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June 2005
Feature Story
Karen Lusky
For the laboratorians at Memorial Hermann Hospital in Houston, disaster
struck in the middle of the night when floodwater began pouring into the
basement-level laboratory during tropical storm Allison in June 2001.
The flooding, which rose to knee level within two hours, not only endangered
some laboratory staff when they later tried to escape but also wiped out
the hospital’s blood supply stored in the lab.
“The hospital had a few units of O-negative blood in the trauma
unit and some blood for individual patients stored in Igloo coolers at
their bedsides,” says Beth Hartwell, MD, Memorial Hermann’s
medical director of pathology and laboratory services. If this limited
supply proved inadequate, staff had planned to travel by canoe to a nearby
hospital to obtain additional units.
The hospital’s backup electrical power went out when water in the
basement short-circuited the switches that controlled generators housed
on upper floors. “Luckily, the laboratory had just installed battery-powered
emergency lights or staff would have been plunged into total darkness
until they located the stash of flashlights,” Dr. Hartwell says.
The hospital immediately asked the local blood center for 20 units of
O-negative red blood cells and 10 units of AB plasma, which the center
was able to deliver in coolers, as flood waters were receding, within
12 to 14 hours. But the blood center sent frozen plasma, forgetting the
hospital had no way of thawing it.
“Those are the details that can escape you in an actual disaster,
which is why planning is so important,” Dr. Hartwell says.
Whether disasters strike suddenly or come with warning, they can disrupt
a hospital’s ability to maintain a sufficient and safe blood supply.
And publicized disasters can trigger a rush of blood donations that in
itself strains the blood collection system.
The AABB Interorganizational Task Force on Domestic Disasters and Acts
of Terrorism aims to prevent both situations. Formed in January 2002 in
response to 9/11, the task force coordinates the collection and allocation
of blood during a domestic disaster. Its members are key or level 1 private
sector and government stakeholders in the blood community, and a short
list of level 2 stakeholders: the CAP, American Association of Tissue
Banks, American Hospital Association, Advanced Medical Technology Association,
National Marrow Donor Program, and the Plasma Protein Therapeutics Association.
In a disaster, hospitals are at “ground zero” in estimating
the number of walking wounded and other casualties and the need for blood,
says Jamie Blietz, director of the AABB National Blood Exchange, which
coordinates much of the logistical support for the task force. “Usually
hospitals get that information first and then must share it with their
blood centers, which report to the AABB task force if needed,” Blietz
says.
The task force deals only with disasters large enough to require federal
assistance—or with situations in which a blood center or hospital
might require its assistance. In such events, “the task force has
the confirmed ability to have all the level 1 organizations, or major
stakeholders in blood, on a conference call to coordinate,” says
Don Doddridge, chairman of the task force. (Level 1 members are the AABB,
America’s Blood Centers, American Red Cross, Armed Services Blood
Program, Blood Centers of America/hemerica, CDC, FDA, and Department of
Health and Human Services.) Level 2 stakeholders such as the CAP would
be brought in as needed to help manage the crisis.
The linchpin for national or local disaster planning is the task force’s
Disaster Operations Handbook: Coordinating the Nation’s Blood
Supply During Disasters and Biological Events. The handbook is designed
to help blood centers, hospital blood banks, and transfusion services
respond to any disaster that boosts the demand for blood or interrupts
the blood supply.
“Hospitals that think the handbook’s guidance applies only
to trauma centers should think again,” says Glenn Ramsey, MD, medical
director of the blood bank at Northwestern Memorial Hospital, Chicago,
who is the CAP’s representative on the AABB disaster task force.
“Hospitals that view themselves as nontrauma centers are going to
see trauma patients in a mass trauma disaster,” he says.
The task force plans to update the Disaster Operations Handbook this
year and periodically thereafter to incorporate lessons learned from disasters
as they occur and the U.S. government’s TOPOFF—for Top Official
Exercises—program, which simulates a large-scale terrorist or bioterror
event about every two years. The AABB task force participated in TOPOFF
3 in April, which consisted of bioterror and chemical attacks in two states.
Each disaster or disaster drill leaves a blueprint for sharpening future
response efforts. The hurricane season of 2004, for one, provided new
learning points for the blood community. “We learned that focusing
on the hurricane’s projected path is a mistake,” Doddridge
says, “because the hurricane can strengthen and change course quickly.”
Instead, disaster planners have to look at the entire forecast track or
cone of uncertainty because a hospital or blood collection center could
be in that path. Hurricanes threaten the hospital’s blood supply
not so much by creating casualties as interrupting collection efforts
before and after.
Experience has shown that hospitals also need to think about how they
will communicate during a disaster, internally and with the blood center
and emergency management agencies. “Cell phones can work in a disaster,
but the circuits typically get overloaded,” says Memorial Hermann’s
Dr. Hartwell. During tropical storm Allison, staff found that some—but
not all—of their cell phones worked. The hospital previously had
dedicated emergency phone lines but has now added mobile intrahospital
phones and two-way radios for emergencies that make it possible for staff
to talk to others in the hospital and the blood center, and for engineering
and security personnel to talk to other emergency command centers in the
city.
The handbook’s preparation checklist advises blood centers to identify
four categories of communication vehicles to be used in a disaster: landline
phones, cellular phones, amateur (ham) radios, and e-mail/wireless technologies
such as the Blackberry.
In a disaster, hospitals have to estimate the number of victims as accurately
as possible and have redundant forms of communication to ensure they can
report their projections to blood suppliers. (The handbook instructs hospitals
with more than one blood center to report the information to the primary
supplier, to avoid communicating duplicative information to multiple blood
collectors.)
