BEST PRACTICES :: BLOOD CONSERVATION


How blood conservation can unburden the laboratory post-pandemic


J. Michael O’Bryan, MD, MHA P


rior to the pandemic, America’s laboratories analyzed over thirteen billion medical decision-making diagnostic tests each year. Over the last twenty-four months, there have been an added one hundred million COVID-19 tests into that normal daily output.1


This event intensified the already disrupted work-


flow that began a few years before when facilities started transi- tioning to a value-based healthcare model as the fee-for-service reimbursement model started to dissolve. Critical to delivering better patient outcomes are timely and accurate results, since over 70% of a patient’s care plan that a physician makes is directly tied back to these lab results.1


So, while the healthcare industry


continues to weigh the impact of the pandemic as it contends with a record number of employees leaving the industry, supply chain disruptions, and increasing medical mistakes, laboratorians continue to churn out crucial diagnostic tests that remain integral to the overall goal of delivering good patient care. Roughly 13% of America’s medical professionals in the labora- tory space have left. A recent Forbes article indicated burnout was the chief motivator for leaving, with staffing shortages being the next biggest cause.2


This makes an unfortunate situation even


more dire. Clinical laboratory testing remains an exceedingly multifaceted process (i.e., preanalytical, analytical, and postana- lytical phases).3


remained stable across America’s labs at around 0.31% for all test results.4


Prior to the pandemic, the frequency for error Of that number, most of the mistakes occurred in


the preanalytical phase. Typically, these errors refer to mistakes that occur mostly outside of the laboratory, and stem from issues such as an inappropriate sample collection, delays in transporta- tion, or mislabeling of specimen tubes.3


Under normal working


nounced that due to shortages of raw materials, interruptions in manufacturer supply chains, and increased demand across the globe, sodium citrate tubes would need to be conserved. This issue became more dire when all blood collection tubes were added to the list in January 2022.3


to eliminate duplicate test orders and to work with physicians to only draw blood when “medically necessary.” 5


The FDA urged laboratories However, the


issue is that physicians do not get training on how to determine what is medically relevant when it comes to diagnostic testing. Moreover, overall communication between laboratory and staff on the floor of the hospital has never been much more than amicable, even on a good day. As a result of these tube shortages, increasing numbers of patients, and staffing limitations, many laboratories began to engineer a few practical workarounds. Although some of these workarounds were endorsed by the FDA and the Centers for Disease Control and Prevention (CDC), they were unsafe, outdated, less effective — and in contrast to organizations such as the Clinical and Laboratory Standards Institute (CLSI). The overall worry was whether this response would compromise patient care.1


On the other hand, manufacturers are working


around the clock to ease the burden of shortages through a number of strategies, such as allocating production lines to produce collection tubes with the highest demand. However, it will still take some time before a hospital will see any noticeable relief. Both providers and suppliers need to partner together and consider strategic ways to quicken delivery of available supplies and to approach blood collection in a more innovative way. This could be done by rethinking our continuum of care through blood conservation.


Patient Blood Management Patient blood management is gradually becoming an integral part of a patient’s care in the hospital, but more awareness is necessary.4


Blood conservation is classically only mentioned


when it comes to a patient on the verge of needing a transfu- sion; however, the question must be asked: Could this transfusion have been avoided? Anemia is a prevalent diagnostic illness when patients are admitted to the hospital. On average, it only takes three full days as an inpatient before hemoglobin and hematocrit levels drop into a borderline critical status, due to the amount of blood drawn daily.5


We must begin to fully optimize efficiency Photo by dusanpetkovic1@AdobeStock.com


conditions, the medical laboratory staff does an excellent job of catching these sample error mistakes before being analyzed on the instruments. Since the pandemic began, the number of preanalytical errors has increased one-hundred-fold. A study in the American Journal of Clinical Pathology showed the number of preanalytical errors jumped to 3% over the last two years, with clotted samples being the biggest contributor to rejection rates.4 The driving force behind these large numbers could be from the before mentioned burnout and short staffing or workarounds made necessary from the nationwide blood tube shortage. In June 2021, the Food and Drug Administration (FDA) an-


3 AUGUST 2022 MLO-ONLINE.COM 8


across all departments to limit the number of preanalytical variables that a sample goes through before arriving at the laboratory, and thus, prevent severe diagnostic blood loss and hospital-acquired anemia. Implementation should begin with the emergency department, where turn-around-time and sample quality are essential to clinical decision making. If a hemolyzed sample is drawn, this delays the treatment plan and can result in a drawn-out length of stay and overall poor experience for the patient.6


Reducing Hemolysis Hemolysis can delay treatment, prolong patient stays, and nega- tively impact an organization’s HCAHPS (Hospital Consumer Assessment of Healthcare Providers and Systems) score for patient satisfaction. Studies show that the emergency department produces more hemolytic samples than any other department


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