Platelets: Tips for Inventory Management in Shortages (Platelet TIMS)
By: Allison Collins MD FRCPC, ORBCoN Physician Clinical Coordinator
As part of the preparation for the upcoming blood shortage simulation exercise in Ontario, a document was prepared to assist hospitals in managing their platelet inventories in times of shortage. The full Tips for Inventory Management in Shortages (TIMS) document, including references, is available at: https://transfusionontario.org/en/download/platelet-tips-for-inventory-management-in-shortages-tims/. A summary is presented here.
Although transfusion of ABO identical platelets is the preferred approach, this may not be possible during shortages. Transfusion of cellular-incompatible platelets (a major mismatch) or plasma-incompatible platelets (a minor mismatch) may be necessary. In a cellular-incompatible transfusion, the donor platelets exhibit antigens not present in the recipient (e.g. group A platelets to a group O recipient). This may result in a decreased post-transfusion platelet count increment.
In a plasma-incompatible transfusion, the donor plasma contains antibodies to antigens present on the recipient’s red cells, which may lead to hemolysis in the recipient. Hemolysis is more likely if group O platelets containing high titre anti-A or anti-B are transfused into a non-group O recipient. For this reason, titres of anti-A and anti-B can be performed on group O platelets, and high titre components reserved for group O recipients. A method for performing titres is provided in the full Platelet TIMS document. It has been argued that asking for a ‘boutique’ inventory of group A platelets only, instead of performing titres on group O platelets, defers the burden of testing to sites which do accept group O platelets and perform titres on them (whether or not there is a platelet shortage). This approach should be avoided. Other options for managing unavoidable plasma-incompatible transfusions include limiting the volume of incompatible plasma transfused per 24 hour period, and volume-reducing the component.
If D positive platelets must be transfused to a D negative female of childbearing potential, Rh immune globulin (RhIG) prophylaxis should be administered. One 300µg dose of RhIG will cover multiple platelet transfusions for four weeks. RhIG prophylaxis is not required for males, or for females outside of their child bearing potential years (e.g. over the age of 45).
In times of platelet shortage, splitting of doses is an option for hospitals with the appropriate equipment and expertise. Lowering the platelet count threshold for prophylactic platelet transfusions should be considered, and recommended threshold adjustments are included in the Ontario Contingency Plan as Appendix F. Extension of platelet shelf life should only be considered if authorised by the National Advisory Committee on Blood and Blood Products (NAC) and/or the National Emergency Blood Management Committee (NEBMC).
Interested readers are referred to the Ontario Contingency Plan and the full Platelet TIMS document at https://transfusionontario.org/en/documents/?cat=emergency_blood.
2018 Ontario Blood Shortage Simulation Exercise – Question & Answers from the Orientation Webinar Sessions
By: Wendy Owens, ORBCoN; Dr. Allison Collins, ORBCoN; Helen Cheng, MOHLTC; Esther Sok, MOHLTC; Leonard Chu, MOHLTC; Lisa St-Croix, CBS
In February of this year, ORBCoN held a series of five webinars to provide information to hospitals preparing to participate in the planned provincial blood shortage exercise. The exercise, originally planned for the week of March 5th had to be deferred due to actual low inventory levels of red blood cells at Canadian Blood Services. The exercise will be re-scheduled and hospitals will all be notified as soon as the new date is chosen. In the meantime, we wanted to share with you, the questions that came up during the orientation webinars and the answers that were provided.
|1.||Question: Who will receive the notification during the exercise and will this be the same as for a real blood shortage situation?
Answer: The first notification a hospital would receive of a blood shortage will be through a fax sent to the fax number on file at CBS. These fax numbers are programmed into the sending fax machine. This notification would be completed in the same way in an exercise as for a real situation. Email notification to hospitals would be the secondary communication. This email would be sent to Transfusion Medicine Laboratory primary and secondary contacts on the CBS hospital contact list.
|2.||Question: Who should attend the CBS teleconference calls?
Answer: A point person in the Transfusion Medical Laboratory (TML) should attend these calls. This person can then share updates with others in the TML and with the Hospital Emergency Blood Management Committee (HEBMC). This should be covered in the Hospital Emergency Blood Management Plan.
|3.||Question: Could decisions around triage of blood orders for this exercise be made retrospectively as opposed to in ‘real time’ so as to better manage the workload and not impact patient care?
