Transfusion emergency preparedness for mass casualty events

London 2017: Lessons learned in transfusion emergency planning

BACKGROUND AND OBJECTIVES

Hospitals prepare for emergencies, but the impact on transfusion staff is rarely discussed. We describe the transfusion response to four major incidents (MIs) during a 6-month period. Three events were due to terrorist attacks, and the fourth was the Grenfell Tower fire. The aim of this paper was to share the practical lessons identified.

METHODS

This was a retrospective review of four MIs in 2017 using patient administration systems, MI documentation and post-incident debriefs. Blood issue, usage and adverse events during the four activation periods were identified using the Laboratory Information Management System (TelePath).

RESULTS

Thirty-four patients were admitted (18 P1, 4 P2, 11 P3 and 1 dead). Forty-five blood samples were received: 24 related to nine MI P1 patients. Four P1s received blood components, three with trauma and one with burns, and 35 components were issued. Total components used were six red blood cells (RBC), six fresh frozen plasma (FFP) and two cryoprecipitate pools. Early lessons identified included sample labelling errors (4/24). Errors resolved following the deployment of transfusion staff within the emergency department. Components were over-ordered, leading to time-expiry wastage of platelets. Careful staff management ensured continuity of transfusion services beyond the immediate response period. Debriefing sessions provided staff with support and enabled lessons to be shared.

CONCLUSIONS

Transfusion teams were involved in repeated incidents. The demand for blood was minimal. Workload was related to sample handling rather than component issue. A shared situational awareness would improve stock management. A laboratory debriefing system offered valuable feedback for service improvement, staff training and support.

Emergency preparedness, resilience and response guidance for UK hospital transfusion teams

OBJECTIVES

To present Emergency Preparedness, Resilience and Response (EPRR) guidance for Hospital Transfusion Teams on behalf of the National Blood Transfusion Committee emergency planning working group.

BACKGROUND

The Civil Contingencies Act 2004 requires healthcare organisations to demonstrate that they can deal with major incidents while maintaining critical services. Recent mass casualty events and the use of transfusion-based resuscitation have highlighted the evolving role of the Hospital Transfusion Team.

METHODS

This multi-disciplinary advice is informed by recent global and national experience, the 2018 NHS England clinical guidelines for Major Incidents, and stakeholder workshops.

GUIDANCE

Transfusion staff should be familiar with local EPRR plans including casualty type and numbers. Staff should be exercised as part of wider Trust preparation, with documented roles and responsibilities. Transfusion support should be proactive and include blood issue, regulatory compliance and sample handling. Robust LIMS-compatible emergency identification systems are essential to minimise errors. Emergency stock management requires rapid assessment of existing stock and estimated demand before re-ordering. Initial demand should be based on 2 to 4 red blood cells (RBC) per patient admitted. Patients with significant haemorrhage may require further red cells and early haemostatic support. Where "universal" components are demanded, they should be gender appropriate. Senior staff should lead the response, log and communicate key decisions, and prepare for post-incident recovery.

CONCLUSIONS

Transfusion teams have an important role in ensuring continuity of transfusion support. Teams should develop their EPRR plans based on local plans and national guidance. Emergency preparedness should include post-incident debriefing for ongoing staff support and future service improvement.

Blood transfusions in mass casualty events: recent trends

BACKGROUND AND OBJECTIVES

The US AABB disaster task force recommends estimating 3 RBC units per admission (UPA) for mass casualty events (MCEs). In a previous analysis, median MCE UPA were 2·7 RBCs, 1·2 plasmas and 0·27 platelet doses (Vox Sang 2017; 112:648). Additional recent data were sought from the current era of balanced massive transfusion protocols (bMTPs).

MATERIALS AND METHODS

Publications in English from 1980 to 2020 were reviewed for MCEs using ≥50 RBCs/event and with numbers of admissions available. MCE reports were stratified by era and event-wide or trauma-centre source. The bMTP era included all MCEs since 2010 plus a 2008 bMTP military report.

STATISTICS

Mann-Whitney test.

RESULTS

Thirty-two MCEs met analysis criteria. Event-wide reports used medians [interquartile ranges] of 1·8 [1·2-3·9] RBC, 0·6 [0·3-0·9] plasma and 0·14 [0·06-0·26] platelet-dose UPA. Trauma centres transfused 3·4 [2·7-6·3] RBC, 2·4 [1·3-4·1] plasma and 0·41 [0·34-0·50] platelet-dose UPA, all P < 0·05 vs event-wide. Same-event median post-day-1 transfusions were 50% of day-1 use for RBC, 28% for plasma and 16% for platelets. Compared to prior years, the median plasma/RBC transfusion ratio rose from 0·28 to 0·67 in the bMTP era (P < 0·01). In recent mass shootings, trauma centres transfused up to 42 platelets (range 0·45-0·57 UPA) on day 1.

CONCLUSION

Based on available mass casualty data, we recommend planning for 3 RBC, 1 plasma and one-fourth platelet-dose units per admission for blood centres (event-wide), and 6, 4 and one-half UPA, respectively, for trauma centres, which have seen rising plasma usage and large mass-shooting platelet needs.

Critical developments of 2018: A review of the literature from selected topics in transfusion. A committee report from the AABB's Clinical Transfusion Medicine Committee

BACKGROUND

The AABB compiles an annual synopsis of the published literature covering important developments in the field of transfusion medicine. An abridged version of this work is being made available in TRANSFUSION, with the full-length report available as Appendix S1 (available as supporting information in the online version of this paper).

STUDY DESIGN AND METHODS

Papers published in late 2017 and 2018 are included, as well as earlier papers cited for background. Although this synopsis is comprehensive, it is not exhaustive, and some papers may have been excluded or missed.

RESULTS

The following topics are covered: "big data" and "omics" studies, emerging infections and testing, platelet transfusion and pathogen reduction, transfusion therapy and coagulation, transfusion approach to hemorrhagic shock and mass casualties, therapeutic apheresis, and chimeric antigen receptor T-cell therapy.

CONCLUSION

This synopsis may be a useful educational tool.