Incident preparedness: Incident preparedness: Transfusion readiness for an Transfusion readiness for an international sports eventinternational sports event

Jed B. Gorlin MD, MBAJed B. Gorlin MD, MBAMay 2010May 2010

ObjectivesObjectives

Transfusion issues specific to Asian GamesTransfusion issues specific to Asian GamesDiscuss general incident preparednessDiscuss general incident preparednessShare lessons learned from two local eventsShare lessons learned from two local events

8/08 Republican national convention (RNC)8/08 Republican national convention (RNC)We shared our template for preparedness for the RNC We shared our template for preparedness for the RNC

with Canadian Olympic committee before Vancouver with Canadian Olympic committee before Vancouver OlympicsOlympics

8/1/07 Bridge collapse into Mississippi river8/1/07 Bridge collapse into Mississippi river

2010 Guangzhou Asian 2010 Guangzhou Asian GamesGames

Athletes from 45 Athletes from 45 countries will compete in countries will compete in 476 events in 42 sports 476 events in 42 sports Nov 12-27, 2010Nov 12-27, 2010

Over 200,000 Chinese Over 200,000 Chinese citizens have citizens have volunteeredvolunteered

Countries participating Countries participating include mideast include mideast (Afghanistan to Yemen)(Afghanistan to Yemen)

Non-olympic events Non-olympic events include Board games, include Board games, Dragon boats, Dragon boats, Sepaktakraw and Sepaktakraw and Kabaddi few of which are Kabaddi few of which are likely to need blood likely to need blood transfusion!transfusion!

Incident preparedness Incident preparedness and Transfusionand Transfusion

Inventory: Special issue is Rh(D)- availabilityInventory: Special issue is Rh(D)- availability Types of componentsTypes of components

Patient identification systemPatient identification system CommunicationsCommunications

Linguistic and technicalLinguistic and technical External- mediaExternal- media

Transport of bloodTransport of blood Is blood available for air ambulance?Is blood available for air ambulance?

Restricted accessRestricted access

Blood use following disasters: Blood use following disasters: Historical perspectiveHistorical perspective

Hess review (Hess review (reference at the endreference at the end))US civilian disasters 105-131 unitsUS civilian disasters 105-131 units

Skywalk collapse in KC hotelSkywalk collapse in KC hotelAirliner Sioux City IowaAirliner Sioux City IowaOklahoma City Govt. Center bombingOklahoma City Govt. Center bombingColumbine high schoolColumbine high school

9/11/2001- Al Quieda attack on US9/11/2001- Al Quieda attack on USAbout 600 extra units used following WTC About 600 extra units used following WTC

collapse, NYBC collects >1000 daily!collapse, NYBC collects >1000 daily!

Incident planningIncident planning Many useful resources for planning Many useful resources for planning

templatestemplates AABB disaster planAABB disaster plan

http://www.aabb.org/Documents/Programs_and_Services/Disaster_Response/disastophndbkv2.pdf

CHEST supplement with approach to triage of CHEST supplement with approach to triage of limited medical resources during/following a limited medical resources during/following a disaster event:disaster event:

Definitive care for the critically ill during a disaster: a framework for optimizing critical care surge capacity: from a Task Force for Mass Critical Care summit meeting, January 26-27, 2007, Chicago, IL. Rubinson L, Hick JL, et al; Task Force for Mass Critical Rubinson L, Hick JL, et al; Task Force for Mass Critical Care. Chest. 2008 May;133(5 Suppl):18S-31S.Care. Chest. 2008 May;133(5 Suppl):18S-31S.

Definitive care for the critically ill during a disaster: a framework for allocation of scarce resources in mass critical care: from a Task Force for Mass Critical Care summit meeting, January 26-27, 2007, Chicago, IL. Devereaux AV, Dichter JR, et al Chest. 2008 Devereaux AV, Dichter JR, et al Chest. 2008 May;133: 51S-66S.May;133: 51S-66S.

