Transcript Joint Theater Blood Program Update Major Molly Sloan, MSC, USA

UNCLASSIFIED
Joint Theater Blood Program Update
Major Molly Sloan, MSC, USA
LCDR Mike Roth, MSC, USN
LTC Rick McBride, USAF, BSC
SAFMLS
March 2009
UNCLASSIFIED
UNCLASSIFIED
Agenda
• OIF Theater Initiatives
– Historical Transfusions
– Calculation of MTF Inventories
• 6- σ training utility in a combat environment
– Quality Health Assistance Visits (Q-HAVs)
• Whole Blood Collection Capabilities
• More utility for 6- σ (for smarter people)
• OEF Historical Transfusions
• CENTCOM Initiatives
–
–
–
–
Age of Blood
Frozen Blood
Donor/Transfusion Records Standardization and Consolidation
Platelet Golden Hour Boxes
UNCLASSIFIED
UNCLASSIFIED
UNCLASSIFIED
UNCLASSIFIED
OIF HISTORICAL TRANSFUSIONS
• Overall product transfusions are on a downward
trend
• Between Jan 2008 and Jan 2009 there was a 84%
reduction in the monthly average for all blood
products transfused in OIF
– RBC transfusions were 21,411 and 11,116 for
2007 and 2008 respectively
• Low Period:
January 2009
414 Products
• Peak Period: March 2008
3610 Products
• January 2009 had the lowest blood product
usage in OIF since July 2004
UNCLASSIFIED
Decrease in
Monthly
AVG RBC
Transfusions
from
Jan 2008
to
Jan 2009
400
300
# of RBC Transfused
UNCLASSIFIED
OIF RBC TRANSFUSIONS PAST 12 MONTHS
83%
700
600
500
200
100
0
1-Feb-09
18-Jan-09
4-Jan-09
21-Dec-08
7-Dec-08
23-Nov-08
9-Nov-08
26-Oct-08
12-Oct-08
28-Sep-08
14-Sep-08
31-Aug-08
17-Aug-08
3-Aug-08
20-Jul-08
6-Jul-08
22-Jun-08
8-Jun-08
3-Feb-08
17-Feb-08
2-Mar-08
16-Mar-08
30-Mar-08
13-Apr-08
27-Apr-08
11-May-08
25-May-08
Date
UNCLASSIFIED
UNCLASSIFIED
Quarterly Analysis of MTF Inventories
OIF MTF
Bld Types
Target Inv #
JUN
JUL
Mixed
200
665
636
week 1
246
143
daily high
119
37
daily low
2
1
week 2
124
159
daily high
38
38
daily low
8
8
week 3
197
120
daily high
54
36
daily low
9
5
week 4
98
214
daily high
27
57
daily low
4
8
MTF
UNCLASSIFIED
UNCLASSIFIED
Calculation of 99% C.I.
Confidence Intervals: Estimate of the amount of error in our estimates;
precision of statistical estimates. We are 99% sure the interval contains the
True Population mean.
Z-score for 95% CI= 1.96
Z-score for 99% CI = 2.58
Mean +/-
Z –score x
Standard Deviation
√N
Solution = MINITAB!!
UNCLASSIFIED
UNCLASSIFIED
Minitab Calculations
332 AFTH Transfusions
225
215
205
198
200
182
176
Transfusions
175
152
150
125
151 UI
143
142
138
134
128
117
115
100
170 Target
161
160
92
90
85 83
89
117
124
86
75
56
50
1
UNCLASSIFIED
2
3
4
5
6
7
8
9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24
OCT 07 - MAR 08 Weekly Totals
133 AVG
115 LI
UNCLASSIFIED
PRBC Target Review Process
End of Month
Production
Review
NO
Memo with Data to MED
BDE HQs and MNC-I
w/No Changes
Recommended
YES
Staff to TF MED BDE
units with blood
capabilities
Target
Level
Changes?
Quarterly
Blood Target
Review
*Next review is
APR (will cover
JAN-MAR)
Resolve
with BSU,
BDE G/S-4
and CLIN
OPS
UNCLASSIFIED
Concur?
NO
Resolve with
MNC-I SURG
Section
Brief Data with
Proposed Changes to
MED BDE HQs
NO
Concur?
