As blood supply tightens, so too does mitigation

“But there were some cases where, after a long discussion with the anesthesiologist, the surgeon, we’d say, this patient is so sick—what is the likelihood that he or she will make it through the liver transplant and survive? Because if not, that’s a double waste of all the blood as well as the liver, which could have gone to a different patient. So there were a couple of hard decisions that were being made as part of our policy.”

The AABB began offering a fairly extensive accreditation program for PBM a few years ago, including online training materials and consultants who can go to a hospital and help the transfusion service implement it, Dr. Cohn notes. The accreditation standards are numerous and even her own hospital is not quite ready to apply. But hospitals should be aware of PBM, she says, and a number of smaller hospitals are not.

Hospitals of all sizes should also give more attention to donor recruitment and collections, in her view. If a blood collection center isn’t a possibility, “simply working with their blood centers to host a blood drive once a quarter could be huge.”

Very few hospitals in the country have blood centers to collect blood, she points out. “It’s considered a financial drain and so a lot of hospitals don’t want it. But sometimes hospitals have to lose money in order to have what’s needed.” During the pandemic-related shortages, “those hospitals that operated a blood center weathered the storm much better than other places.”

Data-driven guidelines for transfusion practice are a good starting point for hospitals facing shortages, says UCLA’s Dr. Ziman. “We work closely with our clinical colleagues to follow those guidelines as much as the patient’s clinical situation allows. Every patient’s clinical situation is different, and therefore a patient may not need blood even though the guidelines might say to transfuse.”

Dr. Ziman considers the splitting of units an option during severe shortages. “We’ve split units to provide half doses to two patients, particularly with platelet transfusions where our inventory is really constrained. We evaluate the indication for transfusion—for example, whether the patient requires a prophylactic transfusion to prevent bleeding or if they’re actually bleeding. With this information, we can determine the most patient-centered approach and employ a combination of split units—half doses—as well as trying to delay some transfusions until additional inventory becomes available.”

To prepare for possible case-by-case triage, they implemented prospective auditing of orders and created an emergency blood management plan, Dr. Ziman explains. “If an order doesn’t meet transfusion guidelines, we discuss the patient’s indication for transfusion with the clinician and, when appropriate, cancel or delay orders. We employ additional strategies as our blood supply gets to more critical levels.” During the most recent critical shortage, for example, they worked collaboratively with the surgeons to ensure there was sufficient blood to meet a patient’s anticipated need for surgery before taking the patient into the OR. “It would be the worst-case scenario where you start a surgery and can’t finish because there is not enough blood for the patient,” she says.

The shortages may make it seem urgent to find ways to lower the discard rate. However, achieving lower discard rates has resulted in lean inventories, which can lead to more severe and protracted shortages, Dr. Ziman warns. “I think we learned from the pandemic that ‘just in time’ isn’t great for pandemic preparedness,” she says. “We’re collecting just enough to take care of patients without excess reserve so there isn’t excess wastage. I believe we must get away from a strategy aimed at minimizing wastage and rather focus on ensuring there is enough blood on the shelves for routine patient care as well as for unexpected emergencies.” This patient-centered and community-centered strategy will come with some amount of acceptable wastage, she says. “If we get to the point where there’s no wastage—if that’s the goal—there will be times when there are no blood products for patient care.”

The Blood Services Section of the National Institutes of Health Clinical Center Department of Transfusion Medicine, which collects blood products to provide transfusion services for clinical trial patients, doesn’t have an emergency room, says section chief Kamille West-Mitchell, MD. “So we don’t have to be ready for a major emergency the way a lot of blood centers do.”

But there can still be complications or unanticipated effects from the therapies under study. One example is when an infusion of a cellular therapy results in complications such as cytokine release syndrome or coagulopathy. During the pandemic, “we did have major unanticipated bleeding of patients in the ICU on clinical trials and we needed to respond immediately,” she says.

Where patient blood management is most likely to be used at the NIH is before surgeries, when in multidisciplinary meetings clinicians decide a procedure will take more blood than is available and they reschedule to be sure it is a safe procedure. The transfusion service instituted triage criteria when the pandemic began “because we anticipated we would have shortages,” Dr. West-Mitchell says. “These are the points at which we also developed critical thresholds for inventory.”

She does not advocate the splitting of red cell units as a means of stretching the blood units on hand. In her setting, splitting units for pediatric patients is commonplace, “but for an adult you’re not going to use less than a unit of red blood cells.” But one of the current hot topics in transfusion medicine is low-dose platelets, products that contain fewer platelets than the minimum threshold for a standard unit. “We don’t use this approach at NIH, but clinical trials suggest that low-dose platelet transfusions are safe to prevent bleeding in some stable patients,” Dr. West-Mitchell says.

