Times are tough for blood banks and clinical laboratories working with blood products. In January, the American Red Cross announced that it was facing its worst blood shortage in more than a decade. The organization cited ‘relentless challenges’ due to the COVID-19 pandemic, including an overall 10% drop in the number of people donating blood, as well as ongoing blood drive cancellations and staffing limitations. . The pandemic has contributed to a 62% drop in blood drives in schools and colleges.
Clinical labs and the transfusion medicine community say they are feeling the pinch.
“We have lost 10 to 15 percent of our blood donor pool” from people working from home and businesses that do not organize their usual blood drives, said Magali Fontaine, MD, PhD, director of the transfusion service of the University of Maryland Medical Center in Baltimore. and professor of pathology at the University of Maryland School of Medicine. What is more concerning, she said, is that “the shortage we are currently experiencing is likely here to stay due to the circumstances surrounding its impact on blood donors and donation practices.”
Additionally, there has been a shortage of phlebotomists, in part because of the Great Resignation, Fontaine noted. The good news, she said, is that there are signs the situation may slowly improve as businesses reopen and blood suppliers work hard to “review and use technology to access to donors, especially social media”.
Creative solutions to an unprecedented challenge
With a Level 1 trauma center as well as organ transplant and cancer programs, Fontaine Medical Center easily processes 50 to 150 units of blood per day and transfuses 60,000 products per year. “Our constant worry is that one of these patients will wear us out in no time,” she said. “So we have to constantly monitor the remaining patients in the hospital, or the trauma patients who haven’t been admitted yet.”
Fontaine and his colleagues are taking all precautionary measures to preserve their blood supply and blood products. They scrupulously apply their transfusion directive. If a transfusion is ordered outside the guideline, the laboratory intervenes and verifies that the indication is relevant, Fontaine said. They also rigorously maintain a 5-day blood supply; whenever it starts to drop, they enter into discussions with the heads of intensive care areas to monitor patients more closely, perhaps by postponing certain operations or using blood salvage techniques until stocks recover. And, they ensure that no product expires by taking units from smaller sister hospitals in the health system before they go to waste.
The University of Maryland is not alone.
“It’s just unprecedented,” said Aaron Shmookler, MD, assistant professor of pathology, anatomy, and laboratory medicine at West Virginia University (WVU) in Morgantown.
WVU’s Ruby Memorial Hospital is served by three blood providers. Just before the pandemic, Shmookler and his colleagues implemented a way to transfer blood products between hospitals in their health system using a courier service. This was designed both to save money and to ensure units would not expire without being used. But it turned out to be prescient: Shmookler recently got a call about a patient from a partner hospital who was hemorrhaging, needing blood fast. He was lucky enough to be able to immediately send units to help.
His lab also employs other practices. Using guidance from the Association for the Advancement of Blood and Biotherapies to expand the blood supply, they developed crisis care standards for the use of blood products in their hospital and shared them in their network of 16 hospitals for others to adapt as they please. This includes measures such as the provision of O-positive red blood cells for urgent transfusion to men or women who are no longer of childbearing age (conventional level) and the prophylactic non-use of platelets (crisis level). “It’s a way to make sure we’re conserving the blood supply as much as possible and transfusing patients who absolutely need blood,” Shmookler said.
In addition, his group closely monitors inventory every day, maintains open communication with hospital management and other centers, works with blood suppliers, and considers alternative strategies for transfused patients who do not not include blood. “If you have cases of severe trauma, we can give you other drugs such as prothrombin complex concentrate or recombinant factor VII,” he said.
At George Washington University (GW) Hospital in Washington, DC, Xiomara Fernandez, MD, uses skills she learned while training in Hawaii, where time and distance from nearby islands and states Continental states require clinical laboratories to be self-sufficient.
Like other centers, his lab is strict about enforcing hemoglobin transfusion thresholds, putting an alert in their electronic health records ordering system. If a supplier still orders products, the order must be approved by the blood bank resident or attending physician. Training clinicians is key, said Fernandez, medical director of transfusion and coagulation medicine, and assistant professor of pathology at the GW School of Medicine & Health Sciences. Its hematology department has also been helpful in guiding primary providers on when to transfuse.
The blood bank reviews all platelet and plasma orders, she said. And, because providers tend to order blood products “just in case” for procedures, blood bank staff confirm that these procedures are moving forward so that product is not wasted. But there are still surprises. Fernandez said it was the first time she had experienced a shortage of cryoprecipitate, in part due to a lack of staff to prepare the products. She and her colleagues are pushing thromboelastography tests to guide transfusion or determine if cryoprecipitate is needed.
On the positive side, media coverage of the shortages means doctors and nurses are more aware of the situation and less likely to get upset with the blood bank, Fernandez noted. “They realize it happens everywhere, and it’s not something the blood bank or the lab or the hospitals do,” she said. It also encouraged smaller hospitals that may not have patient blood management programs in place, she said.
From blood products to blood tubes
Overtesting has always been a concern among clinical labs around the world, but it’s become a “particular concern” now with blood tube shortages likely to last year-round, said Neil Harris, MD, director of the Core (Chemistry/Hematology) Laboratory at the University of Florida (UF) and Clinical Professor in the Department of Pathology, Immunology, and Laboratory Medicine at the UF College of Medicine.
During the pandemic, healthcare facilities experienced a shortage of blue vacuum tubes for blood sample collection due to high usage of these tubes for coagulation testing and limited supplies to manufacture more tubes. Other types of tubes followed suit.
In January 2022, the Food and Drug Administration updated its device shortage list to include all blood sample collection tubes (product codes GIM and JKA), and recommended that laboratory managers and other Healthcare staff are considering conservation strategies to minimize the use of blood collection tubes. Their advice includes only taking blood samples considered medically necessary, reducing testing during routine wellness visits, and considering point-of-care testing that does not require collection tubes.
Fortunately, Harris said: “We are not at the stage where we would refuse any test.” But lab workers can be more specific in advising on tests, recommending that they match a patient’s history. Clinicians could use prothrombin time, partial thromboplastin time, platelet count, and fibrinogen. Some specialized tests, such as tests that detect propensity for venous or arterial thrombosis, should be performed on an outpatient basis after the patient is discharged, as results may appear positive in the presence of acute inflammation.
Harris and his UF colleagues William Winter, MD, DABCC, FAACC, FCAP, and Maximo J. Marin, MD, authored an article to provide guidelines for laboratory ordering practices in coagulation testing. It’s in press at the med lab.
“A considerable portion of laboratory testing is believed to be, for lack of a better term, non-productive,” said Winter, professor of pathology and pediatrics and medical director of clinical laboratory support services and point-of-care testing. on duty. “We wanted to highlight to the lab community that through better ordering practices we could reduce the cost of lab testing, we could potentially improve lab testing because it would be more guided, and as a side effect – at least to short term – we could reduce the use of tubes.
The article provides a series of suggestions, such as requesting fewer standing orders, combining orders to reduce tubing usage, and using syringes instead of disposable tubing when placing infusions or central lines. inserted at the periphery.
“There are many creative ways to reduce test and tube usage without negatively affecting patient outcomes that labs and clinicians should think about,” Winter said.
The AACC is hosting a conference June 3-4 in Alexandria, Virginia on the role of the laboratory in reducing errors and improving quality in the preanalytical phase. It will cover test orders, said Winter, one of the presenters. For more information or to register, visit www.aacc.org/meetings-and-events
Karen Blum is a freelance medical and science writer who lives in Owings Mills, Maryland. +Email: [email protected]