Brief to
MNC-I
Surgeon
YES
Staff to
remaining
MNC-I
customers
YES
Execute
Proposed
Target Levels
UNCLASSIFIED
UNCLASSIFIED
UNCLASSIFIED
Blood Services
•
Packed Red Blood Cells
Transfused
–
–
–
–
–
•
Fresh Frozen Plasma Transfused
–
–
–
–
–
•
April—7
May— 12
June— 40
July--- 10
Aug--- 10
April—2
May— 6
June— 11
July--- 0
Aug--- 0
Other Products Transfused
–
–
–
–
–
April---0
May---0
June---2 (Whole Blood)
July--- 0
Aug--- 0
UNCLASSIFIED
45
April
May
June
July
August
40
35
30
25
20
15
10
5
0
PRBC
FFP
Cryo
PLT
WB
UNCLASSIFIED
Blood Services
•
Packed Red Blood Cells
Transfused
– Sep --- 9
– Oct --- 35
– Nov --- 30
•
MASCAL Jun 07
45
April
Multiple Traumas
Oct & Nov 07
40
May
June
July
35
August
Fresh Frozen Plasma
Transfused
– Sep --- 0
– Oct --- 6
– Nov --- 1
• Other Products Transfused
– Sep --- 0
– Oct --- 0
– Nov --- 0
UNCLASSIFIED
September
30
October
25
November
20
15
10
5
0
PRBC
FFP
Cryo
PLT
WB
UNCLASSIFIED
UNCLASSIFIED
UNCLASSIFIED
Quality Healthcare Assessment Visits
• December 2007: UK Whole Blood recipients identified
• 11 United Kingdom Patients were identified as receiving emergency
non-FDA licensed blood products throughout OEF/OIF
– 5 Military
– 6 Contractor
• 51 non-FDA licensed products were transfused from a total of 47
donors
• 20 of 47 donor collections had traceable retrospective (EIA) results
• 7 of 11 recipients products were negative for all required EIA tests
(HIV, HCV, HBsAg, HBc, HTLV)
• Four recipients had varying levels of testing on donor samples (see
later slides)
UNCLASSIFIED
UNCLASSIFIED
Quality Healthcare Assessment Visits
Patients FWB
Plts
Total
Total
Products
Products Requiring
Total
%
Rapid
Received
Testing Resulted Complete Testing
SC
CH
MR*
BS
RS
DR
VM
PH
WY
PN*
DW*
15
1
0
0
0
0
0
0
6
0
3
4
0
7
1
1
1
2
1
0
6
3
19
1
7
1
1
1
2
1
6
6
6
19
1
5
1
1
1
2
1
6
5
5
4
1
5
1
1
1
2
1
0
1
3
21%
100%
100%
100%
100%
100%
100%
100%
0%
20%
60%
Total
25
26
51
47
20
43%
MR = received 2 sets of double platelets
PN and DW = received one set of double platelets
UNCLASSIFIED
Y
Y
Y
Y
Y
EIA
Testing
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
See specific patient comments on upcoming slides
UNCLASSIFIED
Quality Healthcare Assessment Visits
Process Audited
ISBT-128
Label
Procedures
Total Applicable Points
Testing
of Whole
Blood
Shipping
Specimens
for Testing
of Whole
Blood
Collection
Release
Storage
Disposition
Look-back
Procedures
Totals
10
62
24
68
8
10
6
12
200
6
32
18
42
8
6
2
12
126
Total Survey Points
Obtained
Percentage
Rating
Total Critical Points
Total Critical Points
Obtained
Percentage Critical Area
Compliance
Commendable
100%
10
62
24
68
8
10
6
12
200
Trained
80-99%
8-9
50-61
19-23
54-67
6-7
8-9
5
8-9
160-199
Practiced
65-79%
7
40-49
16-18
44-53
5
7
4
7
130-159
Untrained
<64%
<6
<39
<15
<43
<4
<6
<3
<6
<129
5
26
14
34
6
5
1
10
100
Critical Tasks
UNCLASSIFIED
UNCLASSIFIED
Quality Healthcare Assessment Visits
100%
95%
90%
85%
80%
75%
ISBT 128
labeling
UNCLASSIFIED
Testing of
Whole Blood
Shipping
Specimens for
Testing of
Whole Blood
Collection
Release
Storage
Disposition
Lookback
Procedures
Totals
UNCLASSIFIED
OEF HISTORICAL TRANSFUSIONS
• Overall product transfusions are on an upward
trend
• Between Jan 2008 and Jan 2009 there was a 36%
