fort hood mascal lab lessons learned 1lt misty youngblood march 25, 2010

Fort Hood MASCAL

Lab Lessons Learned

1LT Misty Youngblood

March 25, 2010

of X

Objectives

• Identify the sequence of events that occurred during the MASCAL

• Evaluate the current MASCAL procedures in use at Medical Treatment Facility

• Recommend improvements to the current procedures related to a MASCAL event

of X

The first 2 hours1330-1530

April 21, 2023

19 - Emergency release Requests 3 - Blood Product shipments received 2 - Bodies admitted to morgue 2 - Blood Product inventories completed - EOC established

of X

The next 5 hours1530-2030

April 21, 2023

26 - Emergency BP Requests 6 - Blood Product Shipments 4 - EOC meetings 1 - Body admitted to morgue - Employees released ~2000 hrs

of X

Overnight2030-0830

April 21, 2023

5 - EOC meeting every 1-3 hours10 - Bodies admitted to morgueFinal BP shipment ~2345 hrs

of X

Totals

• 45 Emergency Requests– 16 patients & 138 Blood Products– 126 transfused

• 10 shipments of BPs

• 13 Bodies admitted to Morgue

April 21, 2023

of X

Dept/Hospital AAR’s

• “Top Six” that affected Laboratory Operations

1. Patient ID

2. BP Inventory Management

3. Communication with Transfusion Services

4. Morgue

5. Staff knowledge of BP administration policies

6. Specimens no orders/not labeled

April 21, 2023

of X

Issue # 1Patient ID

3 “systems” to ID patients

#1 - MASCAL pack – PAD, pt accountability – Stored in PAD– Blue armband w/# to track pt movement– Not for clinical/treatment purpose– Not registered in CHCS

of X

Patient ID (cont)

#2 - Trauma pack – ED, clinical data– Forms stored in ED– No armband, no preprinted pt ID’s– Pt ID’s not registered in CHCS– Could not find immediately

April 21, 2023

of X

Patient ID (cont)

#3 - John Doe registration in CHCS– Used for unidentified trauma patients– Pts registered in CHCS upon arrival– Cannot be pre-registered - PAD issues

• No preprinted ID bracelet/labels

– Too slow for true MASCAL - not used

April 21, 2023

of X

Patient IDConsequences

• Patients transported without ID bracelet– Pt’s ID in ER, OR, ICU & PAD did not match

• Poor documentation and tracking through Patient care

April 21, 2023

of X

Patient IDConsequences

• Inconsistent patient ID– One pt had 14 different pt IDs

• MC1 & MC3, 3 different SSN last 4, room #, different name spellings

– MC4 – ID for 2 patients (3S & ICU)

• BP reconciliation took 3-5 working days

• Type specific blood could not be used

of X

Patient IDRecommendations

Meeting - PAD, ED, DPALS, Business Ops

• Create one “system”– Use for unknown trauma pts and MASCAL– ED staff familiar with system because of more

frequent use– Must be immediately available

of X


• TRAUMA/MASCAL pts in CHCS– 100 ED, 100 PAD (for DIME locations)

• TRAUMA/MASCAL 001 with system generated-SSN

– PATCAT 92 FMP98, DOB Field 2010– Embossing cards, armband and labels– Each form will have ID already stamped

April 21, 2023

of X


• Other Recommendations:– Need realistic MASCAL training– PAD added to ED’s emergency recall– Utilize only O RBCs

April 21, 2023

of X

Issue #2BP Inventory Management

• Multiple shipments of BP– Too many BPs received to process & store

• Delay issuing Platelets

• Post access– Couriers stuck in traffic trying to deliver BPs

of X

BP Inventory Management The numbers

On Hand Transfused Received

PRBCs 56 74 558

FFP 42 32 168

PLTs 1 4 31

CRYO 22 16 130

Many BPs were shipped out 09-11NOV09Not all locations wanted BPs backOutdate rate for NOV 21% and DEC 16% (normal outdate rate <5%)

of X

BP Inventory Management Recommendations

• Coordinate through Trans Svcs

• Ask for Platelets early in the process

• Have access control phone numbers readily available

LAB STATUSSTATUSPERSONNEL

Assigned:

Available:

Key Personnel Chief:

Unavailable:

**58 total personnel present for duty

ASSESSMENT/ISSUES:

