What Do You Need to Know About Management of Blood Shortages Helping Hospitals Prepare… This presentation was developed to help raise awareness about the need to develop an Emergency Blood Management Plan at each hospital. In order for the plan to function properly during a blood shortage, it is important that all staff work together to reduce blood usage in a collaborative and rational manner, following a previously agreed upon set of guidelines / recommendations. Version 2: Oct 30, 2012

Outline Background Standards Ontario Emergency Blood Committee Phases of a Blood Shortage Key elements of an Emergency Blood Management Plan Conclusion References This slide covers the various points that will be described in the presentation

Background Demand for blood continues to grow while donors are aging – raising concerns around sustainability of supply Other causes of a supply shortage include a new transmissible disease, manufacturer supply challenges, pandemic disease affecting balance of supply and demand The goal is to ensure secure access to safe blood components or products for patients who are most in need of them Standards requirement to have a plan Most hospitals in Ontario have now developed a plan to help them manage a blood shortage situation. Prediction models demonstrate there will most likely be a ‘gap’ between supply of blood and demand for blood sometime in the next decade. Blood Shortages can also result from a variety of other causes. One of the most important goals of developing a plan to manage needs for blood in the face of a critical supply shortage is to ensure that patient care will be equable across facilities no matter where they are in the Province. Current regulatory requirements (CSA Z902-10 and CSTM version 3) and Laboratory accreditation requirements state that hospitals need to have a plan in place to respond to blood shortages. (refer to next two slides)

CSA Z902-10 National Standards on Blood & Blood Components 4.2.1.6 Each transfusion service shall have an emergency plan that provides specific procedures to be followed in response to incidents that could endanger the safety, quality, or efficacy of blood or blood components, or the safety of recipients and facility personnel. The emergency plan shall be consistent with the emergency plan and emergency systems of the health care facility in which it operates.

Ontario Laboratory Accreditation (OLA) Requirements: v 4.1 July 2008 I.C.5 Laboratory management shall be responsible for strategic and emergency planning, setting goals and if appropriate, directing research and development. Guidance: TM180 The emergency plan shall address the safety, quality, efficacy and level of supply of blood components / products during an emergency or disaster.

Ontario Emergency Blood Management Committee (OEBMC) Represents stakeholders in blood system and manages communication during a blood shortage, develops / maintains provincial EBMP Hospitals, OHA, OBAC, Patients, CBS, ORBCoN and MOHLTC represented Version 2 of Ontario Plan and Toolkit released Fall 2012 Working and sharing with other provincial blood offices to ensure smooth interface with CBS Contingency planning for a blood supply shortage was identified as a priority by OBAC in the Fall of 2006. The working group was established February 2007. The first draft of the plan was released for comment June 2007. Broad representation within the blood system had input into the development of the provincial plan. Following a provincial mock blood shortage exercise held in March 2010, revisions were recommended to the Ontario plan. The revised version 2 of the plan was released and distributed to hospitals in the Fall of 2012. The revised toolkit includes: Table summarizing roles and responsibilities during phase of a blood shortage (updated) Updated checklist for hospitals to prepare response to a blood shortage (by phase of shortage) Communication (memo) templates for Amber, Red, Recovery and (new) for patients Checklist to plan and hold a blood shortage simulation exercise for your hospital (new) Generic hospital emergency blood management plan (HEBMP) (updated) Training checklist to document training of staff on HEBMP (new) example of a competency quiz to be used with training plan (new) example of a notification worksheet to document notification of a blood shortage to key stakeholders (new) Documentation log sheet for transfusions (new) Documentation log sheet for deferred or cancelled surgeries (new) Power-point presentation (updated)

Phases of a Blood Shortage Plan Inventory Level Hospital Action Green Normal Practice good blood management, Establish Emergency Blood Management Committee (HEBMC), develop and test emergency blood management plan Amber Reduction of inventory by up to 50% Reduce stock inventory by 25-50% Initiate internal communication Emergency blood management committee (EBMC) meets Triage blood requests Review elective OR cases, consider deferral (document) Red Shortage is severe and anticipated to be prolonged Reduce inventory to critical levels (25% of optimal) Initiate heightened internal communication EBMC meets and initiates and monitors plan for reduction of blood use (blood issued only for life threatening need) Decisions are documented Recovery CBS inventory improves Ensure return to normal operations occurs at a gradual and controlled pace Review event and revise plan as needed This table depicts the basic phases of a blood component / product shortage. Inventory levels generally refer to red cell inventory but could also apply to other products.

Green Phase – Develop Your Plan Good Blood Management Inventory levels defined Protocol to review blood usage and ordering practices to optimize utilization Minimize blood component / product wastage Develop an Emergency Blood Management Committee Include staff who order, issue and administer blood as well as senior administration Goal is to ensure all relevant hospital personnel will respond in a coordinated manner Strategies for reduction in the use of blood components and / or products must be defined Develop an Emergency Blood Management Plan Identify Triage team / officer Train staff on plan Test plan through mock exercise and revise if required Planning should be done when the blood supply is at normal levels. Hospitals should strive to put policies in place to ensure optimal utilization of blood. Staff should be trained on these policies. This phase provides the opportunity to put together a committee to develop the contingency plan for the hospital and to also act in a decision making capacity should a blood shortage occur. This committee could also be one of the functions of an existing committee. For example, many of the same services would be represented on the Hospital Transfusion Committee (HTC). Development of policies around good management of blood is also a role for the Hospital Transfusion Committee.