increase in the monthly average for all blood
products transfused in OEF
– RBC transfusions were 5,178 and 6,613 for
2007 and 2008 respectively
• Low Period:
February 2008
404 Products
• Peak Period: August 2008
1282 Products
• August 2008 had the highest blood product
usage in Afghanistan to date
UNCLASSIFIED
31%
Increase in
Monthly AVG
RBC Transfusions
from Jan 2008 to
Jan 2009
400
300
# of RBC Transfused
UNCLASSIFIED
OEF RBC TRANSFUSIONS PAST 12 MONTHS
700
600
500
200
100
0
1-Feb-09
18-Jan-09
4-Jan-09
21-Dec-08
7-Dec-08
23-Nov-08
9-Nov-08
26-Oct-08
12-Oct-08
28-Sep-08
14-Sep-08
31-Aug-08
17-Aug-08
3-Aug-08
20-Jul-08
6-Jul-08
22-Jun-08
8-Jun-08
25-May-08
11-May-08
27-Apr-08
13-Apr-08
30-Mar-08
16-Mar-08
2-Mar-08
17-Feb-08
3-Feb-08
Date
UNCLASSIFIED
UNCLASSIFIED
Age of Blood Initiative
• Develop course of action for improved red
cell manufacture and CENTCOM
distribution
– Provide fresher blood for trauma patients
– Adding at least 7 days shelf life to CENTCOM
inventories should theoretically reduce RBC
requirements by ~10%
– Off-set a potential increase in expiring “older”
unused blood
UNCLASSIFIED
UNCLASSIFIED
Age of Blood Initiative
• Conference held in Sep 2008
– Develop action plan to improve blood product
manufacture, labeling, storage and
distribution to CENTCOM AOR
– Attendees included:
•
•
•
•
Armed Service Blood Program Office (ASBPO)
CENTCOM Joint Blood Program Office
TRANSCOM Medical Planners
Directors of Service Blood Program Offices
UNCLASSIFIED
UNCLASSIFIED
Age of Blood Initiative
• Recommendations
– Improve blood manufacturing process to
insure blood is prepared for distribution NLT
48 hours post collection and arrives at
ASWBPL NLT 4 days post collection
– Identify and eliminate choke points
– Have RBCs arrive in theater by 7th day post
collection
UNCLASSIFIED
UNCLASSIFIED
Choke Points
• Turn around time for testing
– Change: Use a combination of regional military/civilian test centers
• Only one dedicated mission from ASWBPL to Al Udeid each week
– Change: Add a second channel flight on Tuesday (started on 28
October 2008
• Work schedule for 379th Blood Transshipment Center (BTC) Al
Udeid
– In September 2008, BTC shift hours switched from days to nights to
maximize throughput of blood upon arrival at Al Udeid to theater
distribution.
– In the same 12 hour shift:
• Plane delivering blood arrives at Al Udeid
• BTC receives, processes and packages the shipment
• Outgoing shipment delivered to cargo handling for intra-theater distribution
UNCLASSIFIED
RBC Tracking:
Days of shelf-life
remaining
Inter-modal Distribution Lanes (IDL)
CENTCOM – Blood Shipments
42-36
37-29
32-25
24-18
30-0
RBC Tracking: Days of shelf-life remaining
BDC
ASWBPL
East
RBCs must arrive
at ASWBPL
NLT Day 7
BTC
TCN
48 hrs
As
JMR
Needed
ASWBPL
East
Sun/Wed
JMR
FEDEX
24 hrs
*MTF
2-3 opportunities/week
Channel Mission:
Once/week opportunity
EUCOM
ASBBC
BDCs
BSD
Mon/Thurs
JMR
BTC
Qatar
2-3 opportunities/week
BSD
Iraq
*MTFs
BSD
Afghan
MTFs
As Needed
Kuwait
JMR
Mondays Only
HOA
JMR
* Note: BSD Iraq facilitates the
rotation of RBCs with ~ 7 days
shelf-life from E:II MTFs to major
E:III MTFs; it’s difficult to rotate
inventory in Afghanistan due to
remote locations and aircraft
availability.
