Intra-hspital Bld Bank Needs Identificatin Tl Develped by DC EHC Intrductin and purpse: The DC Emergency Healthcare Calitin (DC EHC r Calitin ) regularly reviews and updates its cllective vulnerabilities thrugh updates t its Hazards Vulnerability Analysis (HVA). The 2011 revisin identified ptential limitatins in emergency bld supply fr the District f Clumbia as a pssible vulnerability during an emergency r disaster. Further investigatin was cnducted during 2012 t better understand the bld supply situatin. This included meetings with the American Red Crss (ARC) and the American Assciatin f Bld Banks (AABB). In additin, a survey f the bld prduct prcessing and use at DC EHC acute care facilities was cnducted. These activities revealed a rbust capability at the natinal and reginal levels fr managing and distributing bld supplies during an emergency r disaster. At the same time, intra-hspital cmmunicatins between the clinical departments and their respective bld banks was identified as a pssible area fr imprvement. This template tl was develped t imprve and expedite the cmmunicatin f needs frm clinical departments t their intra-facility bld bank. Facilitating this interactin can expedite the transmissin f prjected bld prduct needs t reginal bld banks, reducing the prbability that bld prducts will be delayed r insufficient t meet emergency needs. This tl des nt set any standard, and its use is nt mandated. Sme facilities may in fact have a mre sphisticated mechanism fr cmmunicating between clinical services and their bld bank. This template is designed t supprt thse facilities that d nt have a pre-designated prcess. Backgrund: A range f calculatins have been published fr estimating bld prduct needs during emergencies and disasters. Few have been validated thrugh any cntrlled studies. The fllwing cncepts are relevant, and referenced t the publicatins list at the end f this dcument: US Department f Defense (DD) has, in the past, used estimates f 3 uprbcs f type O fr each admitted trauma casualty. A 2007 HHS survey study generally supprts the abve DD estimate. It is ntable that 60% f all US hspitals respnded t this survey. The average utilizatin f bld was 3 uprbc fr all patient types requiring bld transfusin - i.e. nt just trauma. A PAHO study uses aggregate data frm multiple cuntries and this prvides an estimate f 2.33 uprbc per trauma patient acrss all types f trauma situatins. The PAHO publicatin als recmmends that systems estimate their ttal PRBC needs, and then add 4% fr emergency (disaster) situatins. There is n data prvided n hw this is calculated. 1
Specific frmulas fr burns have been published, but they are supprted by nly limited data (e.g. burn area fr grafting +dnr site/32xttal bld vlume = predicted amunt needed during a burn victim's hspital curse) A histrical US military perspective ntes that 16% f all casualties reaching medical care in the Vietnam War required sme frm f bld transfusin. In 2000, 8% f admissins at Maryland Shck Trauma required transfusin services. The CDC prjects that 50% f all casualties will typically arrive within the first hur after a large scale dmestic, traumatic incident (the veracity f this estimate is questinable). An estimate fr earthquake impact n US cites prjects that 30% f the ppulatin seeking medical care will require hspitalizatin. Of these, nly 5-10% will require bld prducts. Massive bld transfusin usage rates were dcumented in ne UK study. In this study, the fllwing were median usage rates per case. 11 uprbc 4 uffp 2 PLT 2 Cryprecipitate The median use f uprbc fr massive transfusins in a US study was higher at 18 uprbc. In this study, varius amunts f FFP were transfused but as the rati came clser t 1:1, patient mrtality imprved. The fllwing are aggregated bld prduct use estimates in each f these majr US incidents: San Francisc earthquake, 1989: 40 uprbc Oklahma City bmbing, 1995: 131 uprbc Wrld Trade Center, 2001: 258 uprbc (in first 24 hurs) In summary, the aggregate bld use after dmestic US disasters has nt been extreme r verwhelming, but a significant ptential fr this remains. The data cited abve suggests that, in certain types f mass trauma situatins, the AABB estimatin f 3 uprbc average need per trauma casualty, aggregated acrss all casualties, may be an accurate prjectin. The abve data elements were utilized in cnstructing the fllwing