Blood Shortage

General Principles

• Blood shortage plans may be instituted to ensure that:
  • Blood is available for all essential transfusion to all patients equally.
  • Overall blood usage is reduced to ensure that the most urgent cases receive the supply which is available.
• Shortage plans operate in three phases depending on NHSBT stock levels:
  • Green: normal circumstances where supply meets demand. Focus on principles of patient blood management.
  • Amber: reduced availability of blood for a short or prolonged period.
  • Red: severe, prolonged shortage of blood.
• At all times, hospitals and blood supply centres should actively strive to minimise blood shortages.
• National stock levels are monitored daily and production levels amended to ensure stock levels are kept at a pre-set target level. Additional measures which may be taken to ensure this:
  • Calling more donors (may be of a certain group, depending on nature of shortage).
  • Increasing production:
    • Extending shifts.
    • Extending opening times of donation centres.
    • Increasing the number of mobile donation centres.
    • Importing blood products from other blood services.
  • For platelets: hospitals may be asked to delay transfusion or accept units of a different blood group. They may also:
    • Suspend bacterial screening so as to bring stocks in earlier.
    • Import platelets from other blood services.
    • Reduce the number of buffy coats to produce pooled platelets from 4 to 3.

Hospital Emergency Blood Management

• Every hospital should have an Emergency Blood Management Group.
• This group should focus on triage and appropriate provision of blood during blood shortages. Hospitals will need to reduce blood usage insofar as is possible.
• All indications for transfusion should be reviewed.
• Non-surgical management should be considered wherever possible.
• Adverse incidents with the operation of the plan should be reported to SHOT, SABRE and NHSBT.
• Over-dependence on RhD negative O red cells should be avoided.
• Amber Phase:
  • Elective procedures where patients are likely to require blood product support (>20% chance of transfusion) should be postponed.
  • Higher transfusion triggers for transfusions should be considered.
  • Refer all transfusion requests outside of approved indications for transfusion to a consultant haematologist.
  • Reduce reservation period of blood to 12 hours where possible.
  • Procedures which can continue / scenarios where red cells will be approved for transfusion in Amber phase (but not the Red phase): 
    • Palliative cancer surgery.
    • Patients with symptomatic (but not life-threatening) post-operative anaemia.
    • Urgent (patients likely to suffer severe morbidity without intervention), but not emergent, surgery.
    • Patients with symptomatic (but not life-threatening) anaemia. 
  • Platelet stock-holding in hospitals will be restricted, and hospitals should only order platelets where there is a specific identified requirement.
  • Platelets issued in the Amber phase will have a maximum expiry of 24 hrs.
  • The following platelet transfusions will not be approved in the Amber phase:
    • Prophylactic platelet transfusion for ASCT (except for APML).
    • Long-dated platelet units.
    • Specific requests for RhD negative platelets: RhD positive platelets should be administered with anti-D as appropriate.
    • Specific requests for CMV negative platelets.
• Red Phase:
  • All transfusion requests should be reviewed by a consultant haematologist.
  • An order of priority based on clinical need should be established.
  • The following patients will remain the highest priority for red cell transfusion:
    • Ongoing resuscitation.
    • Emergency (patients likely to die in 24 hrs without intervention) surgery, including cardiac, vascular and organ transplantation.
    • Cancer surgery with curative intent.
    • Life-threatening anaemia.
    • In utero transfusions.
    • Patients with anaemia / thrombocytopaenia resulting from stem cell transplant / chemotherapy (patients who have yet to be initiated on chemotherapy / conditioning should be deferred where possible).
    • Severe bone marrow failure.
    • Sickle cell crises affecting organs.
    • Sickle cell patients aged 16 and under with a history of CVA.
    • Thalassaemia major (but consider lower transfusion thresholds).
  • For platelet transfusion, all requests must be made to NHSBT by a consultant haematologist. The following patients will remain the highest priority for platelet transfusion:
    • Massive transfusion for any condition with ongoing bleeding.
      • Maintain plt >50×10⁹/L.
      • For polytrauma or CNS bleeding, maintain >100×10⁹/L.
    • Active bleeding associated with severe thrombocytopaenia or platelet function defects.
    • NAIT to maintain plt >30×10⁹/L (>100×10⁹/L if ICH suspected or confirmed).