As Needed
JMR
IDL #1
Bahrain
NSA
Ships
IDL #2
Jan 2008/ajh
RBC Tracking:
Days of shelf-life
remaining
42-36
Inter-modal Distribution Lanes (IDL)
CENTCOM – Blood Shipments
37-29
32-25
24-18
30-0
RBC Tracking: Days of shelf-life remaining
BDC
ASWBPL
East
RBCs must arrive
at ASWBPL
NLT Day 7
CHANGE - 1
BTC
BSD
Channel Mission:
Once/week opportunity
CHANGE - 2
*MTF
2-3 opportunities/week
2-3 opportunities/week
CHANGE - 3
REQUIREMENT: Fresher blood needed for optimal care of surgical patient.
Course of Action: Identify and Eliminate Chokepoints.
Change 1: RBCs must arrive at ASWBPL within 4 calendar days of collection
Change 2: Add second weekly flight from ASWBPL. RBCs arrive at Al Udeid (AUAB) within 7 days
post collection.
Change 3: 379th Expeditionary Blood Transshipment Center (EBTC) AUAB switches work scheduled
for facilitate throughput of shipments to theater Blood Support Detachments (BSD).
Jan 2008/ajh
Inter-modal Distribution Lanes (IDL)
CENTCOM – Blood Shipments
RBC Tracking:
Days of shelf-life
remaining
42-36
35
34-31
28-21
30-0
RBC Tracking: Days of shelf-life remaining
BDC
ASWBPL
East
BTC
RBCs must
arrive
at ASWBPL
NLT Day 4
BSD
*MTF
Fresh Blood (≤14 Days Old)
*MTF
Remaining Shelf Life 3-4 Weeks
Channel Mission:
Twice/week
OUTCOMES
-Provides a window (~7 days) where fresher blood is available at three Level III MTFs
(Trauma Centers)
-Provides longer dated blood for remote FOBs; easing the resupply mission
12
10
8
6
31-Jan-09
24-Jan-09
17-Jan-09
10-Jan-09
3-Jan-09
27-Dec-08
20-Dec-08
13-Dec-08
6-Dec-08
29-Nov-08
22-Nov-08
15-Nov-08
8-Nov-08
1-Nov-08
25-Oct-08
18-Oct-08
11-Oct-08
4-Oct-08
27-Sep-08
20-Sep-08
13-Sep-08
6-Sep-08
30-Aug-08
23-Aug-08
16-Aug-08
9-Aug-08
2-Aug-08
26-Jul-08
19-Jul-08
12-Jul-08
5-Jul-08
28-Jun-08
21-Jun-08
14-Jun-08
7-Jun-08
31-May-08
24-May-08
17-May-08
10-May-08
3-May-08
26-Apr-08
19-Apr-08
12-Apr-08
5-Apr-08
29-Mar-08
22-Mar-08
15-Mar-08
8-Mar-08
1-Mar-08
23-Feb-08
16-Feb-08
9-Feb-08
2-Feb-08
UNCLASSIFIED
31 Jan 2009 - 6.5 Days
28 Jan 2009 - 8.8 Days
Most Recent Shipments:
2
Shipments: N=65
Highest Average Age: 17.0 Days (03 Jan 2009)
Lowest Average Age: 5.6 Days (17 Jan 2009)
Average Age past 12 Months: 11.5 Days
AVERAGE AGE (In Days)
UNCLASSIFIED
AVERAGE AGE OF BLOOD (in Days)
UPON ARRIVAL at Al Udeid Air Base
18
16
14
4
Multi-Shipment Weeks Began on 28 Oct 2008
0
SHIPMENT ARRIVAL DATE
UNCLASSIFIED
TRAUMA CENTERS % OF RBC TRANSFUSED (AGE in DAYS)
NOVEMBER – DECEMBER – JANUARY
2007 vs 2008
2007
2008
•
•
•
•
•
•
•
•
•
•
n = 2931
Average Age: 35.3 days
Lowest Age: 13 days
Highest Age: 42 days
% of RBCs transfused that
were ≤ 14 Days Old: 0.03%
n = 823
Average Age: 33.5 days
Lowest Age: 9 days
Highest Age: 42 days
% of RBCs transfused that
were ≤ 14 Days Old: 11.8%
