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Kip Kuttner

The COVID-19 challenge

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I'm just curious but are you referring to the possible staffing issues due to staff getting sick and having the good sense to not go to work or are you concerned about any possible impact on the patient load?  Or both?  From what little I have read of the symptoms I can't imagine any patients hospitalized needing much blood bank support.  I would think the biggest issues will be staffing.   

:coffeecup: 

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I'm hoping our donor supply remains strong and healthy donors don't get scared off from giving blood.

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I worry about donations if people get sick in large number and they can't donate we might  experience blood products shortage.

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We've been in short supply of RBC's and platelets for so long now it's going to be hard to notice.  One good thing that has come of it is the intensified scrutiny of every order - providers have been made keenly aware and are re-evaluating their ordering practices.  I guess necessity is the godfather of  compliance.

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I have a question - can hospitals go on lockdown and keep employees from leaving?

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Posted (edited)

There are many facets to this question. I would think each institution has a disaster plan.  It is an AABB requirement and I am sure a requirement for many other accreditation firms.

From the blood supplier point of view:

About 60% of the blood we distribute comes from mobile collections.  Businesses, churches, schools and so forth permit us to hold collection events.  If the local health departments discourage "gatherings" or even isolating parts of a community, this will adversely affect the blood supply.  While the FDA encourages blood donation, the local messaging is what really matters.  Isolation of well donors has already happened in places like Seattle and New York and is reducing the blood supply.

Will the virus penetrate the population such that blood donors become unwell?  This is hard to predict but look at Italy. Also the duration is difficult to plan for but with China it has taken about 31/2 months for the number of reported cases to fall.

One might hope that different parts of the country are affected at different times permitting the movement of blood from one region to another. However given the mobility of the population it is possible that multiple regions are affected simultaneously and movement of blood is not possible.

Hopefully, blood suppliers have begun to communicate with their hospital customers regarding the state of the blood inventory and the future ability to collect blood. 

From the hospital's point of view, what would happen if the supply became critical?  When would you consider postponing elective surgeries, or rationing blood.  Would you consider issuing splitting a whole blood unit in half and making that the "dose" in order to extend the supply (what makes the red blood cells harvested from a 450-500mL of whole blood a dose?)

When do you start rationing blood/platelets?  What about those transfusion dependent? do you divert those whole blood units intended for trauma patients to the chronically transfused.

What happens if the hospital is overrun by those with respiratory illness like is happening in Italy?

What about unwell staff? Will there be enough well to run the institution?  I understand in Italy, administrators are transporting patients and pathologists (like me god forbid) are working in the ER .

Are you sure there is an adequate supplies in your supply chain chain for each of your supplies/reagents so you can carry out business as usual?  Silly things like hand sanitizer and toilet paper, gowns, gloves are already at a premium in certain parts of the country.

 

I am mostly curious about your response to different levels of blood availability.  How do you decide to post pone surgeries.  After that should transfusion demand outstrip the supply what do you do and what is the trigger for implementing the action. 

Thanks

 

 

 

 

 

Blood Industry Joint Press Release for Website - final 3.12.20.pdf

Edited by Kip Kuttner

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I have to admit that when I first responded I was not looking at the big picture!  I guess I've been away from the trenches long enough to have lost some of my perspective.  I have to say that my priorities would still be staffing first and blood supply a very close second.  Since my last facility did not have donor capabilities and depended on ARC for our blood supply I'm not sure how much I would have been able to do concerning the blood supply beyond encouraging folks that were well to donate.   :coffeecup:

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The new AABB standard 1.4 entitled “Operational Continuity” is timely in that it forces us to take a look at our existing processes and have a plan for situations we could not have anticipated, just like COVID-19.

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As of today, Saturday May 14th, we are looking at a looming blood shortage, here in Michigan and the US (for the reasons already outlined above).  We had an unusually bad shortage in the US last January, but that will be nothing compared to this.  We are currently considering lowering (again) transfusion thresholds, as well as coordinating with other facilities  for the anticipated shortage of products.

The problem here is that we are going to be in it for the long haul, and it is going to get much worse.  Any efforts to encourage donation are going to be especially  important during this time.

Scott

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For platelets you can cut the dose in half with no worsening of clinical outcomes. Randomized trial in NEJM called the PLADO (platelet dose) study some years ago (Sherrill Slichter was the senior author).  Most platelets do little or no good, so this is actually a good idea for patients and helps with inventory in times of shortage.  Try to give ABO identical as the increment is higher, the duration of increment is longer and the patients bleed less.

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N Engl J Med. 2010 Feb 18;362(7):600-13. doi: 10.1056/NEJMoa0904084.

Dose of prophylactic platelet transfusions and prevention of hemorrhage.

Abstract

BACKGROUND:

We conducted a trial of prophylactic platelet transfusions to evaluate the effect of platelet dose on bleeding in patients with hypoproliferative thrombocytopenia.

METHODS:

We randomly assigned hospitalized patients undergoing hematopoietic stem-cell transplantation or chemotherapy for hematologic cancers or solid tumors to receive prophylactic platelet transfusions at a low dose, a medium dose, or a high dose (1.1x10(11), 2.2x10(11), or 4.4x10(11) platelets per square meter of body-surface area, respectively), when morning platelet counts were 10,000 per cubic millimeter or lower. Clinical signs of bleeding were assessed daily. The primary end point was bleeding of grade 2 or higher (as defined on the basis of World Health Organization criteria).

