As the physicians who lead blood bank operations, pathologists serve as translators between the blood bank and patient-care teams.
Blood is a vital component of the human body and its functioning. As such, it’s easy to think that all physicians learn the latest best practices surrounding blood and its administration in medical school. Unfortunately, as many pathologists realize later, that’s not necessarily the case.
Compounding matters, COVID has affected the stability of our blood banks and the larger blood supply. Blood preserving and extending practices once rare before the pandemic have become commonplace. In this new world order, good lines of communication between the physicians and laboratorians inside the blood bank and our colleagues outside of it are more crucial than ever.
Here we’ll delve into what’s changed or changing in the blood supply landscape and the procedures and best practices that can help us all to survive a shortage.
The Gap in Blood Knowledge Among Physicians
Transfusions and things related to blood management are very clinical, and the time constraints of medical school can make it challenging to teach all the clinical aspects of medicine. There’s often an assumption that clinical decisions, like when to transfuse a patient, will be learned in post-graduate training.
That is largely where people learn about the use of blood products, but it's usually not systematic. In other words, you might learn about blood transfusion as a resident or fellow, but there's probably not a clear lecture about it. The instruction might be more informal, eg, “When XYZ happens, we always do this.” Some of those instances are based on culture rather than evidence-based medicine.
Additionally, different physicians’ transfusion practices are often very individualized and specific to their field. That can lead to lack of agreement on when to do what or how much is needed. We're not all reading from the same play book, so to speak.
COVID’s Impact on the Blood Supply
In the old days—even just a few years back—the assumption was that the blood bank had what it needed. For the most part, that was a fair assumption; if it wasn't, we in the blood bank would tell you. But from what we've experienced in the last 12 months or so, it's not such a good assumption anymore.
There's a lot of volatility in our blood inventory for a few reasons. Weather has always been a factor—blizzards and hurricanes prevent donors from donating and blood products from being transported. But the pandemic has brought additional staffing shortages and supply chain issues.
It's hard to have an adequate blood supply when you don't have adequate staff to collect the blood needed or move blood products from point A to point B. This is a very human-dependent process, and keeping people healthy in the time of COVID is a struggle. If you don't have the staffing from start to finish, the system breaks down.
More recently, supply chain issues have been the major fly in the ointment. If we lack the necessary equipment or supplies, whether it's a bag or a tube or a reagent, it becomes very difficult to “make” blood. There's a lot of rules and regulations around making blood to make the process as safe as possible. We have had situations where certain bags or tubes aren't available. Any of those things could cause downstream problems as far as blood availability.
Procedures for Dealing with Blood Shortages
Pre-COVID, we had procedures in place, but they were relatively loose. Blood shortages were relatively infrequent, and we didn't have to employ them very often.
Unfortunately, shortages have become a more regular event, and, as a result, our procedures for dealing with them have become more defined. At my institution, we now have much more concrete rules about our inventory goals. If they are not being met, internal communications are initiated to clinical services that depend heavily on the blood bank. We’ve also enacted the following practices:
- We’ve set up a shortage group through our electronic medical record secure messaging system to relay blood updates. For example, if I learn of a platelet shortage in the early hours of the morning, I can then send out a text message informing the group that we are critical on platelets and what’s going to happen over the course of the day: whether or not we're expecting additional platelet inventory, giving a heads up that all platelet orders are being triaged, etc.
- We also have an online interface where people can look to see what our inventory is. It’s not in real-time yet—right now it’s updated once a day—but they do have the ability to see what is on the shelf enterprise-wide. We have a multiple hospital health system, and physicians can see what's available at all of those locations. It took us a lot of work to get to that point.
- More prospective review of blood orders are now the norm when we’re in a shortage. Rather than relying as heavily on our clinician colleagues’ judgment about what they’re ordering, it’s more of a conversation about what's being sent out the door for whom and why. Oftentimes, we are looking at every order that comes in to make sure that whoever is getting what we have is truly the most critical patient.
