Melanie Cole (Host): Welcome to Expert Insights with the Carle Foundation Hospital. Hi Melanie Cole and today, we're discussing the extent of the current national blood shortage and why it's happening now. Joining me in this panel are Dr. Rasleen Saluja and Dr. R. Bruce Wellman. They're both Pathologists with the Carle Foundation Hospital. Dr. Saluja and Dr. Wellman, thank you so much for joining us in this thought leadership physician round table, because this is really such an important topic to discuss right now. So, Dr. Wellman, I'd like to start with you. Can you help us to understand the true extent of the current national blood shortage and what's happening? Why is this happening now?

R. Bruce Wellman, M.D. (Guest): Well briefly, prior to COVID, most of the blood donations came from offsite donations involving schools, work, churches and other group settings. COVID changed all that. At that time we'd been seeing a slow decrease in blood utilization. Well, once we started to open up, we found the blood supply, our donor base was not available. Schools were closed, churches are closed, meetings or large groups, gatherings were not encouraged. And so that required an entire resetting of the approach to having blood donors participate in the donation process. So, during COVID, demand went down suddenly in the winter of 2020 and May or June when things started to open up, the demand reestablished itself. And actually we've seen since that shut down in early 2020, actually the blood demand has reached the previous level, if not exceeded it. Today we think we're using about up to 10% more blood cells or red cells and other transfusion products, platelets, FFP than we were prior to the COVID situation.

And so we have a donor supply, donor availability issue with how to get individuals to come in and donate at fixed sites, as opposed to mobiles. And on the other side of the equation, we have more demand for blood products. That has led to a slow decrease in our inventory. Typically, we set ourselves at having about a five day supply. For the last several months of first beginning in May and June, we were down to one or two days. There was slight relief during the middle of the summer, but now we're back down to national inventories of the universal blood product of O positive, being between one and two days supply, if not lower in some locations. And that's had significant consequences for the providers in planning their operations and how they're going to handle more limited blood supply.

Host: Well, thank you for that. So then Dr. Saluja, are we talking about all kinds of blood and platelets or only certain types? And tell us what the Carle Foundation Hospital is doing to assure safety, because as Dr. Wellman said, COVID kind of put the kibosh on people coming in. So how are you reassuring healthcare providers and even the community that it is now safe to donate blood again?

Rasleen Saluja, M.D. (Guest): That's a very important question. And I think that is the question that donors are trying to answer. Should I go donate blood? Is it safe? Do they have precautions in place? At all of our donor facilities, staff are wearing masks. And we're encouraging vaccination, both among donors and staff to create that safe environment.

I think it's very important that Carle maintain the ability for us to draw onsite in hospitals. Where other healthcare facilities, other public facilities throughout the US that said, you know, we don't want to have a blood collection on our campus. And we just don't think that's right. We know that we are using blood. We know that patients need blood and therefore we have to keep our doors open just as we keep our doors open to the public in a safe way; we have to provide a safe site where people can donate blood. I agree with Dr. Wellman, this is one of the worst shortages, and I'll go a little bit further and say, this is the worst blood shortage in 40 years.

It is across all products. As Dr. Wellman told us, blood comes from nice people. Blood comes from people who are donating at their church, donating at their school, young people who are donating at colleges. And I worry about the long-term ramifications because the first time I donated blood was at a high school drive and I continued that tradition in college.

And then so on. God forbid, if this is an extended period, you have kind of a generation that doesn't have that experience. And so they don't develop this habit of giving back and giving blood and knowing how powerful it is and what it can do to save lives. So that's very concerning to me.

It's very important for facilities that are open to the public for other reasons, to continue to allow blood donations and blood collections on their campuses. By federal law, no one can impede the path of blood donor, even in the middle of a government shutdown, even in the middle of laws that prevent movement from state to state, without quarantine, by federal law, you must not impede the path of a blood donor.

They can go anywhere they need to go to donate blood. So I think that protection is very important. And also Carle has actually maintained their employee incentives through HR. There is an Illinois law that allows employers to give time off in exchange for donating blood. So at Carle, we actually do give PTO for donating red cells and we give double PTO for donating platelets. So we've maintained those incentives. And I think those are great incentives for staff to take advantage of.

