to prove to us they need it.”

Communications with the medical staff remind clinicians about such rules. “The CMO’s office issues a weekly electronic newsletter for physicians and advanced practice providers, which reported the state of the blood supply during the worst of the blood shortages,” Dr. Kopko says.

These limits have not drawn a single complaint from clinicians, she reports, and they align with the alerts in the medical center’s Epic system, which has set the default order for red cells at one unit. “If you try to order red cells for somebody with a hemoglobin greater than 7 g/dL, a best-practice alert pops up with the message, ‘This is your patient’s most recent hemoglobin; do you really need this? And if so, what do you need it for?’” Surgery would be a valid reason.

For large cases, they send portable refrigerators. “We had a case where they said they needed two units of group O negative issued at the same time, and we said the only way we can give you two is if you will take them in a refrigerator. Because we did not want to lose a single unit,” Dr. Kopko explains.

From its audits, the transfusion service knew that inpatient transfusions were not the source of overuse, she notes. But as part of the response to the serious shortages, it became urgent to curb outpatient unit orders. “Where the transfusion service had to get creative was when somebody comes in and we’ve got to get them to stop bleeding quickly. We knew that two-unit outpatient transfusions were the norm here,” and it was important to reduce that usage level.

However, for some patients that rule can be bent. “If you’ve got a hematologic malignancy, having to come to the cancer center two times a week can be inconvenient. It’s okay to give two units to somebody with a hemoglobin of 6.9 g/dL who’s had chemotherapy and is not going to come back for two weeks. In times of significant shortage, if they came back a week later, they might not need to get a unit.”

Some hospital-based blood centers are using cold storage of platelets to be administered to bleeding patients, but Dr. Kopko says this doesn’t solve the problem of wastage. “They lose a lot of those units because they’re not good for the oncology patients. The cold storage activates the platelets, and that’s good if you are bleeding but not if you don’t have platelets because you had chemotherapy.”

Blood shortages can create painful dilemmas that may require setting priorities among some patients in line for transfusions, says Ralph Vassallo, MD, chief medical and scientific officer of blood supplier Vitalant, Scottsdale, Ariz. He says he is thankful he doesn’t have to conduct this kind of case-by-case triage, but “Vitalant physicians are involved in the discussions because we’re the stewards” of blood products that can be in short supply.

Surgery schedules usually ensure that four O-negative individuals won’t be requiring transfusion at the same time, particularly since many of the surgeries are elective and surgeons are good at juggling, Dr. Vassallo says. “But sometimes the dice roll against you and four patients who are all O-negative come in bleeding. Then you have to scramble to figure out what you can do.” That may include transfusing a partial unit to somebody else on the floor who also needs O-negative, he notes. “And there are many hospitals getting quite good at doing this. But unfortunately, they’re getting too good—because it’s happening too often.”
“When a surgeon says, okay, I want 20 O-negative red cells because I might have someone who’s bleeding on the table, and we have a 60-year-old gentleman who is the patient, we say you’ll have to switch the patient to O-positive because you need to save those units for women of childbearing age.” The risk posed by O-positive is that “there’s an up to 40 percent chance he might form an antibody in the future, and if he needs an emergency transfusion it makes it a little more difficult.”

Second of two parts
Last month: U.S. blood supply steadier but still short

Patient blood management is important to forestall those kinds of outcomes, Dr. Vassallo notes. A possible next step is moving some units around to hospitals that are part of the same system. “Rather than let a unit expire on the shelf, send it to your sister hospital 40 miles away where you know they’re going to use it.” Those arrangements are on the increase, he says. “They are cutting down the safety stock, if you will, because when you have a lot of extra blood that lasts on your shelves for less than 40 days, if it sits there until the end and then expires, that’s a tragedy.” He says a 2019 CDC National Blood Collection and Utilization Survey found that such expirations were occurring with 20 percent of the distributed red cells.

Distributing units to other facilities, where possible, is one good way to keep the discard rate down, agrees Pampee Young, MD, PhD, chief medical officer, biomedical services, American Red Cross.

“The other way to conserve is to have a mechanism to communicate to your hospitals the different levels of utilization restriction, or varying levels of urgency. You may want to say, for example, when your inventory hits x level, that for massive transfusion protocols you don’t send a platelet out for every cycle, but every other cycle.” This kind of systematic, hospitalwide approach to managing shortages is more effective than jumping to diversion or canceling surgeries, she says.

The Red Cross works with its hospitals to be sure they are aware of these kinds of mitigations, Dr. Young notes. But sometimes triage can be needed; it was called for in some cases at the height of the shortage because of the flood of demands for blood. Unfortunately, sometimes a hospital will exaggerate a situation to try to get the blood it needs.

“Because we’re a blood center and we’re not at the bedside, it can be very, very difficult to know what the actual situation is,” Dr. Young says. During the recent shortages, “We were trying to manage very tight inventory and make sure it went to the patients most needing blood. In one case where a hospital said we have a trauma patient and we need red cells, we said, ‘What blood type do you need?’ And they said As and Os. Well, obviously a single bleeding patient can’t need two different blood types.”

“The system can be hampered by lack of transparency,” she says.

Meeting the needs of the ER and OR can require another tightrope walk, with one set of needs more unpredictable and urgent than the other. “But in the OR, a lot of transfusions happen because of unexpected bleeding and so on,” Dr. Young notes. A crisis is therefore “an opportunity for a closer collaboration with the blood bank and allowing our team to ensure that the right patient mix is scheduled to reflect the availability of products in the blood bank.”

Patient blood management (PBM) caught on in the late 1990s and early 2000s and has reduced over-transfusion, says Claudia Cohn, MD, PhD, chief medical officer of the Association for the Advancement of Blood and Biotherapies (AABB) and director of the blood bank laboratory, associate director of clinical laboratories, and professor of laboratory medicine and pathology, University of Minnesota. “The AABB and other societies came out with evidence-based guidelines for how to more intelligently and rationally use blood.” Using them, her hospital was able to reduce red blood cell use by 15 percent and platelet use by 25 percent, “simply by auditing all of our transfusions, and saying, ‘That wasn’t necessary,’ and sending out a gentle nudge to certain doctors asking, why are you using so much?”

In response to the COVID-19-related blood shortage, her hospital developed a three-tiered plan for dealing with chronic shortages. The first part of the plan would be triggered when they fell below their par levels. “We would institute regular communications with big blood users. For example, every time there was a liver transplant, which is a very heavy blood-use operation, the surgeon would call me and say, ‘I think I need 40 units.’ I would turn to our blood supplier, which almost always said yes,” Dr. Cohn recalls.