During a blood shortage what inventory levels and other criteria are used by transfusion services to decide when to postpone elective surgery?

A transfusion medicine physician in Virginia reports that at a meeting of their recent Blood Utilization Committee (BUC) they discussed creating a plan for dealing with blood shortages. They are hoping to define at what inventory levels should all elective surgeries be canceled and/or prioritized to be allowed to proceed or be canceled. The Virginia physician wonders if such a system has been developed elsewhere. The inquiring physician reports that her hospital's current approach for dealing with a blood shortage situation is to screen EVERY request for transfusion, usually calling the ordering physician, so that cases are triaged. Because a formal guideline has not been established, the problem that has arisen (that they discussed with their BUC) is that the surgeons are not always heeding the warning or the triage recommendation. In her opinion, when a surgeon does not heed the blood bank's warning, the outcome may be bad for the patient, bad for the hospital, and bad for the surgeon They hope to define a system to cancel elective surgeries in some organized manner. Suggestions are welcome!!!

The following responses were submitted.

ADDENDA April 17, 2003

1. A colleague in New Jersey works at a hospital where they have established a hierarchy of warnings that become implemented during a blood shortage situation. The following approach was developed by the blood bank and approved by the Transfusion committee.
   • First, they established the minimum inventory needed to get through two days of routine use
   • At 50 - 75% of minimum inventory, they e-mail nursing and place a notice in the Medical Staff Lounge
   • At 25% - 50% of minimum inventory they recommend that the pretransfusion transfusion trigger be reduced from a hemoglobin of 8 gm/dL to 7 gm/dL. Any request for transfusion of a patient with a hemoglobin above 7 gm/dL is reviewed by the pathologist. They also notify the operating room booking office and the Oncology Center to recommend the recruitment of directed donors (or autologous as indicated), and place a notice in the physician's' boxes about the situation. The recruitment of autologous and directed donations requires coordination, since their blood center requires a 5-day TAT for processing directed and autologous donations
   • At 25% of minimum inventory, they start recommending cancellation of complex surgical cases. They have determined, based on experience, a recommended pre-operative blood order for several types of surgical procedures. For example, for aortic aneurysm they recommend that 4-6 ABO/Rh-compatible RBC units should be on hand. For a lumbar laminectomy with fusion they would recommend that 2-4 ABO/Rh-compatible units be on hand. Any surgery that usually requires more than two RBC units is discouraged.
   In spite of the above policy, it seems the physicians still need several warnings before they appreciate the gravity of the situation.

ADDENDA April 19, 2003

2. A Transfusion Service Supervisor at a hospital in Texas reports that her facility has developed and implemented a secondary "Patient Informed Consent" form that all surgeons must use during times of critical blood shortages. According to the Texan (verbatim): "If the laboratory cannot furnish the amount of product routinely ordered for a surgical case (as determined by the physician's normal ordering patterns) and we are under critical shortage protocol, the hospital requires that the surgeon inform the patient of this fact (for elective cases). The patient must then sign an informed consent stating that they are aware that the physician usually requires that "X" amount of blood be crossmatched for their type of procedure and that only "X" amount is currently available. The form also states that the patient is aware that there will not be any additional product available at the time of surgery so that if additional product is needed the patient is at an increased risk of death. The signature must be witnessed by an Administrator, a Nursing Manager, the Transfusion Medical Director or the house supervisor. During shortages, our OR personnel screen all charts for this release and if the release is not present the case is not allowed to proceed. This form was developed in conjunction with the hospital's attorney since it is strongly felt that the hospital could and would be held liable for allowing cases to proceed when the availability of an adequate blood supply cannot be assured. The implementation of this form has virtually eliminated all conflicts with physicians about whether or not an elective case will proceed during a blood shortage. Anytime an elective case is upgraded to an emergency procedure (during a critical shortage), the CMO, Chief of Surgery and the Chief of Trauma must review (and approve) the case prior to surgery and then it goes for full chart review by the CMO and a committee of surgeons after the case. The physician is at risk of immediately losing privileges if a case is upgraded without appropriate medical necessity justification."

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