1. Incident preparedness: Transfusion readiness for an international sports event Jed B. Gorlin MD, MBA May 2010

2. Objectives Transfusion issues specific to Asian Games Transfusion issues specific to Asian Games Discuss general incident preparedness Discuss general incident preparedness Share lessons learned from two local events Share 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 with Canadian Olympic committee before Vancouver Olympics We shared our template for preparedness for the RNC with Canadian Olympic committee before Vancouver Olympics 8/1/07 Bridge collapse into Mississippi river 8/1/07 Bridge collapse into Mississippi river

3. 2010 Guangzhou Asian Games Athletes from 45 countries will compete in 476 events in 42 sports Nov 12-27, 2010 Athletes from 45 countries will compete in 476 events in 42 sports Nov 12-27, 2010 Over 200,000 Chinese citizens have volunteered Over 200,000 Chinese citizens have volunteered Countries participating include mideast (Afghanistan to Yemen) 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! Non-olympic events include Board games, Dragon boats, Sepaktakraw and Kabaddi few of which are likely to need blood transfusion!

4. Incident preparedness and Transfusion Inventory: Special issue is Rh(D)- availability Inventory: Special issue is Rh(D)- availability Types of components Types of components Patient identification system Patient identification system Communications Communications Linguistic and technical Linguistic and technical External- media External- media Transport of blood Transport of blood Is blood available for air ambulance? Is blood available for air ambulance? Restricted access Restricted access

5. Blood use following disasters: Historical perspective Hess review ( reference at the end ) Hess review ( reference at the end ) US civilian disasters 105-131 units US civilian disasters 105-131 units Skywalk collapse in KC hotel Skywalk collapse in KC hotel Airliner Sioux City Iowa Airliner Sioux City Iowa Oklahoma City Govt. Center bombing Oklahoma City Govt. Center bombing Columbine high school Columbine high school 9/11/2001- Al Quieda attack on US 9/11/2001- Al Quieda attack on US About 600 extra units used following WTC collapse, NYBC collects >1000 daily! About 600 extra units used following WTC collapse, NYBC collects >1000 daily!

6. Incident planning Many useful resources for planning templates Many useful resources for planning templates AABB disaster plan AABB disaster plan http://www.aabb.org/Documents/Programs_and_Se rvices/Disaster_Response/disastophndbkv2.pdf http://www.aabb.org/Documents/Programs_and_Se rvices/Disaster_Response/disastophndbkv2.pdf http://www.aabb.org/Documents/Programs_and_Se rvices/Disaster_Response/disastophndbkv2.pdf 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: CHEST supplement with approach to triage of limited medical resources during/following a 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 Care. Chest. 2008 May;133(5 Suppl):18S-31S. 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 optimizing critical care surge capacity: from a Task Force for Mass Critical Care summit meeting, January 26-27, 2007, Chicago, IL. 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. 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. 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. 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. 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.

7. AABB preparedness plan Very general plan with many elements allowing response to many different kinds of incidents Very general plan with many elements allowing response to many different kinds of incidents Roles include: Roles include: Disaster coordinator Disaster coordinator Communications coordinator Communications coordinator Staffing coordinator Staffing coordinator IT managers IT managers Department 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

8. AABB preparedness Each role has an associated preparedness plan Each role has an associated preparedness plan Example: Communications Example: Communications plan includes both internal and external communications strategies plan includes both internal and external communications strategies Internal plan includes phone tree with up to date list of methods to contact staff 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 External plan includes updated lists of hospital and other key customer contacts

9. 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 plans.

10. Scarce resource strategies RecommendationStrategyGreenYellowRedBlack RBC Increasing O+ levelsIncrease Supply Consider maintaining a frozen blood reserve if severe shortageIncrease Supply Move whole blood donors to 2-RBC apheresis collectionsIncrease Supply Increase recruitment effortsIncrease Supply Use O+ only in emergent transfusion in males or non-child bearing femalesConservation Use erythropoietin (EPO) as an alternative in cancer related anemiaAlternatives Cell SalvageConservation Collect Autologous units for elective surgeriesConservation Consider cross-over Autologous unitsIncrease Supply Enforce lower transfusion triggers (7g hg)Conservation Reduction of the 56-day RBC interdonation interval based upon pre-donation hemoglobin determinationIncrease Supply Reduction of weight requirements for double RBC apheresis by five poundsIncrease Supply

11. Platelet strategies Platelets Accept female donors for Pool and Store pooled plateletsIncrease Supply Accept female apheresis donors - no HLA antibody testingIncrease Supply Increase recruitment effortsIncrease Supply Apply for variance for 7 day outdateIncrease Supply Triage to patients with active bleedingConservation Consider implementing leukoreduced WB pooled plateletsIncrease Supply Reduce pool sizes to platelets from 4 WB donationsIncrease Supply Consider a 24 hr hold until the culture is obtained and immediate release for both Pool and ApheresisIncrease Supply Obtain FDA variance to allow new Pool and Store sites to ship across state linesIncrease Supply Consider Non-LR WB pooled plateletsIncrease Supply Limit use of platelets for patients being treated expectantlyConservation Limit use of platelets for patients with symptomatic bleeding and not transfusing for a numerical triggerConservation Convert less needed ABO Whole Blood to ApheresisIncrease Supply Strategy green yellow red black