AABB preparedness planAABB preparedness plan

Very general plan Very general plan with many elements with many elements allowing response allowing response to many different to many different kinds of incidentskinds of incidents

Roles include:Roles include: Disaster coordinatorDisaster coordinator Communications Communications

coordinatorcoordinator Staffing coordinatorStaffing coordinator IT managersIT managers Department Department

managersmanagers

Critical services-Critical services-facilitiesfacilities

Internal inventory-HSInternal inventory-HS External needs-MedicalExternal needs-Medical TransportationTransportation Recruitment/CollectionsRecruitment/Collections Vendor/supply chainVendor/supply chain Quality/RegulatoryQuality/Regulatory Phone systemPhone system Donor coordinatorDonor coordinator Volunteer coordinatorVolunteer coordinator Safety securitySafety security Response Response

documentationdocumentation

AABB preparednessAABB preparedness

Each role has an associated Each role has an associated preparedness planpreparedness plan

Example: Communications Example: Communications plan includes both internal and external plan includes both internal and external

communications strategiescommunications strategiesInternal plan includes phone tree with up Internal plan includes phone tree with up

to date list of methods to contact staffto date list of methods to contact staffExternal plan includes updated lists of External plan includes updated lists of

hospital and other key customer contactshospital and other key customer contacts

Planning PPlanning PThis is used to ensure constant re-evaluation of an incident. It is similar to a process controltechnique called “Plan, Do, Check, Act” The important elements are a clear chain of command, clear communications strategies and a method for serially developing action plans and evaluating the effect of implementing those plans.

Scarce resource strategiesScarce resource strategiesRecommendation Strategy Green Yellow Red Black

RBC

Increasing O+ levels Increase Supply        

Consider maintaining a frozen blood reserve if severe shortage Increase Supply        

Move whole blood donors to 2-RBC apheresis collections Increase Supply        

Increase recruitment efforts Increase Supply        

Use O+ only in emergent transfusion in males or non-child bearing females Conservation        

Use erythropoietin (EPO) as an alternative in cancer related anemia Alternatives        

Cell Salvage Conservation        

Collect Autologous units for elective surgeries Conservation        

Consider cross-over Autologous units Increase Supply        

Enforce lower transfusion triggers (7g hg) Conservation        

Reduction of the 56-day RBC interdonation interval based upon pre-donation hemoglobin determination Increase Supply        

Reduction of weight requirements for double RBC apheresis by five pounds Increase Supply        

Platelet strategiesPlatelet strategiesPlatelets

Accept female donors for Pool and Store pooled platelets Increase Supply        

Accept female apheresis donors - no HLA antibody testing Increase Supply        

Increase recruitment efforts Increase Supply        

Apply for variance for 7 day outdate Increase Supply        

Triage to patients with active bleeding Conservation        

Consider implementing leukoreduced WB pooled platelets Increase Supply        

Reduce pool sizes to platelets from 4 WB donations Increase Supply        

Consider a 24 hr hold until the culture is obtained and immediate release for both Pool and Apheresis Increase Supply        

Obtain FDA variance to allow new Pool and Store sites to ship across state lines Increase Supply        

Consider Non-LR WB pooled platelets Increase Supply        

Limit use of platelets for patients being treated expectantly Conservation        

Limit use of platelets for patients with symptomatic bleeding and not transfusing for a numerical trigger Conservation        

Convert less needed ABO Whole Blood to Apheresis Increase Supply        

Strategy green yellow red black

Republican National Convention Republican National Convention St. Paul, Minnesota USASt. Paul, Minnesota USA

~45,000 visitors during Sept 1-4, 2008~45,000 visitors during Sept 1-4, 2008 Memorial Blood center had a formal plan in Memorial Blood center had a formal plan in

place several months before the conventionplace several months before the convention ChallengesChallenges

Inventory: We doubled inventory of group O units Inventory: We doubled inventory of group O units at the closest hospitalat the closest hospital

We worked with security to ensure access since We worked with security to ensure access since this hospital was located within limited access this hospital was located within limited access areaarea

Hospital had system for transfusing unidentified Hospital had system for transfusing unidentified patientspatients

Blood center hospital services manager carried a Blood center hospital services manager carried a special communication tool (800 MZ radio) special communication tool (800 MZ radio) 24h/day to ensure around the clock access24h/day to ensure around the clock access

RNC Planning specificsRNC Planning specifics

Non-disaster plansNon-disaster plansNo blood drives in areas near eventNo blood drives in areas near eventAlternative strategies for donor Alternative strategies for donor

recruitment knowing of distractions recruitment knowing of distractions occurring during eventoccurring during eventTelevision advertising too expensiveTelevision advertising too expensive

TransportationTransportationContacted police to assure access to Contacted police to assure access to

hospitals near eventhospitals near eventConsider using two drivers if parking access Consider using two drivers if parking access

restrictedrestricted

RNC preparedness plansRNC preparedness plans

Transportation- Transportation- Emergency identification of vehiclesEmergency identification of vehicles

