Open letter to the U.S. health care community

Keeping Our Hospital Partners Informed During Novel Coronavirus (COVID-19) Pandemic

March 2020

Thursday, March 19

Dear Transfusion Service Partner,

Every day the American Red Cross works to protect patient care through an adequate and available blood supply. However, amid the nation’s powerful response to the novel coronavirus (COVID-19) pandemic, blood providers are challenged to replace both eligible donors and the needed facilities to operate productive blood drives. Red Cross has had more than 4,600 blood drives canceled, resulting in 143,600 fewer units. Consequently, the Red Cross has launched a nationwide media appeal to generate public awareness of the critical need for continued blood donations throughout the pandemic and that blood is essential to health care. Donating blood is safe and necessary. Please encourage the continuation of blood drives and donations in your hospital and community.

As we work to build new blood supplies, we are also aggressive in securing those products already on the shelf. We appreciate your rapid response to our request for proactive conservation to safeguard limited inventories. Through our combined efforts, the rate of decline of the red blood cell supply has slowed. However, we have yet to realize the full impact of the pandemic response and government ordered quarantines. Our inventory projections indicate red blood cells will be severely constrained by next week. We must remain vigilant.

With red blood cell supplies expected to worsen quickly, we are discontinuing stock rotations and auto-return/replenish ordering. We recommend hospitals retain products in-house through expiration as our ability to restock with longer dated products will be greatly diminished. Place new orders only as inventory is used or expired.

Several hospitals and health systems around the country have already chosen to cancel elective surgeries. If you have not done so, we strongly recommend hospitals postpone or cancel elective surgical procedures at this time.

Due to constrained supplies on antigen negative red blood cells, Red Cross is taking added measures to meet special needs. Antigen negative units will be released for patient need only. Stock antigen negative orders will be discontinued for the foreseeable future. Antigen screened orders should be placed via Connect and include the required patient information. Consider reducing the use of antigen negative units by at least 30%. Some approaches already implemented by hospitals treating many sickle cell patients include:

Limit use of CEK negative units to sickle cell patients who are alloimmunized to at least one clinically significant alloantibody.
Reschedule sickle cell patients based on (actual or anticipated) pre-procedure HbS (<30% for stroke and <40% for non-stroke). Alternatively, consider modified exchange procedures in lieu of full exchange procedures. Alternatively, consider a simple transfusion in lieu of an exchange transfusion.
- Use CEK prophylactically only for females of childbearing potential.

Fortunately, platelet collections have largely withstood the effects of coronavirus. Collected at Red Cross fixed sites with an established donor base, they have not been affected by the drive cancellations and donor loss impacting red blood cells. Currently, we have a strong and stable supply of platelets and are filling orders as scheduled.

To best enable our teams to efficiently and appropriately triage these limited supplies, all product orders, including STAT orders, HLA orders and IRL orders must be placed online via CONNECT.

Increased coordination and communication with your hospital is vital to Red Cross’s ability to manage this unprecedented event. We appreciate your continued diligence in educating hospital staff on the severity of the situation, the need for restrictive blood product use and the ongoing need for blood donations.

Sincerely,

Pampee P. Young, M.D., Ph.D.
Chief Medical Officer
American Red Cross

Sunday, March 15

Dear Transfusion Service Partner,

Already, the American Red Cross is experiencing the adverse effects of the coronavirus pandemic (COVID-19) on our blood collection operations. With a rapidly increasing number of blood drive cancellations across the country, the impact to the national blood supply is inevitable. We are steadfast in our efforts to recruit and collect blood despite these ongoing challenges; however, the volatility of the situation requires that we act now to safeguard the anticipated limited supplies.

We are taking several precautionary measures to manage declining supplies. Beginning this week, we will reduce order fulfillment on scheduled and ad hoc orders for red blood cells (RBCs). We have also established a STAT blood product volume threshold and will start reviewing all STAT orders for need before release. Both these actions are designed to secure products for immediate patient needs and limit the routine stocking of products during short supply. To maximize product stewardship, where necessary, we are discontinuing stock rotations.

Although we have not had to make any change to our distribution model yet, we are prepared to take additional action to consolidate inventories into strategic sites across the country should supplies become severely constrained. From these larger sites, we would deploy a direct shipment delivery model that would allow the Red Cross to manage limited inventories more effectively and reduce lost transit time. Should we need to make these changes, you will be notified in advance.

As your hospital prepares to implement its contingency plans, we strongly recommend you consider the following steps to ensure continued access to blood to those most in need:

Update all clinical staff that the current COVID-19 pandemic has put tremendous strain on the blood supply.
- Establish formal and routine status alerts to medical staff and nursing leadership on the need for vigilance.
- Prioritize coordination with the operating room, emergency department, and floor staff to avoid wastage due to temperature limits/time out of the blood bank.
Implement a prospective review of all blood product ordering before release from the blood bank. Specifically,
- Verify that the transfusion is expected within the next 8 hours. Cancel orders where the clinical need has changed.
- Lower transfusion triggers for RBCs and platelet transfusions.
- For stable non-emergent patients, review orders > 2 RBC units at one time (give one then reassess). Limit the use of O negative RBCs to women of child-bearing age and pediatric females. Use O positive RBCs for emergent transfusion of males and post-menopausal women.
- As soon as possible, switch from O RBCs to type-specific RBC transfusions in emergent transfusions or massive transfusions.
- Use group A plasma for emergent transfusions and massive transfusions.
- Set goal to reduce blood product utilization by 25%.
Carefully monitor your inventory to minimize product expiration. Place short-dates in the front so staff can easily access them. Set an outdate target of zero.
- Readily move products between hospitals in your community to limit outdating.
Determine the minimum required inventory held at your hospital. Do not stock blood products on your shelf for “just-in-case” scenarios. The blood supply cannot support stocking orders at this time.
Increase flexibility when placing product orders with your blood provider:
- Order platelets of any blood group by choosing “Any Type” in Connect.
- Accept PAS and 100% plasma platelets interchangeably
- Limit attribute specificity to allow for greater fulfillment options.
Implement less aggressive targets for routine red cell exchange transfusions whenever possible.
Utilize one unit (rather than two unit) platelet transfusion strategies for non-bleeding adult oncology outpatients (Gehrie et al. Vox Sang 2019; 114:517-22).

Another immediate action you can take to protect the blood supply is to actively promote blood donations within your hospital and your community. Ongoing blood drives are imperative to ensuring a readily available supply. When possible avoid canceling scheduled blood drives within your hospital, and please help us raise public awareness on the critical need for healthy, eligible donors to donate blood now.

With the closure of schools, colleges and universities throughout the nation, blood collectors lose an active and vital donor base. We expect the impact to be broad and inventories to deteriorate quickly. Given the rapidly changing nature of this situation, we will provide frequent updates on our status so that you may keep your teams informed. Continue to communicate with your Red Cross account manager regarding any changes within your hospital that may impact our service, primarily as it pertains to deliveries to the blood bank. Additionally, our medical directors are readily available to guide you on managing blood product shortages.

Sincerely,

Pampee P. Young, M.D., Ph.D.
Chief Medical Officer
American Red Cross