12. Republican National Convention St. 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 place several months before the convention Memorial Blood center had a formal plan in place several months before the convention Challenges Challenges Inventory: We doubled inventory of group O units at the closest hospital 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 We worked with security to ensure access since this hospital was located within limited access area Hospital had system for transfusing unidentified patients 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 Blood center hospital services manager carried a special communication tool (800 MZ radio) 24h/day to ensure around the clock access

13. RNC Planning specifics Non-disaster plans Non-disaster plans No blood drives in areas near event No blood drives in areas near event Alternative strategies for donor recruitment knowing of distractions occurring during event Alternative strategies for donor recruitment knowing of distractions occurring during event Television advertising too expensive Television advertising too expensive Transportation Transportation Contacted police to assure access to hospitals near event Contacted police to assure access to hospitals near event Consider using two drivers if parking access restricted Consider using two drivers if parking access restricted

14. RNC preparedness plans Transportation- Transportation- Emergency identification of vehicles Emergency identification of vehicles IT/Technical services IT/Technical services Computer down back up plans Computer down back up plans Alternative phone communication plans Alternative phone communication plans Power outage- generators at both hospital, blood center Power outage- generators at both hospital, blood center Coordination with Federal/State/Local agencies Coordination with Federal/State/Local agencies

15. RNC preparedness plan Communication strategies Communication strategies Internal Internal Phone trees Phone trees Back up responsibilities, cross-training staff Back up responsibilities, cross-training staff External External Media communication plans Media communication plans Vendor plans Vendor plans Alternative providers Alternative providers Supply chain issues Supply chain issues Safety and security issues Safety and security issues

16. Bridge collapse in Minnesota I am the medical director both of the blood center and the local trauma hospital 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 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 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 The response has been cited as an example of excellent medical preplanning

17. Hennepin County Medical Center I-35W Bridge Collapse Response AUGUST 1, 2007

18. 35W Bridge Built 1967 Built 1967 Rated as: structurally deficient, but not in immediate need of replacement Rated as: structurally deficient, but not in immediate need of replacement 2000 ft span, 64 ft high 2000 ft span, 64 ft high 141,000 cars / day 141,000 cars / day Mississippi 390 ft wide, avg 7ft depth Mississippi 390 ft wide, avg 7ft depth

19. HAZARDS Too many to name…

21. RESPONSE SUMMARY Collapse to last patient transported: Collapse to last patient transported: Initial clearing of all sectors: 1 hr 35 mins Initial clearing of all sectors: 1 hr 35 mins Last EMS transport: 2 hrs 6 mins Last EMS transport: 2 hrs 6 mins 50 patients transported by EMS 50 patients transported by EMS 8-13 casualties via other vehicle 8-13 casualties via other vehicle Over 100 patients treated in 24 hours Over 100 patients treated in 24 hours 13 deaths 13 deaths No serious injuries to first responders No serious injuries to first responders 29 ambulances used in first 4 hours 29 ambulances used in first 4 hours

23. Destination Hospitals - EMS

24. Hospital A Hospital B Hospital C Clinics Healthsystem Public Health Agencies EMS Agencies Jurisdiction Emergency Management A A B CA B C C B Regional Hospital Resource Center Multi-Agency Coordination Center EM EMS PH

26. HCMC Response Initial information at 6:10pm Initial information at 6:10pm Hospital near capacity – 5 ICU beds available Hospital near capacity – 5 ICU beds available 2 current critical cases in resuscitation area 2 current critical cases in resuscitation area Charge RN turned on TV Charge RN turned on TV Alert Orange declared at 6:15 Alert Orange declared at 6:15 ED staff paged: ‘get to HCMC now’ ED staff paged: ‘get to HCMC now’ Initial patients received (critical) at 6:40 Initial patients received (critical) at 6:40

28. HCMC Response 25 patients received in 2 hours 25 patients received in 2 hours 1 dead on arrival 1 dead on arrival 6 intubated 6 intubated 5 directly to OR 5 directly to OR 16 total admissions (60%) 16 total admissions (60%) By 7pm: By 7pm: 25 ICU beds open 25 ICU beds open 10 OR open and staffed 10 OR open and staffed 3 CT scanners running 3 CT scanners running

29. MD perspective Physicians at the scene: 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 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. 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.

30. HCMC central role HCMC provides primary paramedic service HCMC provides primary paramedic service Closest Level 1 trauma center Closest Level 1 trauma center Houses the West Metropolitan Medical Resource Control Center (WMMRC) that provides information to regional hospitals and ambulances 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. Web based MNTRAC system kept live information flowing about ER status, bed availability, patient numbers and patient destination.