IT/Technical servicesIT/Technical servicesComputer down back up plansComputer down back up plansAlternative phone communication plansAlternative phone communication plansPower outage- generators at both Power outage- generators at both

hospital, blood centerhospital, blood centerCoordination with Federal/State/Local Coordination with Federal/State/Local

agenciesagencies

RNC preparedness planRNC preparedness plan

Communication strategiesCommunication strategies InternalInternal

Phone treesPhone treesBack up responsibilities, cross-training staffBack up responsibilities, cross-training staff

ExternalExternalMedia communication plansMedia communication plans

Vendor plansVendor plans Alternative providersAlternative providers Supply chain issuesSupply chain issues

Safety and security issuesSafety and security issues

Bridge collapse in MinnesotaBridge collapse in Minnesota

I am the medical director both of the I am the medical director both of the blood center and the local trauma hospitalblood center and the local trauma hospital

When a major bridge collapsed it was a When a major bridge collapsed it was a real test of the emergency medical real test of the emergency medical systemsystem

Many lessons were learned both about Many lessons were learned both about medical response to an event and efficient medical response to an event and efficient use of blood resourcesuse of blood resources

The response has been cited as an The response has been cited as an example of excellent medical preplanningexample of excellent medical preplanning

Hennepin County Hennepin County Medical CenterMedical Center

I-35W Bridge I-35W Bridge Collapse Collapse ResponseResponse

AUGUST 1, 2007AUGUST 1, 2007

35W Bridge35W Bridge Built 1967Built 1967 Rated as: Rated as:

structurally structurally deficient, but not deficient, but not in immediate need in immediate need of replacementof replacement

2000 ft span, 64 ft 2000 ft span, 64 ft highhigh

141,000 cars / day141,000 cars / day Mississippi 390 ft Mississippi 390 ft

wide, avg 7ft wide, avg 7ft depthdepth

HAZARDSHAZARDS

Too many to name…Too many to name…

RESPONSE SUMMARYRESPONSE SUMMARY Collapse to last patient Collapse to last patient

transported:transported: Initial clearing of all sectors: 1 hr Initial clearing of all sectors: 1 hr

35 mins35 mins Last EMS transport: 2 hrs Last EMS transport: 2 hrs

6 mins6 mins 50 patients transported by EMS50 patients transported by EMS 8-13 casualties via other vehicle8-13 casualties via other vehicle Over 100 patients treated in 24 Over 100 patients treated in 24

hourshours 13 deaths13 deaths No serious injuries to first No serious injuries to first

respondersresponders 29 ambulances used in first 4 29 ambulances used in first 4

hourshours

Destination Hospitals - EMSDestination Hospitals - EMS

0

5

10

15

20

25

Hospital

HCMCU of MNorthANW

Hospital A

Hospital B

Hospital C

Clinics

Healthsystem

Public HealthAgenciesEMS Agencies

JurisdictionEmergency Management

AA

B

C A

B

C C

B

Regional Hospital Resource Center

Multi-Agency CoordinationCenter

EM EMS PH

HCMC ResponseHCMC ResponseInitial information at 6:10pm Initial information at 6:10pm

Hospital near capacity – 5 ICU beds Hospital near capacity – 5 ICU beds availableavailable

2 current critical cases in resuscitation 2 current critical cases in resuscitation areaarea

Charge RN turned on TVCharge RN turned on TVAlert Orange declared at 6:15Alert Orange declared at 6:15ED staff paged: ‘get to HCMC now’ED staff paged: ‘get to HCMC now’Initial patients received (critical) at Initial patients received (critical) at

6:406:40

HCMC ResponseHCMC Response25 patients received in 2 hours25 patients received in 2 hours

1 dead on arrival1 dead on arrival6 intubated6 intubated5 directly to OR5 directly to OR16 total admissions (60%)16 total admissions (60%)

By 7pm:By 7pm:25 ICU beds open25 ICU beds open10 OR open and staffed10 OR open and staffed3 CT scanners running3 CT scanners running

MD perspectiveMD perspective

Physicians at the scene:Physicians at the scene:Minneapolis EMS has several MDs that ride Minneapolis EMS has several MDs that ride

with staff. 3 reported directly to scene and with staff. 3 reported directly to scene and provided support to the command post and provided support to the command post and direct field triagedirect field triage

Many additional medical personnel came to Many additional medical personnel came to the scene (from nearby hospitals). the scene (from nearby hospitals). Appreciated BUT created safety concerns as Appreciated BUT created safety concerns as they were ill-equipped and ill-trained to be they were ill-equipped and ill-trained to be working in such a hazardous environment.working in such a hazardous environment.

