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Joint Theater Blood Program Update

Joint Theater Blood Program Update. Major Molly Sloan, MSC, USA LCDR Mike Roth, MSC, USN LTC Rick McBride, USAF, BSC. SAFMLS March 2009. Agenda. OIF Theater Initiatives Historical Transfusions Calculation of MTF Inventories 6- σ training utility in a combat environment

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Joint Theater Blood Program Update

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  1. Joint Theater Blood Program Update Major Molly Sloan, MSC, USA LCDR Mike Roth, MSC, USN LTC Rick McBride, USAF, BSC SAFMLS March 2009

  2. Agenda • OIF Theater Initiatives • Historical Transfusions • Calculation of MTF Inventories • 6- σ training utility in a combat environment • Quality Health Assistance Visits (Q-HAVs) • Whole Blood Collection Capabilities • More utility for 6- σ (for smarter people) • OEF Historical Transfusions • CENTCOM Initiatives • Age of Blood • Frozen Blood • Donor/Transfusion Records Standardization and Consolidation • Platelet Golden Hour Boxes

  3. OIF HISTORICAL TRANSFUSIONS • Overall product transfusions are on a downward trend • Between Jan 2008 and Jan 2009 there was a 84% reduction in the monthly average for all blood products transfused in OIF • RBC transfusions were 21,411 and 11,116 for 2007 and 2008 respectively • Low Period: January 2009 414 Products • Peak Period: March 2008 3610 Products • January 2009 had the lowest blood product usage in OIF since July 2004

  4. OIF RBC TRANSFUSIONS PAST 12 MONTHS

  5. Quarterly Analysis of MTF Inventories

  6. Calculation of 99% C.I. Confidence Intervals: Estimate of the amount of error in our estimates; precision of statistical estimates. We are 99% sure the interval contains the True Population mean. Z-score for 95% CI= 1.96 Z-score for 99% CI = 2.58 Standard Deviation √ N Mean +/- Z –score x Solution = MINITAB!!

  7. Minitab Calculations

  8. PRBC Target Review Process Memo with Data to MED BDE HQs and MNC-I w/No Changes Recommended Brief to MNC-I Surgeon NO End of Month Production Review Target Level Changes? Concur? Staff to TF MED BDE units with blood capabilities NO YES Quarterly Blood Target Review YES Resolve with MNC-I SURG Section Execute Proposed Target Levels *Next review is APR (will cover JAN-MAR) Brief Data with Proposed Changes to MED BDE HQs Concur? NO YES Resolve with BSU, BDE G/S-4 and CLIN OPS Staff to remaining MNC-I customers

  9. Merry Christmas! From Camp Bucca

  10. Blood Services • Packed Red Blood Cells Transfused • April—7 • May— 12 • June— 40 • July--- 10 • Aug--- 10 • Fresh Frozen Plasma Transfused • April—2 • May— 6 • June— 11 • July--- 0 • Aug--- 0 • Other Products Transfused • April---0 • May---0 • June---2 (Whole Blood) • July--- 0 • Aug--- 0

  11. MASCAL Jun 07 Multiple Traumas Oct & Nov 07 Blood Services • Packed Red Blood Cells Transfused • Sep --- 9 • Oct --- 35 • Nov --- 30 • Fresh Frozen Plasma Transfused • Sep --- 0 • Oct --- 6 • Nov --- 1 • Other Products Transfused • Sep --- 0 • Oct --- 0 • Nov --- 0

  12. Quality Healthcare Assessment Visits • December 2007: UK Whole Blood recipients identified • 11 United Kingdom Patients were identified as receiving emergency non-FDA licensed blood products throughout OEF/OIF • 5 Military • 6 Contractor • 51 non-FDA licensed products were transfused from a total of 47 donors • 20 of 47 donor collections had traceable retrospective (EIA) results • 7 of 11 recipients products were negative for all required EIA tests (HIV, HCV, HBsAg, HBc, HTLV) • Four recipients had varying levels of testing on donor samples (see later slides)

