Hospitals across the country are delaying surgeries as blood utilization spikes.
There has been at least a 10% increase in blood transfusions as patients resume care they deferred during the COVID-19 pandemic, many of whom are sicker, according to Vizient, the group purchasing organization that helps source supplies for more than half of the U.S. health systems. Donations are also down, which have delayed some non-urgent procedures.
It's a perfect storm, said Akiva Faerber, a senior principal at Vizient. Utilization has gone up and supply has plummeted, which has not only compromised patient care but also inflated prices, he said. The price of O positive and O negative red blood cells has gone up 30% per unit in the past 12 months, Vizient said.
More than a third of community blood centers across the country reported having a one-day supply or less, according to America's Blood Centers' daily update from 59 community blood centers.
"This is the worst I have seen it in my 47 years in this business," Faerber said. "And it is not going to get better very soon."
There is a severe shortage of O positive and O negative blood, which is concerning because summer is typically when non-urgent surgery volumes increase as well as trauma cases, said Meg Femino, vice president for emergency management at Beth Israel Lahey Health.
Beth Israel Lahey hospitals are triaging daily operating room cases and may delay elective cases when appropriate, she said.
"We have recommended hospital conservation guidelines across our medical surgical service lines that are high users of blood," said Femino, adding that BILH is setting up blood drives at its hospitals.
Hospitals are considering cutting back on non-urgent surgeries or adjusting blood transfusion thresholds to conserve supplies. But clinicians were already concerned that preventative and elective care put off or skipped during the pandemic could have significant impacts on health outcomes. It could also further stress patients and providers, who were already reporting higher levels of burnout and anxiety.
Meanwhile, vacant offices and schools have hamstrung blood donation drives. Blood suppliers are also having issues with staffing.
The Cleveland Clinic said it is facing a blood shortage just as the rest of the country, but it has not had to stop any services. The University of Utah Health said it has had to manage intermittent blood shortages, but it hasn't been acutely impacted by the latest disruption.
"There has been some low periods in the past, but you would have to go back a number of years to see supplies this short for a prolonged period of time," said Dr. Glenn Ramsey, chair of the College of American Pathologists' transfusion, apheresis, and cellular therapy committee who practices at Northwestern Medicine. "It has definitely been a nationwide problem for about two weeks."
Liver transplants are some of the most blood-intensive procedures, Ramsey noted. Providers may be able to limit the number of units for outpatient transfusions for the chronically anemic and chemotherapy patients. But those are tricky scenarios, he said.
Providers can't plan around gunshot wounds, obstetrical hemorrhages or other emergencies.
"A common theme we have been hearing from blood suppliers is that hospitals are seeing increased usage; some are still catching up from care deferred due to COVID," said Ramsey, adding that recent coverage gains through Medicaid expansion or the Affordable Care Act may also be straining supplies.
There has also been a shortage of blue cap test tubes used to test blood coagulation, although supplies are replenishing, experts said. Blue cap tubes have the anticoagulant sodium citrate, which is in short supply, according to the Food and Drug Administration.
As of mid-June, Becton Dickinson and Greiner were manufacturing and shipping blue top tubes, but they continue to be on allocation as they work through back orders, said Scott Grubenhoff, senior director of contract services for Vizient. Becton Dickinson, which is the market leader for blue top test tubes, expects to have their back orders fulfilled by the end of October; Greiner said by the end of July.
The shortage has impacted nearly every facet of a health system, from the emergency room for trauma and acute elective cases to outpatient facilities monitoring patients on blood thinners. Some physicians routinely do hemoglobin tests before non-urgent surgeries.
Adjusting practices to minimize tube waste, limit use to clinically necessary circumstances and maximize laboratory efficiencies could conserve supplies, said Darren Triller, director of strategic initiatives at the Anticoagulation Forum.
"It's important for health system leaders to have a clear communication strategy to ensure everyone in medicine, nursing, laboratory and pharmacy is on the same page," he said.
The shortage of blue top tubes is expected to persistent through 2021, according to the College of American Pathologists. Without those supplies, physicians have to guess a patient's risk of excessive bleeding or developing clots, which can be life-threatening.
The CAP recommended reducing routine coagulation testing for low-risk surgeries when clinically appropriate. Limit standing orders for testing, particularly for stable patients on long-term blood thinners.
Nurses and phlebotomists should avoid using sodium citrate tubes as discard tubes and only draw blue top tubes when testing has been ordered. Clinical labs should source sodium citrate tubes from alternative suppliers, but only if there are written procedures and manufacturers are validated.
Labs should avoid 3.8% tubes as a replacement for 3.2% tubes and only use expired tubes as a last resort, the CAP noted.