Blood Contingency Planning: Panic or Plan

1. Blood Contingency Planning:Panic or Plan 2011 Annual Blood DayNovember 2nd, 2011 Susan Nahirniak MD, FRCPC

2. Objectives • During the course of this talk • Discuss the need for contingency planning. • Review highlights of the National Blood Shortage Plan and the“Allocation of Blood in Red Phase to Massively Bleeding Patients Triage Document” • Identify key elements needed in Provincial Blood Shortage Plans

3. A Duty to Plan “The requirement to plan properly cannot be emphasized strongly enough. It is unreasonable to burden medical staff with a dilemma when it lies in society’s power to help resolve these issues ahead of time. Whatever the moral obligation that doctors have to society, it is not sufficient to try to resolve these difficult issues ‘on the hoof’ in the midst of a pandemic. They must be settled before a pandemic arrives.” RJ Harwood. Anaesthesia 2009; 64: 216-29.

5. National Plan for the Management of Shortages of Labile Blood Components National Advisory Committee on Blood & Blood Products and Canadian Blood Services

6. Purpose of the Plan • Maximizeeffectiveness of a national response to any crisis which impacts the adequacy of the blood supply in Canada. • Provide a framework for consistent and collaborative blood shortage management plans across provinces, health authorities and hospitals.

7. The Guiding Principles The Plan operates within the existing blood system structure, including the legislative and regulatory framework currently in place. The Plan assumes that all efforts to increase the available supply of blood components have been exceeded. The Plan promotes collaboration. The Plan is based upon established ethical principles.

8. The Guiding Principles • The Plan recognizes previous and ongoing work in this domain and represents an iterative process. • The Plan acknowledges potential legal liability concerns. • The Plan assumes that all areas of the country served by CBS would be simultaneously affected in an approximately equal manner; however provincial and/or regional differences can also be addressed by the Plan. • The Plan acknowledges Canada’s diverse geography and diverse expertise in Transfusion Medicine.

9. The National Plan addresses…. Phases of Shortage – Definitions and criteria Roles and Responsibilities for: Canadian Blood Services Ministries of Health (Quebec has MOU only) Health authorities Hospitals Emergency Blood Management Committee framework for National, Provinical and Local (i.e. Regional Health authority or hospital) levels Communication strategies and templates

10. Stakeholder Identified Challenges Stakeholder review of draft in Fall of 2008 • Major themes in comments: • Collaboration with Provinces and HemaQuebec • Communication • Criteria around Green, Amber and Red Phases • Criteria for cessation / refusal of therapies

11. National Blood Shortage Plan INVENTORY & Phases

12. What does the inventory look like? • CBS averaged 17,372 RBC units in inventory across the country, with a target of 5 days (>15,425 units) during 2005-09 • During that time there was: • 1 day <10,000, • 10 days<11,000 • 38 days <12,000 • Only 2.5% of the time did the inventory level drop below 12,000 units (<4 days on hand)

13. Lowest in the developed world

14. Double the need by 2050

15. Three + Recovery Phases Green phase: ideal inventory to short-term minor shortages that can be managed with existing CBS/hospital actions Amber phase:the current or projected national blood inventory is (or will be) insufficient for hospitals to continue usual transfusion practice. Red Phase: the existing or expected national inventory is insufficient to meet the needs of all requests for non-elective blood products. Recovery Phase: blood inventories have begun to increase and are expected to be maintained at a level which would enable hospitals to move from Red to Amber and subsequently to the Green Phase, or from Amber to Green Phase

16. National CBS Inventory - RBCs

17. Guideline for the use of RBC transfusions in children and adults in shortage situations

18. Concern re: RBC Inventory • A patient requiring massive transfusion in a blood shortage with a very poor chance of survival could potentially consumes 10 or more units of blood, could that / should that be alternatively diverted to save other patients with a much better chance of survival?

19. Guideline for the use of platelet transfusions in children and adults in shortage situations

20. We’ve never left Green!

21. National Blood Shortage Plan Emergency Blood management committees

22. National Blood Emergency Management Committee Mandate: The NEBMC will develop recommendations and provide advice to the P/T Ministries of Health, hospitals/health authorities and CBS to support a consistent and coordinated response to critical blood shortages in Canada It will: Provide advice to the COO of CBS with respect to declaration of amber or red phase situation Provide recommendations on distribution of blood components Provide recommendations concerning communication of shortages key messages Ensure communication between the NEBMC and the P/TEBMCs

23. NEBMC Membership • Chair of NEBMC = Chair of NAC • All NAC members (incl. Quebec) • All P/T Blood Representatives • CBS representatives • COO; Executive Medical Director; Exec Director & Director of Product & Hospital Services plus the Directors of Operations Support, Government Relations, Internal Communications, Media Relations/External Communications • Hema-Quebec Representative • Health Canada BGTD representative (ex officio) • Two blood transfusion recipient representatives

24. Provincial/Territorial EBMC Membership • Recommended: • P/ T Blood Representative • Provincial NAC member(s) • Chief Medical Officer of Health • Medical Director & Manager, PBCP • CBS • Regional Med. Director(s); Reg. Dir of Product & Hospital Services and HCLS • Representatives from • Tertiary Care Transfusion Services • Rural and/or Remote site The links to the NEBMC