HCMC central roleHCMC central role

HCMC provides primary paramedic HCMC provides primary paramedic serviceservice

Closest Level 1 trauma centerClosest Level 1 trauma centerHouses the West Metropolitan Medical Houses the West Metropolitan Medical

Resource Control Center (WMMRC) Resource Control Center (WMMRC) that provides information to regional that provides information to regional hospitals and ambulanceshospitals and ambulances

Web based MNTRAC system kept live Web based MNTRAC system kept live information flowing about ER status, information flowing about ER status, bed availability, patient numbers and bed availability, patient numbers and patient destination. patient destination.

HCMC-EDHCMC-ED

Lead ER MD declared an external Lead ER MD declared an external disaster disaster

““Orange Alert” automatically:Orange Alert” automatically:Recalls key personnel, holds on duty Recalls key personnel, holds on duty

personnelpersonnelClears patient reception areasClears patient reception areasOpens hospital command center staffed by Opens hospital command center staffed by

key administrative and clinical personnel key administrative and clinical personnel identified by premade vests.identified by premade vests.

24 critically ill patients brought to ED, 5 24 critically ill patients brought to ED, 5 in the back of pick-up trucks (with EMTs)in the back of pick-up trucks (with EMTs)

HCMC: Incident HCMC: Incident communicationcommunication

Communication was difficultCommunication was difficultVolume of calls overwhelmed land and Volume of calls overwhelmed land and

cell phone linescell phone linesGET and WIPS- Government priority access GET and WIPS- Government priority access

for land and wireless lines now availablefor land and wireless lines now availableSome solutions archaic but nonetheless Some solutions archaic but nonetheless

worked: example: runners within the worked: example: runners within the hospitalhospital

800 MHz radios, walkie talkies, MNTRAC- 800 MHz radios, walkie talkies, MNTRAC- Web based communication worked bestWeb based communication worked best

HCMC: Media- PRHCMC: Media- PR

Intense national attentionIntense national attentionFew designated spokespersons Few designated spokespersons

systematically provided information and systematically provided information and interviews on a scheduled basis.interviews on a scheduled basis.Allowed consistent and focused information Allowed consistent and focused information Early in the event media provided Early in the event media provided

misinformation: (they requested any misinformation: (they requested any medically trained person to go to the bridge medically trained person to go to the bridge to help, recalled all HCMC personnel and to to help, recalled all HCMC personnel and to go to the HOSPITALS to donate blood-oops!)go to the HOSPITALS to donate blood-oops!)

Confidentiality considerationsConfidentiality considerations

Patient tracking difficult and patients Patient tracking difficult and patients (even from the same family) taken to (even from the same family) taken to different hospitalsdifferent hospitals

Confidentiality issues addressed PRIOR to Confidentiality issues addressed PRIOR to this event by inter-hospital compact that this event by inter-hospital compact that allowed for sharing of information for allowed for sharing of information for public safety tracking and reunification.public safety tracking and reunification.

Difficulty in identifying single organization Difficulty in identifying single organization to coordinate communication with general to coordinate communication with general publicpublic

HCMC: Disaster PlanHCMC: Disaster Plan

Incident went smoothly BECAUSE a pre-Incident went smoothly BECAUSE a pre-plan was in place AND drilled regularly.plan was in place AND drilled regularly.Plan includes notification of off-duty Plan includes notification of off-duty

personnel,personnel,Web based action sheetsWeb based action sheetsJob directions availabile at every work Job directions availabile at every work

stationstationAbility to expand/contract as neededAbility to expand/contract as needed““the middle of a disaster is not a great time the middle of a disaster is not a great time

to be exchanging business cards”to be exchanging business cards”

Supplies and EquipmentSupplies and Equipment

ED supplies became temporarily ED supplies became temporarily exhaustedexhausted

Hospitals may wish to have disaster Hospitals may wish to have disaster supplies brought to ED by default and supplies brought to ED by default and need to have a good replacement need to have a good replacement mechanism in place.mechanism in place.

