key: cord-0745455-qx5hului
authors: Ojha, Shashank; Gupta, Abhaykumar Malind; Nagaraju, P.; Minal, Poojary; S.H., Sumathi
title: Challenges in platelet inventory management at a tertiary care oncology center during the novel coronavirus disease (COVID-19) pandemic lockdown in India
date: 2020-07-01
journal: Transfus Apher Sci
DOI: 10.1016/j.transci.2020.102868
sha: f236f9a01b7fe8e4564e9629fd7adade06ec4a23
doc_id: 745455
cord_uid: qx5hului

The novel coronavirus disease (COVID-19) has been declared a pandemic by the world health organization and to limit the spread of the disease, many countries in the world, including India, had enforced a lockdown. Despite no restriction over the platelet donation activities, plateletpheresis donors became apprehensive regarding the possible risk of spread of the COVID-19 during the platelet donation and in the hospital premises. Many of them started hesitating for platelet donations. With this, the blood center started having an acute shortage of platelets. Various confidence-building steps were implemented by the blood center to promote voluntary plateletpheresis. The blood center staff and individual donors were educated to prevent the spread of COVID-19. The donor organizations and plateletpheresis donors were informed about the steps to be taken by the blood center during the donation and necessary steps for the prevention of the possible spread of COVID-19. With the help of these measures, the confidence of the individual platelet donors and the donor organizations was restored in the blood center and regular plateletpheresis was continued. These measures may also be useful to other blood centers in the COVID-19 pandemic and this experience may be useful if a similar pandemic lockdown happens in the future.

The novel coronavirus disease (COVID-19) is caused by severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2). On March 11, 2020, the COVID-19 has been declared as the J o u r n a l P r e -p r o o f pandemic by the World Health Organization [1] . To limit the spread of the disease, many countries in the world, including India, had enforced a 'lockdown'. The Indian government had declared an overall national lockdown from March 25, 2020, to May 31, 2020, with restriction to extend even further [2] . With the enforcement of lockdown, only essential grocery and medical facilities were allowed for the general population. With continuous COVID-19 reporting on 24x7 news channels and sometimes fake news on social media, the general population, including the plateletpheresis donors became very apprehensive regarding the risk of entrapping the COVID-19 infection while donating platelets or in the hospital premises. Due to this many regular donors started hesitating for plateletpheresis.

Platelet has a short shelf life of only five days and hence platelets need to be collected as per the requirement and cannot be collected and stored similar to the Red Blood Cell units [3] . Our center is a tertiary care oncology institute with specialization in the bone marrow transplantation (BMT). Thrombocytopenia is frequent in oncology patients due to the disease and its treatments such as chemotherapy and radiotherapy. At the time of lockdown, many patients were already admitted to the BMT, hemato-oncology, and onco-surgery departments. Many of these patients require platelet transfusions regularly and it may be life-saving for a few of them. The present study was aimed to analyze the impact of lockdown on the plateletpheresis donations and various measures implemented to overcome them.

The study was conducted at a tertiary care oncology hospital-based blood center. This was a combined prospective and retrospective analysis of plateletpheresis in the pre lockdown and lockdown phase. All the data was retrieved from the blood center registers. The lockdown started on March 25, 2020, and the 30-day data before that and 30-day data during lockdown was analyzed. All the plateletpheresis procedures had been performed as per the department standard operating procedures.

Data was computerized using Microsoft Excel spreadsheet and statistical analysis was carried out using statistical software SPSS for Windows, Version 23.0, IBM Corp. USA. Descriptive statistics such as mean, standard deviation (SD), and range values were calculated for normally distributed continuous variables. Frequency data across categories were compared using the Chisquare/Fishers Exact test as appropriate. A two-sided probability of P-value <0.05 was considered to be statistically significant.

In the pre lockdown, a total of 1507 patients (out-patient and admitted) visited the hospital, whereas only 432 patients visited in the lockdown phase. In the pre-lockdown phase, our median daily SDAP inventory was 16 which reduced to 10 (p˂0.001) in the lockdown phase. In the pre lockdown phase, a total of 120 SDAPs was collected, whereas only 69 SDAPs were collected in the lockdown phase. The majority of SDAPs transfusions were group-specific in the pre lockdown phase as compared to the lockdown phase (76 vs 38, p=0.328). As the number of J o u r n a l P r e -p r o o f hospital admissions decreased, the median number of SDAPs collected and issued had also decreased significantly in the lockdown phase; in pre lockdown, it was three SDAPs each whereas it was two SDAPs each in the lockdown phase (p˂0.001). The maximum number of SDAPs issued in a single day in pre lockdown was eight, while the same was four in the lockdown phase.