Host: What a great initiative. And as you say, really important incentives. So Dr. Wellman, what's been the impact that this shortage has had on your ability to accept incoming traumas, accidents, surgeries, obstetric hemorrhage. I mean, oncology patients. This is across the board and really for healthcare facilities all over the world, I imagine right now.

Dr. Wellman: Well, we've been fortunate in that we haven't faced say some of the extreme situations that a Dr. Saluja can probably relate from her recent experiences during training up at Northwestern, where they had a much more severe situation. We have communicated the shortage to our medical staff. We've encouraged minimization of transfusion, wherever possible.

We've made suggestions on how that could be achieved. We track our inventories daily with through with our partner Impact Life, the regional donor center, as far as what's available to us. And so far, we really haven't reached the point where we have to, take any more direct action. But I'd leave to Rasleen, who's been more intimately involved with actually making those interventions to protect the availability of the units that could be in short supply. We've changed some of our practices around O negative blood, which is probably the one we try to protect the most so that we have it available for pregnant females or females under 40 or 50 years old who may have children. We don't want to sensitize them, but we've taken some other steps to minimize our use. So Rasleen, you want to talk a little bit about some of the measures you've seen put in place?

Dr. Saluja: Absolutely. I think we've taken advantage of the opportunities available through our bloodless program to look at alternatives for transfusion, to make sure that we're using cell saver, cell salvage technology if that's an option for that case, to plan for large use cases, to put them on days, for example, planned large use cases like hips, they would be scheduled Tuesday or Wednesday, so that Saturday blood collections we could say, okay, by this point in the week, we would probably have a better supply on a Tuesday or Wednesday, as opposed to first thing, Monday morning, after like a long weekend of traumas. We did have to start at one point in Northwestern rerouting Group O livers. We never collected blood on site the way that University of Chicago did. So they were able to collect from family members and friends, not necessarily for that patient, that would be a directed donation. So, they did not do that, but they weren't able to make solicitations, if someone needed blood to say, hey, if you have family and friends here, we have a donation center up on this floor, would you be able to donate to help refresh our supply?

It's interesting because actually that's where the first blood bank was generated. It was a physician in Chicago who had given surgeons three credits. And when they used blood, they would have relatives of patients come in and make a deposit. And that is the origin of the word blood bank.

So, in terms of what we're doing to mitigate and to minimize blood usage, it can get really bad where you're canceling elective surgeries, you're rerouting transplants. We don't do liver transplants here at Carle. I hope we never get to the point where we have to reroute traumas. But if the blood shortage were to get any worse, that would come down the line.

So it is really scary, probably the worst, or the experience that was the most scary for me was a young woman, 12 or 13 and she was having pediatric trauma and we didn't have any O negative blood for the next two hours. And she was bleeding very slowly and I didn't want to sensitize her with O positive. So I let her hemoglobin get very, very low. It was a long discussion with her parents and her pediatrician and the peds trauma surgeon. And I said, I think we can get blood and we can get our first shipment at 5:30, if we can just wait, this may not have lifelong consequences. The other option was to give her O positive blood and then co-administer it with RhoGAM and hope she didn't get sensitized. We were able to make a request from another hospital and get it ambulanced over from a different part of the city. And she was able to get one unit and then the, the rest of the blood came, early in the morning in the first shipment, but it was scary and I don't like doing it. I really hope that our blood supply comes back into a stronger position.

Host: So Dr. Wellman, can you tell us what Carle providers, especially providers that order blood need to know about how they can help prevent the worsening of that situation, including any best practices for ordering blood and what transfusion thresholds and triggers to use. I'd like you both actually to have a chance to chime in on this question.

So Dr. Wellman, why don't we start with you and then Dr. Saluja chime in and expand on what he says.

Dr. Wellman: Well, there are recommendations and guidelines on transfusing red cells, platelets, plasma, and cryoprecipitate. So for red cells, for a non-bleeding patient, who is not exhibiting any symptoms, the hemoglobin level really can get seven or lower without any consequence. And when you transfuse, we recommend giving a single unit and making sure if the patient is symptomatic, that the symptoms get better.

