Transcript Document 7280614

Incident preparedness:
Transfusion readiness for an
international sports event
Jed B. Gorlin MD, MBA
May 2010
Objectives
Transfusion issues specific to Asian Games
 Discuss general incident preparedness
 Share lessons learned from two local
events

 8/08
Republican national convention (RNC)
 We
shared our template for preparedness for the
RNC with Canadian Olympic committee before
Vancouver Olympics
 8/1/07
Bridge collapse into Mississippi river
2010 Guangzhou Asian Games
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Athletes from 45
countries will compete in
476 events in 42 sports
Nov 12-27, 2010
Over 200,000 Chinese
citizens have volunteered
Countries participating
include mideast
(Afghanistan to Yemen)
Non-olympic events
include Board games,
Dragon boats,
Sepaktakraw and Kabaddi
few of which are likely to
need blood transfusion!
Incident preparedness
and Transfusion
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Inventory: Special issue is Rh(D)- availability
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Types of components
Patient identification system
 Communications
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Transport of blood
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Linguistic and technical
External- media
Is blood available for air ambulance?
Restricted access
Blood use following disasters:
Historical perspective

Hess review (reference at the end)
 US
civilian disasters 105-131 units
 Skywalk
collapse in KC hotel
 Airliner Sioux City Iowa
 Oklahoma City Govt. Center bombing
 Columbine high school
 9/11/2001 About
Al Quieda attack on US
600 extra units used following WTC
collapse, NYBC collects >1000 daily!
Incident planning
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Many useful resources for planning templates
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AABB disaster plan
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http://www.aabb.org/Documents/Programs_and_Se
rvices/Disaster_Response/disastophndbkv2.pdf
CHEST supplement with approach to triage of limited
medical resources during/following a disaster event:
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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 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 May;133: 51S-66S.
AABB preparedness plan
Very general plan
with many elements
allowing response to
many different kinds
of incidents
 Roles include:
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Disaster coordinator
Communications
coordinator
Staffing coordinator
IT managers
Department managers
Critical services-facilities
 Internal inventory-HS
 External needs-Medical
 Transportation
 Recruitment/Collections
 Vendor/supply chain
 Quality/Regulatory
 Phone system
 Donor coordinator
 Volunteer coordinator
 Safety security
 Response documentation
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AABB preparedness
Each role has an associated preparedness
plan
 Example: Communications

 plan
includes both internal and external
communications strategies
 Internal plan includes phone tree with up to
date list of methods to contact staff
 External plan includes updated lists of hospital
and other key customer contacts
Planning P
This is used to ensure
constant re-evaluation
of an incident. It is
similar to a process
control
technique 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
Scarce resource strategies
Recommendation
Strategy
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
Green
Yellow
Red
Black
Platelet strategies
Platelets
Strategy
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
green yellow
red
black
Republican National Convention
St. Paul, Minnesota USA
~45,000 visitors during Sept 1-4, 2008
 Memorial Blood center had a formal plan in
place several months before the convention
 Challenges
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Inventory: We doubled inventory of group O units at
the closest hospital
We worked with security to ensure access since this
hospital was located within limited access area
Hospital had system for transfusing unidentified
patients
Blood center hospital services manager carried a
special communication tool (800 MZ radio) 24h/day to
ensure around the clock access
RNC Planning specifics
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Non-disaster plans
 No
blood drives in areas near event
 Alternative strategies for donor recruitment
knowing of distractions occurring during event
 Television
advertising too expensive
 Transportation
 Contacted
police to assure access to hospitals near
event
 Consider using two drivers if parking access
restricted
RNC preparedness plans
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Transportation Emergency