Key Elements of a Hospital Emergency Blood Management Plan (HEBMP) Identify key individuals to notify if a severe blood shortage occurs (include Technical, Medical, Nursing and Administrative staff) Develop a communication strategy around notification Develop a guide to stepwise reduction of blood use increasing the restriction down to extreme critical levels and provide tools to document decisions Contact and work with nearby hospitals to implement processes to allow for transfer of blood products between sites Include plan for recovery in a managed and controlled manner to ensure inventory levels can improve and stabilize before usage returns to normal activity

Key Individuals Emergency Blood Management Committee (EBMC): Notify: Transfusion Service Director and Manager, Anesthetist, Surgeon, Hematologist/Oncologist, Chair of the Hospital Transfusion Committee (HTC), Transfusion Nurse Specialist, Transfusion Safety Officer, ER physician, Risk Manager Notify: CEO, Medical and Chief of Staff, Division Chiefs for Surgery, Anesthesia, Trauma/Emergency, Hematology and Medicine, Directors of Laboratory, Diagnostic Services, Nursing, Head of facility disaster planning HTC members, EBMC members Risk Management, Patient relations, Public relations These are suggestions only. Personnel to be notified may differ at each facility. Key individuals include: Directors of Emergency, Surgery, Oncology, Hematology, Transfusion service, Director of Nursing, Manager of Transfusion service, CEO, VP Medical Affairs and VP Nursing. These staff should all be notified should the blood supplier notify the hospital of a critical blood supply shortage. This notification should occur in writing. The notification should provide some guidance as to how restrictions to blood usage will be applied. The notification should also provide some indication of what blood component / product is affected, the cause of the shortage and (if known) the anticipated length of time of the shortage.

Communication Plan Prepared memos that can be used (templates) and customized as required by the situation A list of who to contact and at what phase of the plan to contact them should be prepared and approved by the EBMC Release of communications should be the responsibility of the Transfusion Service Director or Chair of HEBMC Communication should clearly state how decision making around blood issuing will be managed, dependant on the severity of the inventory restriction Ensure close communication is maintained with the blood supplier – Canadian Blood Services Templates of suggested memos are included in the ‘Toolkit’ provided by the MOH-LTC BPCO.

Guide for Restriction of Blood Use This guide should be developed and adopted by the EBMC, examples include: Reduce inventory held on site by 50% or more Close review (triage) of blood order requests and follow strict protocol for acceptable ordering Reduce dose per treatment where feasible Review elective surgical list for possible deferral of cases that have a high probability of blood use Restrict blood use to life threatening situations only Follow guidance provided from OEBMC / MOHLTC Reducing inventory can often be enough of an action if the blood shortage is not severe or prolonged. If, however, the shortage reaches critical levels, other actions will be required. Reviewing blood orders can help to triage requests to ensure all personnel are following the guidelines developed by the HTC or EBMC. One strategy to reduce usage in supply shortages is the reduce the dose provided to patients in each treatment. For example, some strategies include splitting available blood components to provide doses for two patients (platelets, plasma). The EBMC should develop a list of elective OR procedures that are associated with high blood usage. These are the surgery cases that may be considered for deferral in a blood supply shortage. Elective, support transfusions may be considered for deferral where they can be tolerated safely. In these cases, there should be a process in place to provide notification to patients and their families why the deferrals are necessary.

Transfer of Blood Between Sites Develop relationships with other nearby facilities Develop plan for transferring products between sites to optimize available blood inventory during a severe shortage to ensure patients in the most need will be supported Redistribution plans may already be in place Hospitals should ensure that there is a process in place to allow for the transfer of blood components / products between hospital sites. This will aid in sharing resources in critical shortages and help ensure that the patients most in need of blood will receive it.

Recovery Critical piece of plan Notification of recovery should be issued to those that originally received notification of the shortage Requests for blood components/products should continue to be restricted for a period of time Blood usage should resume very gradually and in a controlled manner Refer to guide for the restriction of use and slowly return in a step wise manner to normal utilization activity The recovery phase of the blood shortage is a crucial piece of the plan. Once the blood supplier notifies hospitals that inventory levels are increasing, it is important that hospitals do not return to normal operations immediately. Return to normal activity and recall of deferred procedures should occur at a controlled pace and in a gradual manner to make sure that the supplier inventory does not fall again and return to a shortage situation.

Conclusion A blood shortage can occur when it is least expected Rare occurrence means staff feel unprepared to respond if there is no plan in place and no training has been done A communication plan will ensure that the appropriate people receive information to improve decision making Planning and practice improve confidence and the ability to react consistently, rationally and efficiently

References Ontario contingency plan for management of blood product shortages and Toolkit, Ontario BPCO contingency planning working group. V2 June 30, 2012. National plan for the management of shortages in labile blood components. National Advisory Committee on Blood and Blood Products & Canadian Blood Services; January 18, 2012. CSA National Standards for Blood and blood components CSA Z902-10. Ontario Laboratory Accreditation (OLA) Requirements version 4 .1released July 2008. Development of an integrated blood shortage plan for the National Blood Service and hospitals. NHS and NBS Chief Medical Officer’s National Blood Transfusion Committee Dec 2004. An integrated plan for the National blood service and hospitals to address Platelet shortages. NHS and NBS Chief Medical Officer’s National Blood Transfusion Committee. Gateway ref 6514 06 Sept 2006. How do I manage a blood shortage in a transfusion service? Transfusion 2007;47:760-762