Shortages of blood collection tubes continue

Covid has again drawn attention to supply chain issues, this time relating to shortages of blood collection tubes. It’s surprising how something so trivial can have an outsized impact and how difficult it is to get answers from both industry and the FDA.

In the United States, the FDA first listed a shortage of sodium citrate tubes (the light blue top) on their device shortages. They euphemistically describe the problem as being due to an “increase in demand and recent supplier supply issues”. These light blue upper tubes are used to measure clotting and have been used more frequently as clotting abnormalities have been a significant issue with Covid.

Now, the FDA says shortages are more widespread, affecting all types of tubes. Vacuum tubes, aka “vacutainers”, are made of plastic or glass. The color of the cap indicates the type of additive contained in the vacutainer.

Becton-Dickinson is a leader in this market. A BD spokesperson said that during Covid they saw “the most unpredictable demand BD has seen in our company’s history.” They added: “Globally, BD produced nearly half a billion more blood tubes in 2021 compared to 2020…Like all companies in all industries worldwide, BD is experiencing limited availability and access to raw materials, delays shipping and transportation costs and labor shortages, which impede our ability to increase production.

Christine Nielsen, CEO of the Canadian Society for Medical Laboratory Science, added a broader perspective. She said the problem was not limited to tubes but included basic supplies like buffered saline solution. Nelson said: “It’s also a challenge because we’ve moved to just-in-time inventory in all areas, including labs… They’re updating, just like food is no longer fresh. It’s no longer reliable and you can’t use it. We can’t store it either.”

Nelson also noted that many lab manufacturers have focused their attention on rapid point-of-care testing with Covid, a marked change for businesses.

One of the key responses in Canada has been an awareness campaign called “Using Labs Wisely,” which is part of a larger “Choosing Wisely” effort. They have many sound suggestions, including:

  • Do not do annual screening blood tests unless directly indicated by the risk profile

If you do enough tests, something will come back wrong and lead to unnecessary further investigation. “Abnormal” results are found in at least 5% of people, although this may be their norm.

  • Do not routinely measure vitamin D in low-risk adults.

Instead, just give vitamin D supplements.

Consider if and how a test result will change patient care, which is often overlooked in routine screening labs.

For hospitalized patients, Using Labs Wisely offers two particularly helpful suggestions:

  • “In a hospital setting, do not order repeat CBC and chemical tests in the face of clinical stability. Only one blood draw per day for ‘routine’ daily lab tests can add to the suppression of the equivalent of 1 ⁄ 2 unit of blood per week? The result is that 20 to 30 tubes of blood are wasted and iatrogenic anemia has a negative effect on patient outcomes.”
  • Do not request baseline laboratory studies (complete blood count, coagulation test, or serum biochemistry) for asymptomatic patients undergoing low-risk non-cardiac surgery.

The shortages in Canada are serious enough that there is talk of limiting outpatient testing if the situation worsens. They have the added problem that the United States no longer allows tube exports.

Neilson echoed a concern often raised by Rodney Rohde, professor of clinical laboratory sciences at Texas State University, the growing shortage of medical laboratory professionals.

Both spoke of severe staff shortages of up to 26%, Covid itself and burnout. In Canada, there is a lack of internships.

Dispatches say the shortages are expected to last for months.

This problem of shortage of vacuum cleaners is just one example of the problems of just-in-time inventory, shortage of personnel as much as possible and dependence on overseas production. We also need to do a better job of educating the public and physicians about these shortages; Canada seems to have done a better job on this.

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