So you want to basically be very conservative. And this is true in critically ill patients. And even in surgical patients where the hemoglobin threshold in a non-bleeding patient who is asymptomatic really, those patients are fairly safe at low levels. Now once they become symptomatic and you need to address that, then you do it a unit at a time and you try to assess an outcome that prevents unnecessary transfusion, like automatically giving two or three units instead of just giving one and seeing if the patient is better. And so from a red cell standpoint, that's the case. We also, in large volume transfusions, we need people to make sure we get blood specimens so that we know what the blood type is.

We use O positive blood for most patients who are actively bleeding where we don't know their blood type, if they're females under the age of 40 or 50, we'll start with O negative and then assess the situation. But we have 40% or so of the population is O positive and we tend to use more O positive than the percentage of the population.

And that's sort of the critical backstop that we have to maintain. So we try to get people to get their blood type identified so we can make sure we have other blood types available. If they're a type A or AB for example. So, those are a couple of things we do for red cells. We'll switch people to O positive red cells who are actively bleeding adults, where we are not certain there's an end point again, to protect the O negative supply, but really physicians, I think just need to assess the patient. Be familiar with the guidelines and utilize components judiciously. Overtransfusions is still a problem in the United States. And so we just need to make sure and provide physicians with the information to make the right decision.

Dr. Saluja: I agree with Dr. Wellman completely on this. We need to hold ourselves to the guidelines and we need to understand that what we're doing in giving blood products is a serious endeavor. When we're giving red cells, we really need to start looking at hemoglobin of seven as a trigger, not an abstract threshold.

It is not a good situation when the patient was symptomatically anemic, and you gave two units and now the patient's back up to 10 and you've discharged them. You've overtransfused them, you overtransfused them. You don't need to intervene on an asymptomatic patient unless they are at a hemoglobin of seven, maybe for a cardiac patient. You want to watch them closely. If they start to become symptomatic and have symptomatic anemia, you can give them a unit. Now we're not treating the number. If somebody had a hemoglobin you know, 14 or 15 and they have a sudden blood loss, they can become symptomatically anemic at eight and a half.

They can be short of breath. They can look gravely ill, but even in those scenarios, you want to give one unit at a time and make sure the patient hasn't had a reaction to the blood product itself. You really can shoot yourself in the foot if you give the patient two units and platelets and plasma at the same time, and all of a sudden they develop a fever or they become very short of breath and they weren't short of breath before, because you don't know what's the implicated product.

And nobody wants to hear after they've transfused that, there's a transfusion reaction or there's an issue. When you give blood, you want to monitor closely. You want to look very closely at those vital signs and also be mindful if a patient has failed to rise with hemoglobin. I've seen some cases where someone will give a unit, nothing happens.

Someone to give a second unit, nothing happens. And when they go to give the third unit blood blood bank might become aware of the situation. What's happening is they're actually having a hemolytic transfusion reaction. And the blood you're giving them is essentially exploding. And so at that point, we can intervene and say, okay, there's an issue with compatibility.

You know, what other product can we offer? But you should get a rise in hemoglobin. You should check labs. If you're going to give plasma, you really want to see what kind of coagulopathy are you correcting? If you give platelets, you want to stick to those guidelines. You're not really at risk of an intracranial hemorrhage until your platelets get actually fairly low. If you obviously have a platelet count of 5,000 or 10,000, you can be at risk for an intercranial hemorrhage, but for stable oncology patients, we really want you to use a threshold of 20,000; 50,000 is great for general surgery.

You can go through a general surgery with a platelet count as low as 50,000, especially in non mucosal bleeding surgery, like a simple amputation or an appendectomy at 50,000 is perfectly adequate. A hundred thousand should only be used for large neurosurgical interventions, craniotomy, major spine surgery. That kind of thing. It's even questionable whether or not a hundred thousand should be used as a threshold for a simple procedure, such as an epidural. Like just because you have a needle somewhere near the spine or brain doesn't mean that you necessarily have to give a platelet transfusion at exactly a hundred thousand.