  13. Quality Healthcare Assessment Visits

  14. Quality Healthcare Assessment Visits

  15. Quality Healthcare Assessment Visits

  16. OEF HISTORICAL TRANSFUSIONS • Overall product transfusions are on an upward trend • Between Jan 2008 and Jan 2009 there was a 36% increase in the monthly average for all blood products transfused in OEF • RBC transfusions were 5,178 and 6,613 for 2007 and 2008 respectively • Low Period: February 2008 404 Products • Peak Period: August 2008 1282 Products • August 2008 had the highest blood product usage in Afghanistan to date

  17. OEF RBC TRANSFUSIONS PAST 12 MONTHS 31% Increase in Monthly AVG RBC Transfusions from Jan 2008 to Jan 2009

  18. Age of Blood Initiative • Develop course of action for improved red cell manufacture and CENTCOM distribution • Provide fresher blood for trauma patients • Adding at least 7 days shelf life to CENTCOM inventories should theoretically reduce RBC requirements by ~10% • Off-set a potential increase in expiring “older” unused blood

  19. Age of Blood Initiative • Conference held in Sep 2008 • Develop action plan to improve blood product manufacture, labeling, storage and distribution to CENTCOM AOR • Attendees included: • Armed Service Blood Program Office (ASBPO) • CENTCOM Joint Blood Program Office • TRANSCOM Medical Planners • Directors of Service Blood Program Offices

  20. Age of Blood Initiative • Recommendations • Improve blood manufacturing process to insure blood is prepared for distribution NLT 48 hours post collection and arrives at ASWBPL NLT 4 days post collection • Identify and eliminate choke points • Have RBCs arrive in theater by 7th day post collection

  21. Choke Points • Turn around time for testing • Change: Use a combination of regional military/civilian test centers • Only one dedicated mission from ASWBPL to Al Udeid each week • Change: Add a second channel flight on Tuesday (started on 28 October 2008 • Work schedule for 379th Blood Transshipment Center (BTC) Al Udeid • In September 2008, BTC shift hours switched from days to nights to maximize throughput of blood upon arrival at Al Udeid to theater distribution. • In the same 12 hour shift: • Plane delivering blood arrives at Al Udeid • BTC receives, processes and packages the shipment • Outgoing shipment delivered to cargo handling for intra-theater distribution

  22. Inter-modal Distribution Lanes (IDL)CENTCOM – Blood Shipments RBC Tracking: Days of shelf-life remaining 42-36 37-29 32-25 24-18 30-0 RBC Tracking: Days of shelf-life remaining BDC ASWBPL East BTC BSD *MTF CHOKE POINTS RBCs must arrive at ASWBPL NLT Day 7 2-3 opportunities/week 2-3 opportunities/week Channel Mission: Once/week opportunity Sun/Wed BSD Iraq *MTFs JMR As EUCOM ASBBC Mon/Thurs BSD Afghan JMR Needed MTFs JMR FEDEX ASWBPL East TCN BTC Qatar BDCs As Needed Kuwait 24 hrs 48 hrs JMR Mondays Only HOA JMR * Note: BSD Iraq facilitates the rotation of RBCs with ~ 7 days shelf-life from E:II MTFs to major E:III MTFs; it’s difficult to rotate inventory in Afghanistan due to remote locations and aircraft availability. As Needed Bahrain NSA Ships JMR IDL #1 IDL #2 Jan 2008/ajh

  23. Inter-modal Distribution Lanes (IDL)CENTCOM – Blood Shipments RBC Tracking: Days of shelf-life remaining 42-36 37-29 32-25 24-18 30-0 RBC Tracking: Days of shelf-life remaining BDC ASWBPL East BTC BSD *MTF RBCs must arrive at ASWBPL NLT Day 7 2-3 opportunities/week 2-3 opportunities/week Channel Mission: Once/week opportunity CHANGE - 1 CHANGE - 2 CHANGE - 3 REQUIREMENT: Fresher blood needed for optimal care of surgical patient. Course of Action: Identify and Eliminate Chokepoints. Change 1: RBCs must arrive at ASWBPL within 4 calendar days of collection Change 2: Add second weekly flight from ASWBPL. RBCs arrive at Al Udeid (AUAB) within 7 days post collection. Change 3: 379th Expeditionary Blood Transshipment Center (EBTC) AUAB switches work scheduled for facilitate throughput of shipments to theater Blood Support Detachments (BSD). Jan 2008/ajh

