Disaster planning:
  Keeping your blood supply high,

  dry, and flowing

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.”