key: cord-0836531-lpp5ijkn
authors: Shopsowitz, Kevin E.; Lim, Christina; Shih, Andrew W.; Fishbane, Nick; Berry, Brian R.; Bigham, Mark; Petraszko, Tanya; Trudeau, Jacqueline; Wyatt, Maureen; Yan, Matthew T. S.; Morrison, Douglas
title: Impacts of COVID‐19 and elective surgery cancellations on platelet supply and utilization in the Canadian Province of British Columbia
date: 2021-07-26
journal: Vox Sang
DOI: 10.1111/vox.13180
sha: bc69366ce5a60d54ee4fad6e8a9d7d40510888bb
doc_id: 836531
cord_uid: lpp5ijkn

BACKGROUND AND OBJECTIVES: The coronavirus disease 2019 (COVID‐19) pandemic raised concerns about the vulnerability of platelet supply and the uncertain impact of the resumption of elective surgery on utilization. We report the impact of COVID‐19 on platelet supply and utilization across a large, integrated healthcare system in the Canadian province of British Columbia (BC). MATERIALS AND METHODS: Historical platelet use in BC by indication was compiled for fiscal year 2010/2011–2019/2020. Platelet collections, initial daily inventory and disposition data were assessed pre‐COVID‐19 (1 April 2018–15 March 2020) and for two COVID‐19 time periods in BC: a shutdown phase with elective surgeries halted (16 March–17 May, 2020) and a renewal phase when elective surgeries resumed (18 May–27 September 2020); comparisons were made provincially and for individual health authorities. RESULTS: Historically, elective surgeries accounted for 10% of platelets transfused in BC. Initial daily supplier inventory increased from baseline during both COVID‐19 periods (93/90 units vs. 75 units pre‐COVID‐19). During the shutdown phase, platelet utilization decreased 10.4% (41 units/week; p < 0.0001), and remained significantly decreased during the ensuing renewal period. Decreased platelet utilization was attributed to fewer transfusions during the shutdown phase followed by a decreased discard/expiry rate during the renewal phase compared to pre‐COVID‐19 (15.2% vs. 18.9% pre‐COVID‐19; p < 0.0001). Differences in COVID‐19 platelet utilization patterns were noted between health authorities. CONCLUSION: Decreased platelet utilization was observed in BC compared to pre‐COVID‐19, likely due to a transient reduction in elective surgery as well as practice and policy changes triggered by pandemic concerns.

Blood products rely on a complex infrastructure of donors, distribution networks and hospital transfusion services to meet clinical demand. Platelets, with a relatively short shelf-life of 5-7 days, are particularly vulnerable to perturbations to the supply-demand equilibrium. Concerns over potential platelet shortages are not new, for example, related to ageing donor and recipient populations [1] ; however, the COVID-19 pandemic had the potential to exacerbate these vulnerabilities in ways not previously experienced by healthcare systems. Potential problems included the disruption of donor networks and blood collection, production and logistics networks (reduced supply) and/or by increasing platelet use through large numbers of critically ill COVID-19 patients (increased demand). On the other hand, decreases in non-COVID-19-related healthcare visits due to both behavioural changes and policies like halting elective surgeries [2, 3] , or policies to extend platelet shelf life, for example, through cold storage [4] , could counter-balance these stressors by reducing demand.

Understanding the multifaceted influence of COVID-19 on platelet supply and demand is crucial for ongoing resource management and future planning. Data are emerging on the effects of the pandemic on platelet utilization [5] . Studies from diverse geographical regions have suggested that although COVID-19 infection is associated with thrombocytopaenia [6] , significant bleeding is uncommon, and hospitalized patients have relatively low platelet transfusion requirements, with some centres reporting decreased overall platelet utilization during the first wave of the pandemic [7] [8] [9] [10] . In one study from a tertiary care centre in India, a diminished inventory caused by decreased donations was offset by a lower demand for platelets during the early phase of the pandemic [11] . Additional data from large health systems over longer time periods are useful to further understand the manifold impacts of COVID-19 on platelet supply and utilization.

The Canadian province of British Columbia (BC) maintains a centralized transfusion database for six health authorities (HAs) that service a population of roughly 5 million residents. Here, we report on BC's baseline platelet use patterns and experience with platelet supply and utilization during the initial 6 months of the COVID-19 pandemic.

This time period encompasses an initial response phase when all elective surgeries were suspended in the province and, subsequently, when elective surgeries were resumed. To our knowledge, this study represents the largest analysis to-date of system-wide platelet use during the COVID-19 pandemic.

BC receives blood components from Canadian Blood Services (CBS), which operates the national blood system outside the province of Quebec. While the majority of platelets issued to hospitals in BC are collected in the province, some are imported from other provinces.