25. P/TEBMC Membership • Others may include: • Health Authority CEO(s) • Health Authority /Tertiary Care designates for: • Medical Director(s), Transfusion Services • Chair(s), Transfusion Committees • Laboratory Managers • Risk Managers • TSOs • Quality Specialists • Nursing administrators • Executive Management representatives • Physician User Group • Blood recipient representatives

26. Hospital / Health Authority – EBMC Membership • Senior/ Executive Management • Medical Director & Manager, Transfusion Service • Chair, Transfusion Committee • Department Heads for • Int. Medicine/ Critical Care/Hematol.; Surgery; Anesthesiology; Emergency Medicine; and O&G • Director of Nursing • Transfusion Safety Officer • Risk Manager • Director of Communications/ Public Affairs

27. National Blood Shortage Plan Phase specific activities

28. HOSPITALPLAN NATIONALPLAN PROVINCIAL PLAN

29. GREEN PHASENOT BUSINESS AS USUAL

30. Green Phase ActivitiesA) Canadian Blood Services Develop a comprehensive disaster preparedness plan Manage the inventory nationally Develop internal strategies to increase collections as required Ensure the ability to share inventory between CBS & Héma-Quebec Work with hospitals to improve information re total inventories & inventory information sharing

31. Green Phase ActivitiesB) Provincial / Territorial Governments Encourage/assist hospitals to implement green phase measures Encourage/facilitate sharing of hospital information among hospitals and with CBS inventory information utilization information Establish Provincial Emergency Blood Management Committees

32. Green Phase- Activities C) Hospitals/ Health Authorities Ensure have active EBM committees That mandate Categories of surgeries/medical interventions Develop algorithms/decision maps for phases Active role during a shortage situations Establish transfusion guidelines, including appropriate indications for transfusions guidelines for ABO, Rh, CMV substitutions audit to these guidelines

33. Green Phase- Activities C) Hospitals/ Health Authorities Inventory management strategies MSBOS or equivalent strategies to minimize outdating (ie. Recycling programs) policies for decreasing units/transfusion Collaboration with CBS determine inventory levels for the various components/groups Green (optimal) Amber (serious) Red (critical) Transparent information sharing

34. Green Phase- Activities D) ALL Simulation exercises Debrief after each exercise Regular review and revision of Contingency Plans

35. AMBER PHASE

36. Amber Phase Activities • NEBMC will convene and • recommend declaration of amber phase • Decide on key messages for communication • P/T and NAC representatives will initiate PEBMC to activate their plans and monitor hospitals to ensure compliance

37. Amber Phase ActivitiesA) CBS COO declares amber phase Activates internal CBS plans for an amber phase Decreases issues to hospitals to levels determined in consultation with the NEBMC Coordinate public communications with provinces/territories

38. Amber Phase ActivitiesB) Provinces/Territories Ensure P/TEBMC is convened Implement communications plan using templates and key messages provided by NEBMC Encourage hospitals to be compliant with and act upon the actions required in the amber phase Monitor compliance with the Plan

39. Amber Phase ActivitiesC) Hospitals/ Health Authorities Activate HEBMC Cancel elective surgical procedures requiring blood Implement stricter transfusion guidelines with triage and approval processes Implement previously defined inventory management strategies decrease inventories sharing between hospitals shorter reserve times Sharing of inventory information with CBS with other hospitals Communicate using templates/ key messages

40. Amber Phase - examples Minimize RBC wastage No blood stored external to the blood bank No advance tagging of units prior to immediate need for transfusion No release of units if line and pt are not ready One unit at a time Increase the recycle and redistribution of red cells

42. RED PHASE

43. Red Phase Activities • NEBMC will convene and • recommend declaration of red phase • Decide on key messages for communication • P/T and NAC representatives will initiate PEBMC to activate their plans and monitor hospitals to ensure compliance

44. Red Phase ActivitiesA) CBS COO declares red phase Activates internal plans for an red phase Decreases issues to hospitals to levels determined in consultation with the NEBMC Coordinates public communications with provinces/territories

45. Red Phase ActivitiesB) Provinces/Territories Continue activities begun in amber phase Continue to assure that all hospitals are implementing red phase plans Monitor compliance with the Plan

46. Red Phase ActivitiesC)Hospitals/ Health Authorities Continue actions begun in amber phase Activate internal plans for a red phase Strict triage and approval for blood product release

47. RECOVERY PHASE

48. Recovery PhaseGradualreturn tonormal Essential that hospital blood usage remains restricted with incremental increases to prevent relapse to red/amber Continue communication strategies Requests for blood components/products shall continue to be monitored and reviewed until notified of a return to the Green Phase.

49. National Blood Shortage Plan Communication plans & templates

50. Communication Structure National Emergency Blood Management Committee Canadian Blood Services Provincial Emergency Blood Management Committee HemaQuebec US Blood Suppliers Regional/Hospital Emergency Blood Management Committee Physician/Nurses/ Technologists/Patients