Mark A . Crowther , MD

Steven L . Allen , MD

● YOU ARE A typical busy hematologist scrambling to stay on schedule while still taking the time to formulate a thoughtful plan for the patient in front of you . Perhaps it is a clotting conundrum . You think to yourself , What diagnostic tests are needed ? You may even subconsciously recall what color top tubes will be drawn , but have you ever worried whether your lab has the necessary tubes ? Or even given a thought to the possibility that global events might impact your ability to evaluate or care for your patients ?

That almost unimaginable development has come to pass . In late May , multiple laboratories began to announce shortages of 3.2 % sodium citrate blue top tubes – the tubes that enable most of our basic coagulation tests to be performed . This shortage is expected to persist through 2021 . In an illustration of the severity of this issue , a major university-owned lab sent out an alert on May 14 that it had only a 14-day supply of blue tops left . How could this happen ?

A perfect storm is the explanation , with COVID-19 at its core . The coagulopathies and thrombotic complications associated with COVID-19 infection markedly increased the demand for coagulation testing . This occurred in the setting of a simultaneous worldwide shortage of sodium citrate , the anticoagulant in blue top tubes . The increased demand exceeded both the available supply and production capacity . The issue has been further exacerbated by a COVID-19 — associated disruption of supply chains , a shortage of plastics , and a product recall . There were even unsubstantiated rumors that thrombosis of the Suez Canal by that grounded container ship ( talk about clotting problems !) had contributed to the shortage .

What can be done to mitigate this potential crisis ? For one thing : choose wisely ! This current shortage emphasizes the importance and relevance of the 2013 Choosing Wisely ® recommendations , an initiative of the ABIM Foundation , from the American Society of Hematology ( ASH ) and the American Society for Clinical Pathology ( ASCP ). ASH recommended , “ Don ’ t test for thrombophilia in adult patients with venous thromboembolism occurring in the setting of major transient risk factors ( surgery , trauma , or prolonged immobility ).” ¹ ASCP recommended , “ Avoid routine preoperative testing for low-risk surgeries

without a clinical indication .” ² This latter recommendation reinforces the need to avoid unneeded prothrombin time / international normalized ratio ( PT / INR ) and partial thromboplastin time testing . These tests are often ordered at admission and in the perioperative setting – yet almost never actually inform care .

A timely addition to the Choosing Wisely campaign recently published by a joint task force from ASH and the American Society of Pediatric Hematology / Oncology echoes these recommendations for the pediatric population . First among their five recommendations is to avoid routine preoperative hemostatic testing in an otherwise healthy child without personal or family history of bleeding . Also included was the suggestion to avoid thrombophilia testing in children with venous access – associated thrombosis and no positive family history . ³

Our ability to conserve our supply of blue top tubes would greatly benefit from the quality improvement objectives of the Choosing Wisely campaign !

In June 2021 , the College of American Pathologists issued formal recommendations outlining practical steps to ameliorate the blue top tube shortage :

1 . Evaluate the clinical necessity of coagulation testing .

2 . Where possible , reduce the frequency of standing PT / INR orders , especially for stable patients on long-term warfarin .

3 . Reduce routine coagulation testing where not clinically necessary , for example , routine preoperative testing for low-risk surgeries without a clinical indication .

4 . Do not draw blue top tubes without a specific order . Avoid the so-called “ hold ” and “ rainbow ” draws and do not use blue tops as discard tubes .

Hopefully , prudent practices and wise choices by the medical community will alleviate demand for blue top tubes and help us avoid a disastrous interruption in our ability to evaluate and care for our patients . Just “ singing the blues ” won ’ t do it ! Hematologists need to lead educational efforts regarding the practical and quality-improving steps that can be taken to reduce use of blue top tubes . Systems hematologists are in an ideal position to lead these initiatives , but we can only help palliate the blue top tube supply crisis . As with all other aspects of the COVID-19 crisis , calming the storm ultimately hinges on vaccination , which would in turn result in reduced demand for coagulation testing and its downstream impacts .

References

1 . Choosing Wisely . American Society of Hematology . December 4 , 2013 . Accessed July 12 , 2021 . https :// www . choosingwisely . org / clinician-lists / american-society-hematology-testing-for-thrombophilia-in-adults /.

2 . Choosing Wisely . American Society for Clinical Pathology . February 21 , 2013 . Accessed July 12 , 2021 . https :// www . choosingwisely . org / clinician-lists / american-society-clinical-pathology-bleedingtime-test /.

3 . O ’ Brien SH , Badawy SM , Rotz SJ , et al . The ASH-ASPHO Choosing Wisely Campaign : 5 hematologic tests and treatments to question [ published online ahead of print , 2021 May 28 ]. Pediatr Blood Cancer . doi : 10.1002 / pbc . 28967 .