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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