Like Dr. Cohn, she says hospitals should not count out the possibility of starting or stepping up their blood collection. “I know the cost of hospital blood banks and they’re out of fashion and somewhere in the minority. But if you need to, you can adjust by increasing or decreasing your own collections.”

The often competing needs of planned scheduled surgeries and emergency care can require transfusion services to consider dramatic interventions, Glenn Ramsey, MD, chair of the CAP Transfusion, Apheresis, and Cellular Therapy Committee, has found. For two or three weeks in January, Northwestern University, where he is director of transfusion medicine, put organ transplant services on a preapproval basis. “So if there was a group O patient who was getting a liver or heart or lung transplant, we were requiring them to check with the blood bank first before they took the offer of an organ,” says Dr. Ramsey, who is also professor of pathology at Northwestern Feinberg School of Medicine.

During regular conferences with state and local departments of health, hospitals in his region of Illinois asked health officials whether hospitals ready to exhaust their blood reserves could cancel or postpone their trauma services. “The answer from the state was no. They would not allow hospitals to go on trauma bypass because of blood shortage.”

“So we had to still be ready for the potential massive transfusion protocol in an obstetrical case with large-scale hemorrhage or severe trauma or gastrointestinal bleeding,” Dr. Ramsey says. “What if we had a supermassive transfusion protocol using more than 20 units? We were able to tell the hospital administration what are the odds on a per-day basis of that happening.” This is the type of balancing act that all hospitals need to think about when a severe shortage might lie ahead, he advises.

Advances in storage capability could help by extending platelets’ shelf life. Clinical research protocols at a number of hospitals across the country, Dr. Ramsey says, are studying whether refrigerated platelets could be stored for perhaps 14 days or longer, in contrast with a five- to seven-day outdate. Some hospitals and blood centers have applied for variance from FDA standards as a means of trying to get through shortages or to meet the platelet demands of rural trauma.

Splitting units is “definitely an option that should be considered in some situations,” in Dr. Ramsey’s view. Half units of platelets might be used in cases in which physicians want a threshold of platelet count for a procedure or for controlling bleeding or for prophylactic use. And it’s not only platelets that are candidates for splitting. Northwestern, in several dozen cases, started giving half units of red cells for the first time ever “to try to stretch our group O supply. We asked physicians to reduce their normal threshold for transfusion in stable patients from 7 g/dL to 6.5 g/dL. And if there was concern about a particular patient at the 6.5 level, we were offering half units to help with those concerns.” Evidence-based guidelines on when to transfuse support this practice, he says.

“There’s also been a growing movement in transfusion therapy on stable patients to use one unit at a time and reassess the patient between units. This is sort of a central tenet of patient blood management these days.” Clinical trials have shown that conservative transfusion practices result in the best patient outcomes, “and that’s been gratifying to see,” Dr. Ramsey says.

Patient blood management may focus on surgical patients but it applies to all patients, by recommending treatment of anemia before the patient needs transfusion, minimizing blood loss in surgical patients, and having a 360-degree view of patients to avoid coagulopathy and anemia, Dr. Ramsey says. It might entail not only figuring out bleeding risks before surgery but also salvaging blood during surgery for patients in the right context and finding ways to reduce unnecessary phlebotomy in the hospital, which is a source of iatrogenic anemia. In the ICU, patients can lose a tremendous amount of blood just through phlebotomy, he notes. A PBM perspective would involve asking: “Do we really need all those lab tests, or can we get by with fewer tests to reduce blood loss in the patients?”

More studies are needed on hematology/oncology patients who may need chronic transfusions, and cardiac disease patients for which there’s uncertainty about balancing cardiac ischemia with blood viscosity, he notes. “But there are a lot more guidelines out there now to help.”

More difficult transfusion protocols could be needed with certain patients, Dr. Ramsey adds. If a patient is requiring a large amount of blood, survivability becomes an important factor, and it becomes particularly important where the hospital’s blood supply may be threatened by one patient’s transfusion needs.

Whatever is done to mitigate a shortage, Dr. Ramsey and Dr. Kopko emphasize the need to involve hospital clinical leadership. Says Dr. Kopko: “The best advice I could possibly give is, if you are the director of your blood bank and you do not personally know your chief medical officer, it’s time to go make a friend. If you have the CMO supporting the things you are doing to mitigate shortages, people are going to get on board.”

Anne Paxton is a writer and attorney in Seattle. Dr. Ramsey and Matthew Karafin, MD, MS, of the Department of Pathology and Laboratory Medicine, University of North Carolina School of Medicine, will give a course on “Using Blood Wisely and in Shortages” on Oct. 8 at CAP22.