Fort Hood MASCAL

1. Fort Hood MASCAL Lab Lessons Learned 1LT Misty Youngblood March 25, 2010

2. Objectives • Identify the sequence of events that occurred during the MASCAL • Evaluate the current MASCAL procedures in use at Medical Treatment Facility • Recommend improvements to the current procedures related to a MASCAL event

3. The first 2 hours1330-1530 19 - Emergency release Requests 3 - Blood Product shipments received 2 - Bodies admitted to morgue 2 - Blood Product inventories completed - EOC established 1400 1430 1500

4. The next 5 hours1530-2030 26 - Emergency BP Requests 6 - Blood Product Shipments 4 - EOC meetings 1 - Body admitted to morgue - Employees released ~2000 hrs 1645 1800 1915

5. Overnight2030-0830 5 - EOC meeting every 1-3 hours 10 - Bodies admitted to morgue Final BP shipment ~2345 hrs 2330 0230 0530

6. Totals • 45 Emergency Requests • 16 patients & 138 Blood Products • 126 transfused • 10 shipments of BPs • 13 Bodies admitted to Morgue

7. Dept/Hospital AAR’s • “Top Six” that affected Laboratory Operations • Patient ID • BP Inventory Management • Communication with Transfusion Services • Morgue • Staff knowledge of BP administration policies • Specimens no orders/not labeled

8. Issue # 1Patient ID 3 “systems” to ID patients #1 - MASCAL pack – PAD, pt accountability • Stored in PAD • Blue armband w/# to track pt movement • Not for clinical/treatment purpose • Not registered in CHCS

9. Patient ID (cont) #2 - Trauma pack – ED, clinical data • Forms stored in ED • No armband, no preprinted pt ID’s • Pt ID’s not registered in CHCS • Could not find immediately

10. Patient ID (cont) #3 - John Doe registration in CHCS • Used for unidentified trauma patients • Pts registered in CHCS upon arrival • Cannot be pre-registered - PAD issues • No preprinted ID bracelet/labels • Too slow for true MASCAL - not used

11. Patient IDConsequences • Patients transported without ID bracelet • Pt’s ID in ER, OR, ICU & PAD did not match • Poor documentation and tracking through Patient care

12. Patient IDConsequences • Inconsistent patient ID • One pt had 14 different pt IDs • MC1 & MC3, 3 different SSN last 4, room #, different name spellings • MC4 – ID for 2 patients (3S & ICU) • BP reconciliation took 3-5 working days • Type specific blood could not be used

13. Patient IDRecommendations Meeting - PAD, ED, DPALS, Business Ops • Create one “system” • Use for unknown trauma pts and MASCAL • ED staff familiar with system because of more frequent use • Must be immediately available

14. Patient IDRecommendations • TRAUMA/MASCAL pts in CHCS • 100 ED, 100 PAD (for DIME locations) • TRAUMA/MASCAL 001 with system generated-SSN • PATCAT 92 FMP98, DOB Field 2010 • Embossing cards, armband and labels • Each form will have ID already stamped

15. Patient IDRecommendations • Other Recommendations: • Need realistic MASCAL training • PAD added to ED’s emergency recall • Utilize only O RBCs

16. Issue #2BP Inventory Management • Multiple shipments of BP • Too many BPs received to process & store • Delay issuing Platelets • Post access • Couriers stuck in traffic trying to deliver BPs

17. BP Inventory Management The numbers Many BPs were shipped out 09-11NOV09 Not all locations wanted BPs back Outdate rate for NOV 21% and DEC 16% (normal outdate rate <5%)

18. BP Inventory Management Recommendations • Coordinate through Trans Svcs • Ask for Platelets early in the process • Have access control phone numbers readily available

19. LAB STATUS PERSONNEL Assigned: Available: Key Personnel Chief: Unavailable: **58 total personnel present for duty STATUS ASSESSMENT/ISSUES:

21. Issue # 3Transfusion Service Communication • Techs- Emergency release and shipments • No one was trained to assist answering phones, inventory etc • Phone line was often busy

22. Transfusion Services CommunicationConsequences • Miscommunication or misinformation to and from providers/nurses • Difficulty getting accurate and timely inventories to EOC

23. Transfusion Services Communication Recommendations • Emergency phone line - internal use during MASCAL • Designate and train additional personnel to: • Inventory BP including incoming shipments • Track BPs issued during MASCAL • Man emergency phone line

25. Issue # 4Morgue • Procedural failures • Body admitted without body bag • PAD was not present • Body was not pronounced prior to admittance • Space • Morgue has room for 4 bodies

26. MorgueConsequences • Transport: • Morgue to truck • truck to truck – refrigeration unit failure • Smoking area near the loading dock • Justice of the Peace came to pronounce victim

27. MorgueRecommendations • Have litters available/know where to get them for easier, respectful transport and storage • Do not let emotions allow deviations from procedures • Designate team to assist with morgue functions

30. Issue # 5Staff Knowledge of BP administration • Lab accused of not releasing FFP • Physicians did not realize they needed to request • Previous proposal by to Blood Utilization and Transfusion Committee to develop trauma pack for blood components was turned down

31. Staff Knowledge (cont) • OR asked if blood issued to a patient could be used for another patient • Blood products issued to one patient transfused to another • BP issued to pt transfused to another pt (the only pt infused via rapid infuser)

32. Staff KnowledgeConsequences • Unable to issue type specific products • Reconciliation of paperwork • Animosity or accusations held against laboratory personnel

33. Staff KnowledgeRecommendations • Establish Mass Transfusion policy • In conjunction with Blood Utilization Committee • Physician would have to request • Continue current policy • Pathologist monitor BP issued to individual patients

34. Staff KnowledgeRecommendations • Continue to issue only type O RBCs during MASCALs • Educate providers during Newcomers Orientation

35. Issue # 6Specimens No orders/not labeled • Multiple unlabeled tubes in bag with one label in bag • No electronic or written orders

36. No orders/labelConsequences • Lab personnel to ER to see what tests were needed • No ordering physician to contact for critical values • Chance for patient ID errors in reporting values increased

37. No orders/labelRecommendations • MASCAL/Trauma registration • Provide preprinted labels, order via CHCS • Establish order sets • Use runners to communicate critical values if necessary

39. What Went Well • Rapid issue of BP – ready prior to the first request • Zero transfusion reactions • Donor Center delivered BP very quickly

40. What Went Well (con’t) • Supply clerk & NCO • Inventoried/Resupplied all areas • Coordinated pick up of BP flown in • Cytotechs automatically reported to Histology section to assist with morgue operations • Histology immediately called for and received trucks for additional morgue storage

41. What Went Well (con’t) • Staff management - work rest cycles considered early and planned for • Food/drink provided to staff • Teamwork from all areas of the laboratory exemplary

42. Conclusion Majority of changes/recommendations involve two key elements: Hospital policy for unknown Patient ID Training and Knowledge base of staff

43. Questions??