Various measures were implemented to minimize the catastrophic effect of the lockdown on the blood center and to ensure continuous plateletpheresis procedures. These measures were as follows. 2. The organizers were informed about the steps to be taken by the blood center during the plateletpheresis and necessary steps for the prevention of the possible spread of COVID-19.

3. All the queries of VBDOs and individual single donor apheresis platelet (SDAP) donors were understood and resolved over the phone or with the help of the personal meeting with a medical social worker.

To increase the number of voluntary plateletpheresis, the platelet awareness camps were organized. In these camps, a prior introductory lecture was given regarding platelet physiology, its need, and the procedure of plateletpheresis. A question-answer session was conducted for all J o u r n a l P r e -p r o o f the potential donor's queries. At the end of the camp, willing donors filled up the donor health questionnaire and a blood sample was withdrawn at the camp after the medical examination.

Further testing was done at the blood center for the eligibility of donation. Social distancing was observed and all the necessary precautions were implemented at the campsite. The camp was organized after due permission of the concerned authorities. After the confirmation of the eligibility, donors were called to the blood center in a staggered manner as per the requirement.

Many regular and first time donors routinely come to the blood center for the whole blood donation. All these donors were demonstrated, plateletpheresis procedure, and the regular need for SDAPs in oncology patients was explained. Active discussion of explanation of the plateletpheresis was done and blood donors were requested to donate SDAP instead of whole blood.

As the voluntary donor database decreased during the lockdown, patient's attendants (family members) were requested to come forward and donate SDAPs. Attendants were also motivated to become a regular repeat SDAP donor in the future. None of the attendants were forced for the SDAP donations.

A modified donor health questionnaire was implemented at our blood center. This was in addition to the routine donor health questionnaire and was in accordance with the national blood J o u r n a l P r e -p r o o f transfusion council (NBTC) guidelines [4] . The addendum included donors and close contacts (family members) travel history, contact history with a confirmed or suspected case of COVID-19, and symptoms of active infection. If the donor gave any positive history or had symptoms suggestive of COVID-19, then the donor was deferred and advised to follow proper social distancing protocols, stay at home and seek medical care if required.

1. Blood center staff was educated about the current COVID-19 crisis and important measures of its prevention like hand hygiene, cough etiquette, social distancing, etc.

2. The need and importance of the universal precautions were reiterated and the staff was instructed to follow the good laboratory practices.

3. Staff education aimed to make them more vigilant and to prevent the possible spread of COVID-19. 4 . Staff members were advised to follow the AABB resource document for blood establishments regarding the COVID-19 outbreak and World Health Organization guidance document on the safety of the healthcare professionals [5, 6] . 5 . The staff was trained regarding the proper use of N95 masks with its proper storage and disposal.

6. Proper donning and doffing of personal protective equipment were also demonstrated. 7. Staff members were asked not to use the wrist-watch or any other hand accessories during the pandemic.

8. Staff was instructed to clean cell phone, pens, and other potentially infected materials with hand sanitizers before entry and exit from the blood center. 2. An SDAP donor schedule book was maintained and donor name, blood group, and date with the time of appointment were entered in the book to avoid errors in the scheduling. 2. An infrared thermometer was used to check the body temperature of all the patients and visitors.

3. If anyone was detected with high temperature, then they were referred to the fever clinic.

to take out extra time while coming for the donation and co-operation with security personnel of the hospital was requested.

1. The use of alcohol-based hand sanitizers by donors at the entry and exit of the donation premises was ensured.

2. Namaste was the preferred mode of greetings instead of the handshake.

3. Only two staff members were dedicated to working in the donation area.

4. Donors who did not have a proper face mask were offered the same from the blood center.

5. Personal protective equipment including N95 mask, hand gloves, etc. was made mandatory for the blood center staff in the donation premises.

6. Worn gloves were cleansed with alcohol-based sanitizer before and after coming in contact with donor and change of gloves was done after each plateletpheresis donation.

7. Safe disposal of gloves, masks, and other potentially infected materials was insured.

1. VBDOs were informed to schedule donors in a staggered manner avoiding more than two donors at a time.

were requested to make themselves comfortable in a separate waiting area. 5. Gathering of people for photos while donation was discouraged instead, donors were asked to take selfies if required.

The blood center staff was posted in 40-50% of the regular strength in batches. If any of the staff members in any batch came positive with COVID-19 then the entire batch would have been quarantined and the next batch would take over. The staff allotted to the blood donation drives were different from the staff who were attending the regular blood center duties.