Answer: Yes. Hospitals can make and document their simulation decisions and actions retrospectively. Hospitals can participate in the exercise in a way to accommodate workload. For example, triage decisions may be made in a less rigorous manner for the exercise to simplify the process.
It would be helpful to clarify what process would be used if decisions were being made in a real blood shortage to ensure that those involved understand the different or abbreviated approach taken for the exercise.
|4.||Question: Can the post exercise survey questions be sent to hospitals prior to the simulation exercise?
Answer: The purpose of the exercise is to test existing communications and processes in the event of a real blood shortage situation. Providing surveys ahead of the exercise may unduly influence behaviour and answers received. The post-survey questions are consistent with the Ontario Contingency Plan for the Management of Blood Shortages. Therefore, the survey questions will not be sent out prior to the exercise.
|5.||Question: Can hospitals receive a copy of their own responses to the post exercise survey to keep on file?
Answer: Yes, this can be provided for hospitals once the report has been completed.
|6.||Question: The Ontario Contingency Planning toolkit mentions that autologous donation might be considered if there is a prolonged Amber phase or if there is a Red phase shortage. Would this actually still be an option?
Answer: Yes, autologous donation was left in as a consideration if the regular blood supply is limited. For elective surgeries, if the patient’s surgery may otherwise be delayed for an extended period, autologous donation may be one option, albeit likely not the first one. It might be a better option to try to optimize the patient’s hemoglobin prior to surgery to reduce the likelihood that they would need transfusion at all depending on the type of surgery they are having. Any alternatives to transfusion in general will need to be considered carefully during an actual blood shortage. Pre-autologous donation for surgery is no longer a recommended strategy for patients without rare blood types; however, in exceptional circumstances, it can still be an option.
|7.||Question: How will the Emergency Management Communication Tool (EMCT) inform users during the mock exercise?
Answer: EMCT is an Incident Management System-based tool that does not depend on knowing specific individuals’ email addresses. Incident tickets will be created on the EMCT test site for text messages. Users will receive automatic notifications via email and/or text message. Users may then log into the EMCT to view information on a dashboard display. Both tickets and dashboard will inform users about the exercise, and in a real blood shortage could inform about the status of any related information such as road closures or affected facilities or services across the province.
|8.||Question: What types of messages will be posted on EMCT for this exercise?
Answer: Because this is an interactive communication exercise, it is difficult to completely predict the content of messages. However, it is expected that the conversations will be high level and will relate to LHIN/regional concerns rather than detailed questions on products and services.
|9.||Question: Who should I inform if the hospital’s EMCT members list is outdated?
Answer: There is a one stop contact for all inquiries related to EMCT: EMCT@LHINS.on.ca
You can send an email to this address to remove old members and add new members. New members will be required to complete training modules, which take about an hour to complete, prior to being set-up in EMCT.
|10.||Question: Who at the hospital should be an EMCT user?
Answer: This could be, but not limited to: Executive personnel, Incident Management and Risk Management personnel and Operations emergency preparedness personnel. Most staff in hospital transfusion services would likely not need to register on EMCT. It would be the role of the registered EMCT users at each hospital to inform others within their facility of relevant information.
|11.||Question: Are there preventive measures for any misinterpretations of messages via EMCT? Is there a possibility that the exercise could be mistaken for a real situation?
Answer: There are two safeguards to help ensure this does not happen-
|12.||Question: Would EMCT ever be used for CBS to notify hospitals of a blood shortage or to make decisions about allocation of blood?
Answer: No. This is not the intent or purpose of EMCT. CBS distributes blood in all provinces except Quebec. The EMCT is only an Ontario tool therefore, it would not be used to notify hospital transfusion services of important information. CBS does have users registered on the tool, however, they currently only have ‘observer status’. No clinical information is to be posted on EMCT for health information privacy therefore, it is not to be used for clinical management of patients. The purpose of using EMCT during this blood shortage exercise is to-
|13.||Question: What should a hospital do if they have not registered on EMCT? Can they still participate in this Blood Shortage exercise?
Answer: The hospital can still participate in this blood shortage exercise in every other aspect than the EMCT portion. If a hospital still wants to register with EMCT, they can contact the email address mentioned above EMCT@LHINS.on.ca and request to be added on to the tool. New users are required to complete some training prior to being granted access to the tool.
If you have any additional questions about your contingency planning for blood shortages or the upcoming provincial blood shortage exercise, please do not hesitate to contact me at firstname.lastname@example.org.