tl fr estimating needs. Intra-facility bld tl: Purpse: This frm is designed t facilitate the ability f a transfusin service in an acute care facility t estimate the prjected bld use needs fr a mass trauma situatin as it is develping. As the incident evlves, the prjectin methd will shift t using mre specific clinical infrmatin based upn the evaluatin f individual patients. Tl instructin: This frm is designed t prcess infrmatin prvided t the transfusin service by the clinical services at their facility. The frm may be sequentially updated (time/date stamped) as the mass trauma situatin evlves: Initial Bld Prducts Prjectin: This utilizes initial casualty estimates (sectin 5). The frm is cmpleted when the patient care receiving area, (usually the emergency department) receives initial ntificatin f the expected number f casualties in rute t yur facility. Frm is then immediately submitted t facility s transfusin services. 2
Sequential Bld Prducts Prjectin (time/date stamped): This utilizes infrmatin frm the initial clinical assessment f the arriving patients. (sectin 6) Fllw-n Bld Prducts Prjectin (time/date stamped): This utilizes infrmatin frm the patient receiving area fr the aggregate chrt f incident patients, based upn the then current assessment f all incident patients. (sectin 6) These are suggested uses nly and the tl may be utilized mre r less frequently by the facility as the situatin dictates. The data shuld be rapidly cnveyed t the apprpriate facility s transfusin services each time new estimates are accumulated. 3
Bld needs estimatin tl 1. FACILITY NAME 2. DATE PREPARED 3. TIME PREPARED 4. REPORTING AREA (e.g. Emergency Department) 5. Initial uprbc ESTIMATES (prjected based upn infrmatin frm EMS r ther surces) Estimated casualties by type Casualty number Multiplicatin estimate **Estimated uprbc (these are estimates nly and shuld nt be interpreted as definitive need) Majr patients: thse expected t require immediate perative and/r critical care resurces Mderate patients: thse that may require a prcedure and pssible admissin Minr patients: thse that are expected t be discharged Ttal expected/estimated: X 3 uprbc X 2 uprbc X 0 0 uprbc 6. SUBSEQUENT Bld Prduct ESTIMATES (prjected frm casualty assessments) MALE FEMALE Multiplicatin estimate Estimated bld prducts (nt definitive need) Massive transfusin prtcls: Number f patients expected t require initiatin f massive transfusin prtcl Number f patients needing immediate perative interventin fr thracic, abdminal, and/r vascular extremity injuries (next 0-4 hurs) Number f patients needing perative interventin which can be temprarily (hurs) delayed Other anticipated significant bld prduct needs fr nn-incident patients Ttals X 18 uprbc X 18 FFP X 3 PLT (single dnr) X 30 Cry X 3 uprbc X 2 uprbc uprbc FFP PLT Cry uprbc FFP PLT Cry 4
References Hess J. Bld use in war and disaster: The US experience. Scand J Trauma Resusc Emerg Med 2005; 13; 74-81. Disaster Operatins Handbk: Crdinating the Natin s Bld Supply during Disasters and Bilgical Events. American Assciatin f Bld Banks. Versin 2.0. Octber 2008. United States General Accunting Office. Maintaining an Adequate Bld Supply is Key t Emergency Preparedness. Statement f Janet Heinrich (Directr, Health Care Public Health Issues) befre the Subcmmittee n Oversight and Investigatins, Cmmittee n Energy and Cmmerce, Huse f Representatives. September 10, 2002. GAO-02-1095T Pan American Health Organizatin (PAHO). Recmmendatins fr Estimating the Need fr Bld and Bld Cmpnents. Washingtn DC, 2010. Fuller G, Buamra O, Wdfrd M et al. Recent massive bld transfusin practice in England and Wales: view frm a trauma registry. Emerg Med J, 2011. 10.1136/emj.2010.104349. Steadman, P, Pegg S. A quantitative assessment f bld lss in burn wund excisin and grafting. Burns 1992, 18:6. 490-1. Duchesne J, Hunt J, Wahl G, et al. Review f current bld transfusins strategies in a mature level I trauma center: were we wrng fr the last 60 years? J Trauma, 2008; 65 (2): 272-8 Kashuk J, Mre E, Jhnsn J, et al. Pstinjury life threatening cagulpathy: Is 1:1 fresh frzen plasma: packed red bld cells the answer? J Trauma, 2008, 65(2): 261-271 Brgman M, Spinella P, Perkins J et al. The ratin f bld prducts transfused affects mrtality in patients receiving massive transfusins at a cmbat supprt hspital. J Trauma, 2007; 63 (4): 805-813 5