CRYO PLTSO+ O = A + A = B + B = A B AB

CRDAMC Transfusion Services 21 13 6 4 0 2 20 20 12 20 1

0 0 0 0 0 0 0 0 0 0 0

Other Sources 0 0 0 0 0 0 0 0 0 0 0

Robertson Blood Center 10 10 100 4 4 4 0 0 0 0 0

Central Texas Blood Center 100 100 100 100 100 100 100 100 100 100 6

Scott and White 20 10 20 10 10 10 20 20 20 20 2

Carter Blood Care 0 0 0 0 0 0 0 0 0 0 0

BAMC

Products enroute

Products issued

TOTAL 151 133 226 118 114 116 140 140 132 140 9

PACKED RED BLOOD CELLS FFP

of XApril 21, 2023

of X

Issue # 3Transfusion Service Communication

• Techs- Emergency release and shipments

• No one was trained to assist answering phones, inventory etc

• Phone line was often busy

of X

Transfusion Services CommunicationConsequences

• Miscommunication or misinformation to and from providers/nurses

• Difficulty getting accurate and timely inventories to EOC

of X

Transfusion Services Communication Recommendations

• Emergency phone line - internal use during MASCAL

• Designate and train additional personnel to:– Inventory BP including incoming shipments– Track BPs issued during MASCAL– Man emergency phone line

of XApril 21, 2023

of X

Issue # 4Morgue

• Procedural failures– Body admitted without body bag– PAD was not present– Body was not pronounced prior to admittance

• Space– Morgue has room for 4 bodies

of X

MorgueConsequences

• Transport:– Morgue to truck– truck to truck – refrigeration unit failure– Smoking area near the loading dock

• Justice of the Peace came to pronounce victim

of X

MorgueRecommendations

• Have litters available/know where to get them for easier, respectful transport and storage

• Do not let emotions allow deviations from procedures

• Designate team to assist with morgue functions

of XApril 21, 2023

of X

Issue # 5Staff Knowledge of BP administration

• Lab accused of not releasing FFP– Physicians did not realize they needed to

request– Previous proposal by to Blood Utilization and

Transfusion Committee to develop trauma pack for blood components was turned down

of X

Staff Knowledge (cont)

• OR asked if blood issued to a patient could be used for another patient

• Blood products issued to one patient transfused to another– BP issued to pt transfused to another pt (the

only pt infused via rapid infuser)

of X

Staff KnowledgeConsequences

• Unable to issue type specific products

• Reconciliation of paperwork

• Animosity or accusations held against laboratory personnel

of X

Staff KnowledgeRecommendations

• Establish Mass Transfusion policy– In conjunction with Blood Utilization Committee– Physician would have to request

• Continue current policy– Pathologist monitor BP issued to individual

patients

of X

Staff KnowledgeRecommendations

• Continue to issue only type O RBCs during MASCALs

• Educate providers during Newcomers Orientation

April 21, 2023

of X

Issue # 6Specimens No orders/not labeled

• Multiple unlabeled tubes in bag with one label in bag

• No electronic or written orders

of X

No orders/labelConsequences

• Lab personnel to ER to see what tests were needed

• No ordering physician to contact for critical values

• Chance for patient ID errors in reporting values increased

of X

No orders/labelRecommendations

• MASCAL/Trauma registration– Provide preprinted labels, order via CHCS

• Establish order sets

• Use runners to communicate critical values if necessary

of XApril 21, 2023

of X

What Went Well

• Rapid issue of BP – ready prior to the first request

• Zero transfusion reactions

• Donor Center delivered BP very quickly

of X

What Went Well (con’t)

• Supply clerk & NCO– Inventoried/Resupplied all areas – Coordinated pick up of BP flown in

• Cytotechs automatically reported to Histology section to assist with morgue operations

• Histology immediately called for and received trucks for additional morgue storage

of X

What Went Well (con’t)

• Staff management - work rest cycles considered early and planned for

• Food/drink provided to staff

• Teamwork from all areas of the laboratory exemplary

of X

Conclusion

Majority of changes/recommendations

involve two key elements:

Hospital policy for unknown Patient ID

Training and Knowledge base of staff

April 21, 2023

of X

Questions??

April 21, 2023

fort hood mascal lab lessons learned 1lt misty youngblood march 25, 2010

Documents

id braceletpts id

xpatient id cont

id patients

spellingsmc4 id

mascal pack pad

blood product shipments

true mascal

mascal eventslide