1. All the plateletpheresis couches were cleaned with 1% hypochlorite in-between donations.

2. All the door handles in the blood center, especially in the donor area were cleaned regularly.

3. The dustbins of the donor area including the biomedical waste were changed at least twice a day or more as per the requirements. 4 . The fumigation frequency of the apheresis area was increased to once in a week.

The main cafeteria of the hospital was closed for dinning to limit the overcrowding and social gathering at lunch. Only take-away food parcels were available. The staff was advised to get the food from home. The refreshment area of staff and donors was separated and a temporary J o u r n a l P r e -p r o o f additional arrangement for staff lunch was done at the blood center to facilitate social distancing even during lunch hours.

More than six air changes per hour (ACH) is the recommended level for any health facility and more than 12 ACH is recommended for the high-risk settings [7] . During the lockdown, the central air conditioning unit was shut down and the natural ventilation was used in the apheresis area.

Apart from SDAP, random donor platelet concentrates (RDPs) were also prepared by the buffy coat method. Whole blood donations were also carried out in a staggered manner so that the RDPs from all the whole blood units may be prepared as per the requirements. As hematooncology and hematopoietic stem cell transplant recipients may require multiple platelet transfusions throughout treatment, SDAPs were the preferred component at out institution to reduce the chances of allo-immunization and platelet refractories. The collected RDPs were used in solid oncology patients, as they routinely do not require frequent platelet transfusions and SDAPs may be preserved for the hemato-oncology patients.

Double dose SDAP (≥6×10 11 ) was collected from donors eligible for double dose SDAP collection as per the institutional protocol (weight ≥70kg and platelet count ≥300×10 3 /µl) after informed consent. The department also made the policy that 'half SDAP' may be given to patients in the case of shortages but the sufficient SDAP inventory was managed and all the patients received the full dose. The total number of double dose SDAP collected was 35 in the pre-lockdown phase whereas 17 were collected in the lockdown phase (p=0.789). 

Despite clear communication from the government that the blood donations will be continued during the lockdown phase, there was some ambiguity and lack of information from some of the civil authorities and police members and they were not allowing the movement of the donors for the same. The authorities were convinced telephonically and presented with all the necessary documents for unrestricted blood donation activities [4,8.9 ]. The authorities were requested to allow the movement of the donors and their vehicles after following social distancing protocols.

During the lockdown, the distributors of the apheresis kits and other related materials were having logistical issues with the supply of the disposables. The constant communication was maintained between the blood center staff and the kit vendors so that any problem in the transport may be handled at the level of the hospital. The minimum threshold of apheresis kit stock was also increased to have extra kits for emergencies.

The majority of our blood center staff were efficient in independently handling the troubleshooting of the apheresis machine. If required company resource personnel were contacted via phone. If the problem persisted or in case of a major technical break-down, company personnel were called to the blood center. For ease of their movement across the checkpoints, a letter/certificate was issued, stating that the person is traveling for hospital-related essential activities and their unrestricted movement was requested. If required, a hospital vehicle was arranged for easier transport.

Being a tertiary care oncology hospital, a minimum buffer stock of platelets has to be maintained for the regular requirements, and unexpected emergencies. Many oncology patients are not admitted in the wards rather they follow-up on the out-patient department basis. Sometime these patients may also require prophylactic or therapeutic platelet transfusions, and its prediction is not possible. In case, SDAPs were not getting utilized then the same was being informed to the nearby hospitals and they could procure SDAPs from our department or vice versa.

Marinating an adequate platelet inventory at a tertiary care oncology institution had been a challenging task in the time of COVID-19 but all the measures implemented by the blood center helped in achieving this herculean task. In the outbreak of an epidemic, the implementation of measures that minimize the chances of spread of infection to the staff and the donor populations are not only the responsibility but also the moral obligation of the blood center. All the above methods minimized the chance of spread of COVID-19 and build up the confidence of donors in the blood center.

Even after conquering the COVID-19, things may never remain the same, and blood centers may have to learn to work with this 'new normal' conditions. Blood centers may inculcate this extra cautiousness in their routine and this may also have a positive impact on the donor population. It will be crucial to gather data and knowledge regarding the experience of different blood centers after the epidemic, which may help in formulating policies for blood and platelet inventory management in future pandemic events. Blood centers must prepare standard operating procedures for these kinds of possible epidemics in the future.

This was a single-center study and measures implemented and expected outcomes may or may not apply to the other centers. As the number of hospital admissions decreased during the lockdown phase, the SDAP requirement had also decreased. This may give a false notion that the SDAP donations had decreased due to the lockdown effect. 

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