Incident preparedness: Transfusion readiness for an international sports event

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 • Discuss general incident preparedness • Share lessons learned from two local events • 8/08 Republican national convention (RNC) • We shared our template for preparedness for the RNC with Canadian Olympic committee before Vancouver Olympics • 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 • Over 200,000 Chinese citizens have volunteered • 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!

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

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

6. Incident planning • Many useful resources for planning templates • AABB disaster plan • http://www.aabb.org/Documents/Programs_and_Services/Disaster_Response/disastophndbkv2.pdf • 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 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.

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

8. AABB preparedness • Each role has an associated preparedness plan • Example: Communications • plan includes both internal and external communications strategies • 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

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

11. Platelet strategies green yellow red black Strategy

12. Republican National Convention St. Paul, Minnesota USA • ~45,000 visitors during Sept 1-4, 2008 • Memorial Blood center had a formal plan in place several months before the convention • Challenges • 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 • 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

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

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

15. RNC preparedness plan • Communication strategies • Internal • Phone trees • Back up responsibilities, cross-training staff • External • Media communication plans • Vendor plans • Alternative providers • Supply chain 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 • 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 • 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. Built 1967 Rated as: structurally deficient, but not in immediate need of replacement 2000 ft span, 64 ft high 141,000 cars / day Mississippi 390 ft wide, avg 7ft depth 35W Bridge

19. HAZARDS Too many to name…

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

23. Destination Hospitals - EMS

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

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

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

29. MD perspective • 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 • 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 • Closest Level 1 trauma center • 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.

31. HCMC-ED • Lead ER MD declared an external disaster • “Orange Alert” automatically: • Recalls key personnel, holds on duty personnel • Clears patient reception areas • 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)

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

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

34. Confidentiality considerations • 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. • 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. • Plan includes notification of off-duty personnel, • Web based action sheets • Job directions availabile at every work station • Ability to expand/contract as needed • “the middle of a disaster is not a great time to be exchanging business cards”

36. Supplies and Equipment • 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. • 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 • 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

38. Transfusion issues • 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 • 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.

39. Emergency Tx and Rh: Group O policy • Emergency Tx: Males may receive O+ • 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 • Major issue is sensitization in females of future child bearing potential • THERE are NO Rh antigens on platelets

40. HCMC Massive Transfusion Policy • 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 • Don’t wait for coagulopathy to develop • 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 • AABB disaster planning • MBC Republican National Convention plan • ABC pandemic flu planning

42. Asia Game disaster planning • 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 Athlete least likely to be invited to Asian Games!  Hangzhou WinTech is located in Fuyang City

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

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

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