identification of vehicles
IT/Technical services
 Computer
down back up plans
 Alternative phone communication plans
 Power outage- generators at both hospital,
blood center
 Coordination with Federal/State/Local
agencies
RNC preparedness plan
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Communication strategies
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Internal
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External
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Phone trees
Back up responsibilities, cross-training staff
Media communication plans
Vendor plans
Alternative providers
 Supply chain issues
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Safety and security issues
Bridge collapse in Minnesota
I am the medical director both of the
blood center and the local trauma hospital
 When a major bridge collapsed it was a
real test of the emergency medical system
 Many lessons were learned both about
medical response to an event and efficient
use of blood resources
 The response has been cited as an
example of excellent medical preplanning
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Hennepin County
Medical Center
I-35W Bridge
Collapse Response
AUGUST 1, 2007
35W Bridge
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Built 1967
Rated as:
structurally
deficient, but not in
immediate need of
replacement
2000 ft span, 64 ft
high
141,000 cars / day
Mississippi 390 ft
wide, avg 7ft depth
HAZARDS
Too many to name…
RESPONSE SUMMARY
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Collapse to last patient transported:
Initial clearing of all sectors: 1 hr 35
mins
 Last EMS transport:
2 hrs 6
mins
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50 patients transported by EMS
8-13 casualties via other vehicle
Over 100 patients treated in 24
hours
13 deaths
No serious injuries to first
responders
Destination Hospitals - EMS
25
20
HCMC
U of M
North
ANW
15
10
5
0
Hospital
Hospital C
Hospital B
Clinics
Hospital A
Healthsystem
Regional Hospital
Resource Center
Multi-Agency Coordination
Center
EM
A
EMS
PH
A
B
Jurisdiction
Emergency
Management
B
C
C
A
B
EMS Agencies
C
Public Health
Agencies
HCMC Response
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Initial information at 6:10pm
 Hospital
near capacity – 5 ICU beds
available
 2 current critical cases in resuscitation
area
Charge RN turned on TV
 Alert Orange declared at 6:15
 ED staff paged: ‘get to HCMC now’
 Initial patients received (critical) at
6:40
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HCMC Response
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25 patients received in 2 hours
1
dead on arrival
 6 intubated
 5 directly to OR
 16 total admissions (60%)
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By 7pm:
 25
ICU beds open
 10 OR open and staffed
 3 CT scanners running
MD perspective
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Physicians at the scene:
 Minneapolis
EMS has several MDs that ride
with staff. 3 reported directly to scene and
provided support to the command post and
direct field triage
 Many additional medical personnel came to
the scene (from nearby hospitals).
Appreciated BUT created safety concerns as
they were ill-equipped and ill-trained to be
working in such a hazardous environment.
HCMC central role
HCMC provides primary paramedic service
 Closest Level 1 trauma center
 Houses the West Metropolitan Medical
Resource Control Center (WMMRC) that
provides information to regional hospitals
and ambulances
 Web based MNTRAC system kept live
information flowing about ER status, bed
availability, patient numbers and patient
destination.
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HCMC-ED
Lead ER MD declared an external disaster
 “Orange Alert” automatically:
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 Recalls
key personnel, holds on duty
personnel
 Clears patient reception areas
 Opens hospital command center staffed by
key administrative and clinical personnel
identified by premade vests.
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24 critically ill patients brought to ED, 5 in
the back of pick-up trucks (with EMTs)
HCMC: Incident communication
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Communication was difficult
 Volume
of calls overwhelmed land and cell
phone lines
 GET
and WIPS- Government priority access for
land and wireless lines now available
 Some
solutions archaic but nonetheless
worked: example: runners within the hospital
 800
MHz radios, walkie talkies, MNTRAC- Web
based communication worked best
HCMC: Media- PR
Intense national attention
 Few designated spokespersons
systematically provided information and
interviews on a scheduled basis.
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 Allowed
consistent and focused information
 Early in the event media provided
misinformation: (they requested any medically
trained person to go to the bridge to help,
recalled all HCMC personnel and to go to the
HOSPITALS to donate blood-oops!)
Confidentiality considerations
Patient tracking difficult and patients
(even from the same family) taken to
different hospitals
 Confidentiality issues addressed PRIOR to
this event by inter-hospital compact that
allowed for sharing of information for
public safety tracking and reunification.
 Difficulty in identifying single organization
to coordinate communication with general
public
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HCMC: Disaster Plan
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Incident went smoothly BECAUSE a preplan was in place AND drilled regularly.
 Plan
includes notification of off-duty
personnel,
 Web based action sheets
 Job directions availabile at every work station
 Ability to expand/contract as needed
 “the middle of a disaster is not a great time to
be exchanging business cards”
Supplies and Equipment
ED supplies became temporarily
exhausted
 Hospitals may wish to have disaster
supplies brought to ED by default and
need to have a good replacement
mechanism in place.
 Stockpiles of commonly needed items
should be available based on guidance by
departments of health and preparedness
program efforts.
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Medical Reserve Corps
National system of local corps
 Pre-credential medical personnel to assist
in the event of external disasters
 Provide training on mass casualty, mass
public health initiative (vaccination, drug
dispensing), psychological care during
disasters
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Transfusion issues
MBC contacted surrounding hospitals and
level 1 trauma centers within 30 minutes
 Additional group O cells sent to hospital
sites likely to receive patients, even if
hospital didn’t request them
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 Concern
was raised that Twins and disaster
traffic might preclude timely delivery further
into the event
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However, only 13 units used that evening
all at HCMC and ~50 products for the 24
critically injured patients by the end of the
week.
Emergency Tx and Rh:
Group O policy
Emergency Tx: Males may receive O+
 There is NO immediate consequence of
transfusing Rh positive red cell units
into Rh negative recipients.
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 RBC
will be more rapidly cleared-so follow
up required if emergency crossing over Rh
types
 Major issue is sensitization in females of
future child bearing potential
 THERE are NO Rh antigens on platelets
HCMC Massive Transfusion Policy
Blood bank works with staff to monitor
patients with large ongoing needs
 Obtain frequent labs (Hct/Hgb, plt, PT
(INR), PTT, fibrinogen to guide Tx
 Don’t wait for coagulopathy to develop
 As RBC transfused approaches 1 x blood
volume platelets are often depleted before
coag factors
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References
Hess JR, Thomas MJG “Blood use in war
and disaster: lessons from the past
century” Transfusion (2003) 43:1622-1633
 AABB disaster planning
 MBC Republican National Convention plan
 ABC pandemic flu planning

Asia Game disaster planning
Event or disaster
at event is unlikely
to use a very large
quantity of blood
 Challenges are
having what blood
is available readily
available and
ability to transfuse
in a chaotic
situation while
minimizing risks
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Athlete least likely to be invited to Asian Games!
Hangzhou WinTech is located in Fuyang City
Challenges during Event
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Patient identification
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Group O units at hospital
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O+ for males
O- for females of child
bearing age if no time to
give type specific
Communications
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Internal
External
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System in place for
unidentified patients
Consider implementing
double red cell collection
technology to increase
availability of O units
Communications
strategies- Cell phone
alternatives
Media plan
Thank You
I am honored to have
been invited to present to
such a special audience
and hope I may serve you
in some additional way.
 Feel free to send any
questions or comments to:
my email: [email protected]

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