Stockpiles of commonly needed items Stockpiles of commonly needed items should be available based on guidance should be available based on guidance by departments of health and by departments of health and preparedness program efforts.preparedness program efforts.

Medical Reserve CorpsMedical Reserve Corps

National system of local corpsNational system of local corpsPre-credential medical personnel to Pre-credential medical personnel to

assist in the event of external assist in the event of external disastersdisasters

Provide training on mass casualty, Provide training on mass casualty, mass public health initiative mass public health initiative (vaccination, drug dispensing), (vaccination, drug dispensing), psychological care during disasterspsychological care during disasters

Transfusion issuesTransfusion issuesMBC contacted surrounding hospitals and MBC contacted surrounding hospitals and

level 1 trauma centers within 30 minuteslevel 1 trauma centers within 30 minutesAdditional group O cells sent to hospital Additional group O cells sent to hospital

sites likely to receive patients, even if sites likely to receive patients, even if hospital didn’t request themhospital didn’t request themConcern was raised that Twins and disaster Concern was raised that Twins and disaster

traffic might preclude timely delivery further traffic might preclude timely delivery further into the eventinto the event

However, only 13 units used that evening However, only 13 units used that evening all at HCMC and ~50 products for the 24 all at HCMC and ~50 products for the 24 critically injured patients by the end of critically injured patients by the end of the week.the week.

Emergency Tx and Rh: Emergency Tx and Rh: Group O policyGroup O policy

Emergency Tx: Males may receive O+Emergency Tx: Males may receive O+There is NO immediate consequence There is NO immediate consequence

of transfusing Rh positive red cell of transfusing Rh positive red cell units into Rh negative recipients.units into Rh negative recipients.RBC will be more rapidly cleared-so follow RBC will be more rapidly cleared-so follow

up required if emergency crossing over up required if emergency crossing over Rh typesRh types

Major issue is sensitization in females of Major issue is sensitization in females of future child bearing potentialfuture child bearing potential

THERE are NO Rh antigens on plateletsTHERE are NO Rh antigens on platelets

HCMC Massive Transfusion HCMC Massive Transfusion PolicyPolicy

Blood bank works with staff to monitor Blood bank works with staff to monitor patients with large ongoing needspatients with large ongoing needs

Obtain frequent labs (Hct/Hgb, plt, PT Obtain frequent labs (Hct/Hgb, plt, PT (INR), PTT, fibrinogen to guide Tx(INR), PTT, fibrinogen to guide Tx

Don’t wait for coagulopathy to Don’t wait for coagulopathy to developdevelop

As RBC transfused approaches 1 x As RBC transfused approaches 1 x blood volume platelets are often blood volume platelets are often depleted before coag factorsdepleted before coag factors

ReferencesReferences

Hess JR, Thomas MJG “Blood use in Hess JR, Thomas MJG “Blood use in war and disaster: lessons from the war and disaster: lessons from the past century” Transfusion (2003) past century” Transfusion (2003) 43:1622-163343:1622-1633

AABB disaster planningAABB disaster planningMBC Republican National Convention MBC Republican National Convention

planplanABC pandemic flu planningABC pandemic flu planning

Asia Game disaster planningAsia Game disaster planning

Event or disaster Event or disaster at event is at event is unlikely to use a unlikely to use a very large very large quantity of bloodquantity of blood

Challenges are Challenges are having what blood having what blood is available readily is available readily available and available and ability to transfuse ability to transfuse in a chaotic in a chaotic situation while situation while minimizing risksminimizing risks Athlete least likely to be invited to

Asian Games!  Hangzhou WinTech is located in Fuyang City

Challenges during EventChallenges during Event

Patient identificationPatient identification

Group O units at Group O units at hospitalhospital O+ for malesO+ for males O- for females of child O- for females of child

bearing age if no time bearing age if no time to give type specificto give type specific

Communications Communications InternalInternal ExternalExternal

System in place for System in place for unidentified patientsunidentified patients

Consider implementing Consider implementing double red cell double red cell collection technology collection technology to increase availability to increase availability of O unitsof O units

Communications Communications strategies- Cell phone strategies- Cell phone alternativesalternatives

Media planMedia plan

Thank YouThank You

I am honored to have I am honored to have been invited to present been invited to present to such a special to such a special audience and hope I may audience and hope I may serve you in some serve you in some additional way. additional way.

Feel free to send any Feel free to send any questions or comments questions or comments to:to:

my email: my email: jed@mbc.orgjed@mbc.org

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