  24. Inter-modal Distribution Lanes (IDL)CENTCOM – Blood Shipments RBC Tracking: Days of shelf-life remaining 42-36 35 34-31 28-21 30-0 RBC Tracking: Days of shelf-life remaining BDC ASWBPL East BTC BSD *MTF *MTF RBCs must arrive at ASWBPL NLT Day 4 Fresh Blood (≤14 Days Old) Remaining Shelf Life 3-4 Weeks Channel Mission: Twice/week • OUTCOMES • Provides a window (~7 days) where fresher blood is available at three Level III MTFs (Trauma Centers) • Provides longer dated blood for remote FOBs; easing the resupply mission

  25. AVERAGE AGE OF BLOOD (in Days) UPON ARRIVAL at Al Udeid Air Base

  26. TRAUMA CENTERS % OF RBC TRANSFUSED (AGE in DAYS)NOVEMBER – DECEMBER – JANUARY2007 vs 2008 2007 2008 n = 823 Average Age: 33.5 days Lowest Age: 9 days Highest Age: 42 days % of RBCs transfused that were ≤ 14 Days Old: 11.8% • n = 2931 • Average Age: 35.3 days • Lowest Age: 13 days • Highest Age: 42 days • % of RBCs transfused that were ≤ 14 Days Old: 0.03% February 2009 – 332nd AFTH Balad transfused RBCs that were only 7 days old

  27. TRAUMA CENTERS % OF RBC TRANSFUSED (AGE in DAYS)NOVEMBER – DECEMBER – JANUARY2007 vs 2008

  28. FROZEN BLOOD • Located at BSDs Balad/Bagram • Equipment Validation: August 2008 • BSD staff trained in country: August 2008 • Final Validation: September 2008 • BSDs stocked with O Positive. • O Negative deglyced only upon request

  29. FROZEN BLOOD

  30. FROZEN BLOOD • First Transfusion: 86th CSH Baghdad 07 NOV 2008 • Burn Victim • 3 Units RBCs (1 PRBC, 2 DRBC) • H&H ↑ from 7.4/22.0 to 8.3/25.1 • No adverse effects/complications report • Second transfusion 332nd AFTH BALAD 08 NOV 2008 • IED Injury • 3 Units RBCs (1 PRBC, 2 DRBC) • H&H ↑ from 6.4/19.0 to 9.4/27.5 • Patient had Febrile reaction to PRBCs, but tolerated Deglycerolized Blood with no problems.

  31. FROZEN BLOOD • First U.S. transfusions of Deglycerolized Blood during hostile conflict since Viet Nam • Dutch have been using Frozen Blood in OEF for several years. • All three Level III MTFs have transfused Deglycerolized Blood • As of 17 Feb 2009, 32 units have been transfused by U.S. MTFs.

  32. CENTCOM THEATER ISSUES • Donor/Recipent Records • More fall-out of British Contractor Whole Blood Collection • Records Shortfall • ASBPO Contract • In-theater Work-around • BSDs scan-in Whole Blood “Lot Release Packets”

  33. Implementation of Platelet Golden Hour Boxes

  34. RESUPPLY • 440th BSD Bagram has split the personnel in their unit between Bagram and Kandahar. • Kandahar operates as a BSD in RC South • Al Udeid BTC supplies Kandahar directly • Bagram eliminated as an interim stop • Blood arrives to Kandahar faster and fresher • Restructured BTC shipments • Dry Ice sent twice/week ensuring delivery is spaced equally • Frozen products sent mid-week • RBCs sent twice/week

  35. RESUPPLY • Future Challenges • Temp Tales • Second Channel Flight

  36. New Theater Delivery System • USAMMC-SWA and AFMOA are coordinating efforts to procure the newly proposed theater blood delivery system. • Advantages • Not subjected to challenges associated with weather allowing it to be operated 365 days/year • Particularly useful in OEF during winter months. • Low maintenance • Requires minimal additional training for BSD staff to operate

  37. New Theater Delivery System

  38. QUESTIONS? SAFMLS February 2009

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