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Joint Theater Blood Program Update

Major Molly Sloan, MSC, USA

LCDR Mike Roth, MSC, USN

LTC Rick McBride, USAF, BSC

SAFMLSMarch 2009

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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

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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

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OIF RBC TRANSFUSIONS PAST 12 MONTHS

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Quarterly Analysis of MTF Inventories

OIF MTF Bld Types Target Inv # JUN JUL

MTF Mixed 200 665 636

week 1     246 143

daily high     119 37

daily low     2 1

week 2     124 159

daily high     38 38

daily low     8 8

week 3     197 120

daily high     54 36

daily low     9 5

week 4     98 214

daily high     27 57

daily low     4 8

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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.

Mean +/- Z –score x Standard Deviation

√ N

Z-score for 95% CI= 1.96Z-score for 99% CI = 2.58

Solution = MINITAB!!

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Minitab Calculations

242322212019181716151413121110987654321

225

200

175

150

125

100

75

50

OCT 07 - MAR 08 Weekly Totals

Transf

usi

ons

133 AVG

115 LI

151 UI

170 Target

124117

56

143

86

161

117

89

205

115

8385

176

142

92

134

182

215

138

90

160

198

152

128

332 AFTH Transfusions

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PRBC Target Review Process

End of Month Production Review

Quarterly Blood Target Review

Memo with Data to MED BDE HQs and MNC-I w/No Changes Recommended

Brief Data with Proposed Changes to MED BDE HQs

YES

*Next review is APR (will cover JAN-MAR)

Resolve with BSU, BDE G/S-4 and CLIN OPS

Concur?NO YES

Target Level Changes?

NO

Staff to TF MED BDE units with blood capabilities

Staff to remaining MNC-I customers

Concur?NO YES

Resolve with MNC-I SURG Section

Execute Proposed Target Levels

Brief to MNC-I Surgeon

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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

0

5

10

15

20

25

30

35

40

45

PRBC FFP Cryo PLT WB

April May June July August

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0

5

10

15

20

25

30

35

40

45

PRBC FFP Cryo PLT WB

April

May

June

July

August

September

October

November

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

MASCAL Jun 07

Multiple Traumas Oct & Nov 07

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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)

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Quality Healthcare Assessment Visits

Patients FWB Plts

Total Products Received

Total Products Requiring

TestingTotal

Resulted%

CompleteRapid

TestingEIA

TestingSC 15 4 19 19 4 21% Y YCH 1 0 1 1 1 100% YMR* 0 7 7 5 5 100% YBS 0 1 1 1 1 100% Y YRS 0 1 1 1 1 100% Y YDR 0 1 1 1 1 100% Y YVM 0 2 2 2 2 100% YPH 0 1 1 1 1 100% Y YWY 6 0 6 6 0 0%PN* 0 6 6 5 1 20% YDW* 3 3 6 5 3 60% Y

Total 25 26 51 47 20 43%

See specific patient comments on upcoming slidesPN and DW = received one set of double plateletsMR = received 2 sets of double platelets

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Quality Healthcare Assessment Visits

Process Audited ISBT-128 Label Procedures

Testing of Whole Blood

Shipping Specimens for Testing of Whole Blood

Collection Release Storage Disposition Look-back Procedures

Totals

Total Applicable Points 10 62 24 68 8 10 6 12 200

Total Survey Points Obtained

Percentage

Rating

Total Critical Points 6 32 18 42 8 6 2 12 126

Total Critical Points Obtained

Percentage Critical Area Compliance

Commendable 100% 10 62 24 68 8 10 6 12 200

Trained 80-99% 8-9 50-61 19-23 54-67 6-7 8-9 5 8-9 160-199

Practiced 65-79% 7 40-49 16-18 44-53 5 7 4 7 130-159

Untrained <64% <6 <39 <15 <43 <4 <6 <3 <6 <129

Critical Tasks 5 26 14 34 6 5 1 10 100

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Quality Healthcare Assessment Visits

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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

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OEF RBC TRANSFUSIONS PAST 12 MONTHS

31%Increase in

Monthly AVG RBC

Transfusions from Jan 2008 to

Jan 2009

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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

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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

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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

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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

Inter-modal Distribution Lanes (IDL)CENTCOM – Blood Shipments

BDCs ASWBPLEast

BTCQatar

HOA

BSD Afghan

BSD Iraq

FEDEX TCN

JMR

24 hrs 48 hrs

RBC Tracking: Days of shelf-life remaining

RBC Tracking:Days of shelf-liferemaining

42-36 37-29 32-25 24-18 30-0

BDC ASWBPL East

BTC BSD *MTF

IDL #1 IDL #2

RBCs must arriveat ASWBPL NLT Day 7

Channel Mission:Once/week opportunity

2-3 opportunities/week 2-3 opportunities/week

Kuwait

Ships Bahrain NSA

*MTFs

MTFs

Sun/Wed

Mon/Thurs

JMR

Mondays Only

As Needed

As Needed

JMR

JMR

Jan 2008/ajh

EUCOM ASBBC

As Need

ed

* 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.

JMR

JMR

CHOKE

POINTS

Inter-modal Distribution Lanes (IDL)CENTCOM – Blood Shipments

RBC Tracking: Days of shelf-life remaining

RBC Tracking:Days of shelf-liferemaining

42-36 37-29 32-25 24-18 30-0

BDC ASWBPL East

BTC BSD *MTF

RBCs must arriveat ASWBPL NLT Day 7

Channel Mission:Once/week opportunity

2-3 opportunities/week 2-3 opportunities/week

Jan 2008/ajh

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).

Inter-modal Distribution Lanes (IDL)CENTCOM – Blood Shipments

RBC Tracking: Days of shelf-life remaining

RBC Tracking:Days of shelf-liferemaining

42-36 34-31 28-21 30-0

BDC ASWBPL East

BTC BSD *MTF

RBCs must arriveat ASWBPL NLT Day 4

Channel Mission:Twice/week

Fresh Blood (≤14 Days Old) Remaining Shelf Life 3-4 Weeks

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

*MTF

35

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

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TRAUMA CENTERS % OF RBC TRANSFUSED (AGE in DAYS)NOVEMBER – DECEMBER – JANUARY

2007 vs 2008

2007• 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%

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%

February 2009 – 332nd AFTH Balad transfused RBCs that were only 7 days old

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TRAUMA CENTERS % OF RBC TRANSFUSED (AGE in DAYS)NOVEMBER – DECEMBER – JANUARY

2007 vs 2008

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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

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FROZEN BLOOD

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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.

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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.

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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”

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Implementation of Platelet Golden Hour Boxes

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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

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RESUPPLY

• Future Challenges– Temp Tales– Second Channel Flight

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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

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New Theater Delivery System

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QUESTIONS?

SAFMLSFebruary 2009