- The final tactic is somewhat specific to our institution, which has a blood donor center in the hospital. We make and manufacture blood, which allows us to do things that a lot of other hospital services may not be able to. These days, that includes splitting blood products in a sterile fashion so that, in theory, each unit can be used by at least two patients.
We don't split units eagerly; it takes time and effort on the part of the blood bank staff. But where necessary, it allows us to stretch what we have a little bit thinner. It’s similar to giving everyone a smaller portion when there’s not enough food at home—at least everybody eats.
The Importance of Maintaining a Partnership
Good communication with physician colleagues is imperative for many of the above procedures to work. Particularly, with the splitting of blood products, it’s a dialogue. Say there are two patients who need platelets, but the blood bank has a limited number of platelets to offer. I might reach out to both patients’ teams to broker a deal: “Hey, I'm able to provide a half unit of platelets, will you accept?”
They will usually say yes, and I'm happy to put our staff to work splitting platelets if I know that both halves are going to be used right away. Typically, we’re only doing this in cases of prophylactic transfusions where both I and the clinical team know that the patient is stable. These decisions should never be made unilaterally, but rather in communication with the patient teams.
Alternatively, if a team doesn’t want to accept a half unit of platelets, they might decide to wait until we have adequate inventory again. I’ll say, “We’re expecting a shipment of platelets in three hours, can your patient wait until then? Very often the answer is “Sure, no problem. Keep us in the queue.” They know as well as I do that the patient in question is stable, for the moment, and that other patients in the hospital might need those blood products more acutely. Those people should go to the front of the line.
That's what triaging is: It's not saying no, it’s deciding who goes first—because we can't all go first. We always avoid denying a request for blood outright. Instead, we strive to manage expectations and have a dialogue about the constraints at hand.
Of course, sometimes my physician colleagues take a hard stance with their requests. In those instances where I’m getting extreme pushback, I try to take the high road and trust their judgment. I assume that pushback is coming from a place of clinical concern. They are of the opinion that a patient is critically ill and needs blood products immediately. I have to trust their judgment, but they also have to trust mine, to some degree, when there's just not enough inventory. It really is a partnership.
The Need for Ongoing Dialogue and Education Around Blood
We will likely continue to deal with more frequent blood shortages for the foreseeable future. Successfully working through these events for the best patient outcomes requires education and cooperation. Those of us on the blood bank side must continue to educate our clinician colleagues about what is a reasonable request.
Conversely, I encourage physicians outside the blood bank to educate themselves on patient blood management best practices. Most medical fields have published on the use of blood products, and most of the articles conclude that we transfuse too much, or they provide very specific parameters on when to transfuse. Fortified with this patient blood management knowledge base, physicians will be able to better communicate about blood inventory, perhaps even eliminating the need for some conversations.
Navigating a blood shortage is about partnership. As long as those of us on both sides of the blood bank can communicate in a professional and collegial manner, we can make it through.
Watch this media briefing on blood supply, management, and donation, led by CAP President Emily E. Volk, MD, FCAP, and featuring Dr. Karp, as well as Julie L. Cruz, MD, FCAP, and Glenn Ramsey, MD, FCAP.
Dr. Julie Katz Karp is the director of transfusion medicine and director of the transfusion medicine fellowship program at Thomas Jefferson University Hospital in Philadelphia, Pennsylvania. She received a Bachelor of Science with distinction from Cornell University and her medical degree from the University of Pennsylvania. She completed residency training in anatomic and clinical pathology at The Johns Hopkins Hospital, where she was also chief resident. She completed a fellowship in blood bank/transfusion medicine at Thomas Jefferson University Hospital.
Her interests include undergraduate and graduate medical education specifically related to transfusion medicine, as well as blood donor health and recruitment. She is board certified in anatomic and clinical pathology and blood bank/transfusion medicine.