February 2009 – 332nd AFTH Balad transfused RBCs that were
only 7 days old
UNCLASSIFIED
UNCLASSIFIED
TRAUMA CENTERS % OF RBC TRANSFUSED (AGE in DAYS)
NOVEMBER – DECEMBER – JANUARY
2007 vs 2008
2008
2009
30.0%
% of RBC Transfused
25.0%
20.0%
15.0%
10.0%
5.0%
0.0%
9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 33 34 35 36 37 38 39 40 41 42
RBC Age (in Days)
UNCLASSIFIED
UNCLASSIFIED
FROZEN BLOOD
•
•
•
•
•
Located at BSDs Balad/Bagram
Equipment Validation: August 2008
BSD staff trained in country: August 2008
Final Validation: September 2008
BSDs stocked with O Positive.
– O Negative deglyced only upon request
UNCLASSIFIED
UNCLASSIFIED
FROZEN BLOOD
UNCLASSIFIED
UNCLASSIFIED
FROZEN BLOOD
• First Transfusion: 86th CSH Baghdad 07 NOV 2008
– Burn Victim
• 3 Units RBCs (1 PRBC, 2 DRBC)
• H&H ↑ from 7.4/22.0 to 8.3/25.1
• No adverse effects/complications report
• Second transfusion 332nd AFTH BALAD 08 NOV 2008
– IED Injury
• 3 Units RBCs (1 PRBC, 2 DRBC)
• H&H ↑ from 6.4/19.0 to 9.4/27.5
• Patient had Febrile reaction to PRBCs, but tolerated
Deglycerolized Blood with no problems.
UNCLASSIFIED
UNCLASSIFIED
FROZEN BLOOD
• First U.S. transfusions of Deglycerolized Blood
during hostile conflict since Viet Nam
– Dutch have been using Frozen Blood in OEF for several
years.
• All three Level III MTFs have transfused
Deglycerolized Blood
• As of 17 Feb 2009, 32 units have been transfused by
U.S. MTFs.
UNCLASSIFIED
UNCLASSIFIED
CENTCOM THEATER ISSUES
• Donor/Recipent Records
– More fall-out of British Contractor Whole
Blood Collection
– Records Shortfall
• ASBPO Contract
• In-theater Work-around
– BSDs scan-in Whole Blood “Lot Release
Packets”
UNCLASSIFIED
UNCLASSIFIED
Implementation of Platelet Golden Hour
Boxes
UNCLASSIFIED
UNCLASSIFIED
RESUPPLY
• 440th BSD Bagram has split the personnel in their
unit between Bagram and Kandahar.
– Kandahar operates as a BSD in RC South
• Al Udeid BTC supplies Kandahar directly
– Bagram eliminated as an interim stop
– Blood arrives to Kandahar faster and fresher
• Restructured BTC shipments
– Dry Ice sent twice/week ensuring delivery is spaced equally
– Frozen products sent mid-week
– RBCs sent twice/week
UNCLASSIFIED
UNCLASSIFIED
RESUPPLY
• Future Challenges
– Temp Tales
– Second Channel Flight
UNCLASSIFIED
UNCLASSIFIED
New Theater Delivery System
• USAMMC-SWA and AFMOA are coordinating efforts
to procure the newly proposed theater blood delivery
system.
• Advantages
– Not subjected to challenges associated with weather
allowing it to be operated 365 days/year
• Particularly useful in OEF during winter months.
– Low maintenance
– Requires minimal additional training for BSD staff to operate
UNCLASSIFIED
UNCLASSIFIED
New Theater Delivery System
UNCLASSIFIED
UNCLASSIFIED
QUESTIONS?
SAFMLS
February 2009
UNCLASSIFIED