And also again, you're, treating a person, not a number. Dr. Wellman and I have both seen situations where people have platelet counts in the 90 thousands, and they're having a minor sort of tangentially related neurosurgical procedure, and this person is going to need to get a whole platelet or they've requested an entire platelet transfusion. Platelets are a very important, difficult to obtain product with a very short lifespan. Platelets come from extremely nice people.

They are very important to saving the lives of oncology patients. Platelets cannot be wasted. And a platelet gets a very large bump. One platelet for a normal person can give a rise of about 25 to 30,000. So one platelet can truly be life-saving for an oncology patient in that it can take them from a platelet count of near zero to enough to prevent an intracranial hemorrhage, and then some. So it is not the place to use platelets at 99,000 because you want to get it to a hundred that's not the way.

So, just have a lot of respect for the products that the donors have given you. None of these donors are paid. We have no paid blood donation in the United States, any plasma centers you might see in town or on TV or around the country, that plasma is used for pharmacologic manufacturing and for manufacturing things for the pharmaceutical industry. In the United States, we don't have any paid blood donation. Every blood product that you transfuse into a patient, whether it's a red cell or a platelet or a plasma, is truly a gift from a donor. And it's very important for us as clinicians to respect it.

Host: Wow. Beautifully said both of you. And I'd like to give you a chance just for a final thought, Dr. Wellman, starting with you. Can you reiterate how we all need to work together across the healthcare system, really to combat this current blood shortage and to help return our local blood supply to its safer levels.

Dr. Wellman: Well, the donor centers and I've been involved with donor centers for over 40 years, are really, attempting to adapt to a new environment and they're trying to work with their communities and other donors in a more direct way, an established capacity that is chairs for them to donate in given labor shortages and things like that.

So they're working very diligently, I think, trying to get an adequate supply so that care is not interrupted. On the other side of the equation, the healthcare industry itself, we need to be mindful of getting our employees to donate as Dr. Saluja said. We're having on-site donations.

Really something we ought to be promoting in our industry and it's contributing to the blood supply that we consume as part of our services. And finally, the physicians have got to really be aware that this is a valuable short supply product at this point. And even when it isn't a short supply, we shouldn't do things that don't have value for patients.

And that's a knowledge, that's a practice and that's something that everybody can work on to minimize it. Bloodless surgery is something that is a program that ought to be more widely implemented across many different hospital settings, because there are a large number of very successful bloodless surgery organizations that have protocols to prep the patient, prep the physicians, and basically avoid transfusion, in a high percentage of their cases.

Host: And Dr. Saluja, last word to you. What would you like other providers to know about this current blood shortage? What you think we can do to mitigate that? Kind of just wrap it all up for us.

Dr. Saluja: I agree with Dr. Wellman. I think that we have to honor the gift that donors have given us and use best practices for our patient and understand that we're giving a transfusion. This is a product from another person and it is not something to be taken on lightly and sticking to transfusion thresholds and triggers consistently as a team, will help us to stay out of trouble as a system and help us to keep our doors open.

So it's really important. As far as becoming a donor, when I look at other providers, I see some healthy young medically eligible people and I, think, it's really important to start a practice of giving blood. It's fantastic. It's a way that you can give back to people. And the feeling of knowing that you've given something that really directly saved someone's life is very impactful. I, myself am a B positive, regular blood donor. It's something that anyone who's medically eligible can do. And , healthcare providers in particular who are aware of the need, you guys are the MVP when you are giving blood. Only 3% of medically eligible Americans give blood. So, to those 3% of people listening out there to this podcast, thank you very much.

Host: Well, thank you very much. And as a B positive person myself, I thank you as well. And it's such an important message that we got today. Thank you so much doctors for joining us. For more information, and to get connected with one of our providers, please visit carle.org or for a listing of Carle providers and to view Carle sponsored educational activities, you can visit our website at carleconnect.com. That concludes this episode of Expert Insights with the Carle Foundation Hospital. I'm Melanie Cole. Thanks so much for listening.