The handbook directs blood collectors to calculate the medical need for
blood for a nonbiological event based on three units of type O RBCs per
current and expected hospital admission. In the book is a “hospital
medical needs assessment” to help blood centers and hospitals calculate
the number of units needed during a disaster.
A hospital can estimate the number of casualties it will see in a mass
trauma disaster based on admissions within the first hour. “Half
of patients present to the hospitals within the first hour [after a disaster],
according to the CDC,” Dr. Ramsey says. But he cautions that the
victims who make it to the hospital first may be the less seriously injured
or “walking wounded,” while the more severely injured arrive
later. “And if hospitals aren’t aware of that, they can misproject
their blood needs.”
Blietz notes that the laboratory and transfusion services have to know
what is going on in the hospital emergency department to project the hospital’s
blood requirements accurately. If there isn’t good communication,
the ED staff may assume the hospital has more blood on hand than it does,
and the hospital can lose precious time in reporting its actual needs
to the blood supplier.
The need for blood in a mass trauma in which most victims are killed
quickly can be fairly minimal. “For example, only 258 units of red
cells were used to treat casualties of 9/11, while a half million were
collected,” says Dr. Ramsey, a member of the CAP’s Transfusion
Medicine Resource Committee. By contrast, nonlethal, smaller-scale trauma
can quickly deplete local blood supplies.
The AABB task force, in fact, aims to prevent a repeat of the excessive
collection of blood that took place after 9/11 by coordinating media messages
so the public receives accurate information about the need for donations.
“We realized during 9/11 that the mass collection taxed the entire
system,” Blietz says. “By coordinating the media messages
for future events, blood collectors across the country can more efficiently
manage a surge of donors. For instance, blood collectors would schedule
donations and/or could put out calls for certain types of blood—in
the case of trauma, they’d ask for group O,” he says.
The disaster handbook directs hospital transfusion services to coordinate
messages about the need for blood donations with the blood collector,
which will be in contact with the task force in the event of a disaster.
“The hospital may wish to refer media inquiries to the blood collector
or contact the blood collector for the appropriate message to convey,”
the handbook says.
In biological disasters, blood centers and hospitals may have to quarantine
their existing supplies of blood and defer donors in the area of the outbreak.
“In this case, the AABB task force would work to bring blood in
from other areas of the country to meet the immediate and sustained blood
needs of the affected area,” Blietz says.
With a widespread smallpox outbreak, blood safety would depend in part
on how effectively local public health authorities contained the outbreak.
The handbook addresses bioterror possibilities, including the need for
mass deferral of blood donors because of population exposure.
A radiological disaster would be a worst-case scenario in that administering
whole blood wouldn’t help victims. “Patients with radiation
poisoning develop pancytopenia, which would require emergency bone marrow
transplants to reverse, which goes a little beyond the regular plan,”
Dr. Ramsey says.
Task force members are now digesting lessons learned from the April TOPOFF
3 exercise in which they were responsible for coordinating the blood community
response. The exercise consisted of a simulated pneumonic plague attack
in New Jersey and a blister chemical agent (mustard gas) attack and car
bomb explosion in Connecticut, and a similar explosion in London, England.
(Canadian and United Kingdom officials participated in the exercise.)
For the task force, the latest TOPOFF reinforced that the “amount
of information you have to process and wade through in a mass disaster
is fairly amazing,” Blietz says. “Thus, one of the challenges
is being able to make decisions based on fact and not speculation during
the disaster.”
In addition, the task force, blood bank community, and federal government
are looking at the possibility of a national blood reserve, with the AABB
task force members maintaining a liquid reserve in depots across the nation,
to be deployed quickly to an area of need.
In addition, newly licensed technology by Haemonetics that allows frozen
blood to be used within 14 days after thawing (rather than within 24 hours,
as has been the case) will help stretch the blood supply in disasters,
says Dr. Ramsey.
In Houston, meanwhile, Memorial Hermann Hospital laboratory employees
learned a number of lessons from their own disaster, including the following:
- A disaster plan must be accessible and easy to follow for it to have
any value. Memorial Hermann has developed a short plan that includes
bulleted, easy-to-follow directions. The plan also stages responses—for
example, if the hospital has two hours to evacuate patients, the bullet
points tell staff what to do first.
- Set priorities to save people and blood first. “Just about everything
else can be replaced,” Dr. Hartwell says. “Lab staff know
to try to get the blood to safety even before moving equipment.”
- Think through how your lab’s design will work in a disaster.
In the 2001 flood, Memorial Hermann’s lab staff found some equipment
wouldn’t fit through the doors, for example. The lab, which has
been in temporary quarters since the flood, is designing a new space
that will be an open lab concept for efficiency purposes; a side benefit
is that everyone can see everyone else as much as possible should a
disaster occur.
- Involve front-line staff in the disaster planning. “You can’t
plan on managers being on the premises when a disaster strikes,”
Dr. Hartwell says. “The front-line staff have to know what to
do. The step-by-step, prioritized directions also help them keep their
head in an emergency.”
- Hold disaster drills regularly and fine-tune the plan. The hospital
had practiced its plan, and if the lab had to be evacuated, staff in
each department knew to meet at a designated place to be accounted for,
which prevented unnecessary rescue and search operations. Says Dr. Hartwell,
“It’s difficult to prepare for a disaster you don’t
know and even harder to plan for all disasters. But even a paper drill
where people sit around the table and walk through each step of a potential
disaster scenario can help enormously.”
Karen Lusky is a writer in Brentwood, Tenn.
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