RESULTS:

In the 1272 patients who received at least one platelet transfusion, the primary end point was observed in 71%, 69%, and 70% of the patients in the low-dose group, the medium-dose group, and the high-dose group, respectively (differences were not significant). The incidences of higher grades of bleeding, and other adverse events, were similar among the three groups. The median number of platelets transfused was significantly lower in the low-dose group (9.25x10(11)) than in the medium-dose group (11.25x10(11)) or the high-dose group (19.63x10(11)) (P=0.002 for low vs. medium, P<0.001 for high vs. low and high vs. medium), but the median number of platelet transfusions given was significantly higher in the low-dose group (five, vs. three in the medium-dose and three in the high-dose group; P<0.001 for low vs. medium and low vs. high). Bleeding occurred on 25% of the study days on which morning platelet counts were 5000 per cubic millimeter or lower, as compared with 17% of study days on which platelet counts were 6000 to 80,000 per cubic millimeter (P<0.001).

CONCLUSIONS:

Low doses of platelets administered as a prophylactic transfusion led to a decreased number of platelets transfused per patient but an increased number of transfusions given. At doses between 1.1x10(11) and 4.4x10(11) platelets per square meter, the number of platelets in the prophylactic transfusion had no effect on the incidence of bleeding. (ClinicalTrials.gov number, NCT00128713.)

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Since all elective surgeries have been postponed and restaurants/bars have closed the BB  has been incredibly slow which is rather scary in itself (the calm before the storm?). Due to this  we have voluntary reduced our inventory to help with the blood supply.

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ARC (American Red Cross) has issued a statement that almost 5,000 blood drives were canceled and a few hundred donation sites due to quarantines. They're trying to get people to start donating at hospitals and other "essential" sites.

The physicians have ramped up elective surgery instead of delaying them. I think it's super selfish to waste blood products during a crisis of this nature when you don't know what the outcome will be or how long the quarantines will last, it's beyond frustrating.

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Platelets are in adequate supply largely due to hospitals (in my service area) enforcing restrictive transfusion measures and postponing elective surgeries. Most blood centers except in New York, Washington state, and California are treading water with respect to RBCs. As usual Rh neg units are in short supply. 
 

Most of the hospitals in my service area are also freeing up beds to treat respiratory infections. These will require fewer transfusions, although patients needing ECMO are of concern. 
 

Looking ahead, it is difficult to predict what will happen.  This is a long term event. My current concern is that blood donors will be fatigued 3 weeks from now and avoid giving blood. That is what happened after 9/11. It could be that you might need that unit of O neg on your shelf 42 days from now. 
 

In my opinion the goal is to provide blood for everyone who needs blood. Measures to restrict are prudent (and the literature indicates this is good medicine).  After this is all over and we are criticized for being too conservative, but no one died for lack of blood, I can live with that. 

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20 hours ago, JJSPLAYHOUSE said:

The physicians have ramped up elective surgery instead of delaying them. I think it's super selfish to waste blood products during a crisis of this nature when you don't know what the outcome will be or how long the quarantines will last, it's beyond frustrating.

I don't understand this.  Not only are they being selfish with the blood products, but also with all of the PPE and other supplies that are in critically short supply nationwide.  I guess I should feel better about at least cutting the number of elective procedures that we are doing, although we are still doing way too many.  The blood shortage is forcing our physicians to abide by the guidelines that we instituted 7 years ago, and it's forcing our Pathologist's to enforce them.  My optimist self hopes that once this emergency passes, the will understand the reasons why we shouldn't over-transfuse and will change their habits.  The pessimist in me thinks that won't happen, though.  I guess we'll see which one comes out on top.

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In a statewide web conference, the blood suppliers in New York State and the NY metro area (parts of New Jersey) provided the reassuring news that by setting up alternate fixed sites for (mostly) whole blood collection, the blood supply has been about normal.  Platelets are collected at fixed sites and the donors have been wonderful.   Transfusion in our area (Rochester NY) is slightly down as we are not transplanting patients without urgent indications (myeloma can sometimes wait, for example) and elective surgery is not happening.  So right now, things in New York State, the worst hit part of the country, are remarkably and thankfully reasonable for blood supply.  We can thank the dedicated staff of the Red Cross and NY Blood Center, and, of course, our courageous and committed donors for this good news.  Hang in there, not that there's any other place to hang.

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In our region demand has decreased enough that supply is stable right now. Bless the donors who still show up to donate and the ARC staff working the drives and at the blood centers.

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For the past week, we have posted 1/3 of our RBC supply on the Blood Hub transfer board (ARC), but unfortunately we have had no takers. I'm sorry to say we will lose a good amount in the coming days/weeks due to outdating.

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On 3/12/2020 at 12:58 PM, bldbnkr said:

I have a question - can hospitals go on lockdown and keep employees from leaving?

I know that HIV was in donor blood.  Has transmission of COVID19 by transfusion been ruled out?

 

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