Platelets are produced from both whole blood and apheresis collections. Buffy coat platelet units, each manufactured from four whole blood units, comprise $70% of platelet production in the prov- [13] . Total population and age data for BC and its HAs were obtained from publicly available government data [14] . Median ages were estimated from population data capped at age 90 years (i.e., individuals aged ≥90 were binned together as 90+). 

The mean of total weekly platelet use in BC was calculated for the three time periods noted above (pre-COVID-19, shutdown, renewal), and statistical testing was performed by analysis of variance with a post-hoc Tukey test for pairwise comparisons. Linear regression was used to assess trend over time for historical annual platelet usage. Initial daily platelet inventory and platelet usage are reported as 7-day rolling average to remove the periodicity of daily counts related to different transfusion practices on weekend versus weekdays. Statistical values are all reported as mean with 95% confidence intervals (CIs) unless otherwise indicated. Weekly mean with 95% CI was also calculated for each of the three largest HAs within the province and for the sub-categories of weekly transfused and expired platelet units (formal statistical testing not carried out for these sub-categories). Provincewide and HA-specific discard rates were calculated as expired/ discarded units divided by total units for the three time periods. For the total provincial data, these rates were statistically compared by chi-squared test for both overall trend and pairwise comparisons with Bonferroni correction. p-values <0.05 were considered to be statistically significant for all comparisons. (Table 1 and Figure 4 ). Figure 4a shows that the decrease in platelet use throughout the pandemic was Key features of the three HAs in BC that utilize the most platelets (86% of total) are summarized in Table 2 

The COVID-19 pandemic has placed an incredible strain on healthcare systems around the world, including sustaining a stable inventory of platelets and other blood products. Initial studies have noted reduced platelet demands for critically ill COVID-19 patients compared to other ICU patients [8] , and several tertiary care centres in New York [9] , Washington [10] and India [11] reported decreased platelet transfusions during the first 1-2 months of the pandemic, possibly due to a combination of low platelet requirements for COVID-19 patients and policies that decreased healthcare utilization (e.g., halting elective surgeries). In our healthcare jurisdictions, we found similar findings that platelet transfusions decreased concurrently with decreased surgeries and hospital admissions. We also found that platelet use remained decreased even when elective surgeries resumed, largely driven by decreased expired/discarded units. Our comprehensive study of system-wide platelet use during the COVID-19 pandemic also demonstrates differential effects on platelet use by health region, potentially related to their different demographics and characteristics.

The overall balance of blood product supply and demand depends on many interacting factors: donors, collection services, distribution networks, hospitals and patients requiring transfusions. All of these are potentially impacted directly and indirectly by COVID-19 and related policies. The Canadian province of BC, with a large integrated healthcare system and transfusion database, provides a unique opportunity to examine these various factors. We found that platelet use significantly decreased compared to baseline during the initial shut- In conclusion, to our knowledge, this is the largest analysis todate of platelet supply and utilization during the COVID-19 pandemic. We found that the platelet supply in BC remained stable during the first 6 months of COVID-19, even with an initial decrease in blood donations. Platelet utilization was significantly decreased in BC during the first 6 months of the pandemic compared to baseline: this appears to have been due to province-wide policies that led to decreased healthcare utilization and platelet transfusions during the initial phase of the pandemic, followed by local practice changes that conception of this work and provided comments and revisions that were incorporated in the final manuscript.

No conflicts of interest were identified in the preparation of this manuscript.

ORCID Kevin E. Shopsowitz https://orcid.org/0000-0003-3988-0837

The current state of the platelet supply in the US and proposed options to decrease the risk of critical shortages

Challenges in platelet inventory management at a tertiary care oncology center during the novel coronavirus disease (COVID-19) pandemic lockdown in India

Expansion of hospital-based blood collections in the face of COVID-19 associated national blood shortage

Transition from room-temperature to cold-stored platelets for the preservation of blood inventories during the COVID-19 pandemic

Blood component use in critical care in patients with COVID-19 infection: a single-centre experience

Thrombocytopenia is associated with COVID-19 severity and outcome: an updated metaanalysis of 5637 patients with multiple outcomes

Pathophysiology, transmission, diagnosis, and treatment of coronavirus disease 2019 (COVID-19): a review

Blood transfusion activity in a general hospital during the COVID-19 pandemic

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Blood supply management in times of SARS-CoV-2 pandemic -challenges, strategies adopted, and the lessons learned from the experience of a hospital-based blood centre

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Adaptations of transfusion systems to the COVID-19 pandemic in British Columbia, Canada: early experiences of a large tertiary care center and survey of provincial activities

Impacts of COVID-19 and elective surgery cancellations on platelet supply and utilization in the Canadian Province of British Columbia