31. HCMC-ED Lead ER MD declared an external disaster Lead ER MD declared an external disaster “Orange Alert” automatically: “Orange Alert” automatically: Recalls key personnel, holds on duty personnel Recalls key personnel, holds on duty personnel Clears patient reception areas Clears patient reception areas Opens hospital command center staffed by key administrative and clinical personnel identified by premade vests. Opens hospital command center staffed by key administrative and clinical personnel identified by premade vests. 24 critically ill patients brought to ED, 5 in the back of pick-up trucks (with EMTs) 24 critically ill patients brought to ED, 5 in the back of pick-up trucks (with EMTs)

32. HCMC: Incident communication Communication was difficult Communication was difficult Volume of calls overwhelmed land and cell phone lines Volume of calls overwhelmed land and cell phone lines GET and WIPS- Government priority access for land and wireless lines now available GET and WIPS- Government priority access for land and wireless lines now available Some solutions archaic but nonetheless worked: example: runners within the hospital Some solutions archaic but nonetheless worked: example: runners within the hospital 800 MHz radios, walkie talkies, MNTRAC- Web based communication worked best 800 MHz radios, walkie talkies, MNTRAC- Web based communication worked best

33. HCMC: Media- PR Intense national attention Intense national attention Few designated spokespersons systematically provided information and interviews on a scheduled basis. Few designated spokespersons systematically provided information and interviews on a scheduled basis. Allowed consistent and focused information 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!) 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!)

34. Confidentiality considerations Patient tracking difficult and patients (even from the same family) taken to different hospitals 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. 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 Difficulty in identifying single organization to coordinate communication with general public

35. HCMC: Disaster Plan Incident went smoothly BECAUSE a pre- plan was in place AND drilled regularly. Incident went smoothly BECAUSE a pre- plan was in place AND drilled regularly. Plan includes notification of off-duty personnel, Plan includes notification of off-duty personnel, Web based action sheets Web based action sheets Job directions availabile at every work station Job directions availabile at every work station Ability to expand/contract as needed Ability to expand/contract as needed “the middle of a disaster is not a great time to be exchanging business cards” “the middle of a disaster is not a great time to be exchanging business cards”

36. Supplies and Equipment ED supplies became temporarily exhausted 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. 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. Stockpiles of commonly needed items should be available based on guidance by departments of health and preparedness program efforts.

37. Medical Reserve Corps National system of local corps National system of local corps Pre-credential medical personnel to assist in the event of external disasters 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 Provide training on mass casualty, mass public health initiative (vaccination, drug dispensing), psychological care during disasters

38. Transfusion issues MBC contacted surrounding hospitals and level 1 trauma centers within 30 minutes 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 Additional group O cells sent to hospital sites likely to receive patients, even if hospital didn’t request them Concern was raised that Twins and disaster traffic might preclude timely delivery further into the event Concern was raised that Twins and disaster traffic might preclude timely delivery further into the event 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. 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.

39. Emergency Tx and Rh: Group O policy Emergency Tx: Males may receive O+ Emergency Tx: Males may receive O+ There is NO immediate consequence of transfusing Rh positive red cell units into Rh negative recipients. There is NO immediate consequence of transfusing Rh positive red cell units into Rh negative recipients. RBC will be more rapidly cleared-so follow up required if emergency crossing over Rh types 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 Major issue is sensitization in females of future child bearing potential THERE are NO Rh antigens on platelets THERE are NO Rh antigens on platelets

40. HCMC Massive Transfusion Policy Blood bank works with staff to monitor patients with large ongoing needs 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 Obtain frequent labs (Hct/Hgb, plt, PT (INR), PTT, fibrinogen to guide Tx Don’t wait for coagulopathy to develop Don’t wait for coagulopathy to develop As RBC transfused approaches 1 x blood volume platelets are often depleted before coag factors As RBC transfused approaches 1 x blood volume platelets are often depleted before coag factors

41. References Hess JR, Thomas MJG “Blood use in war and disaster: lessons from the past century” Transfusion (2003) 43:1622-1633 Hess JR, Thomas MJG “Blood use in war and disaster: lessons from the past century” Transfusion (2003) 43:1622-1633 AABB disaster planning AABB disaster planning MBC Republican National Convention plan MBC Republican National Convention plan ABC pandemic flu planning ABC pandemic flu planning

42. Asia Game disaster planning Event or disaster at event is unlikely to use a very large quantity of blood 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 Challenges are having what blood is available readily available and ability to transfuse in a chaotic situation while minimizing risks Athlete least likely to be invited to Asian Games! Hangzhou WinTech is located in Fuyang City

43. Challenges during Event Patient identification Patient identification Group O units at hospital Group O units at hospital O+ for males O+ for males O- for females of child bearing age if no time to give type specific O- for females of child bearing age if no time to give type specific Communications Communications Internal Internal External External System in place for unidentified patients System in place for unidentified patients Consider implementing double red cell collection technology to increase availability of O units Consider implementing double red cell collection technology to increase availability of O units Communications strategies- Cell phone alternatives Communications strategies- Cell phone alternatives Media plan Media plan

44. 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. 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: Feel free to send any questions or comments to: my email: jed@mbc.org

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