November 2018

Testing Blood Shortage Plans in Ontario Hospitals – 2018 Exercise Highlights. How prepared are we?

By: Wendy Owens ART B Comm Program Manager, Allison Collins MD FRCPC Clinical Project Coordinator, Ontario Regional Blood Coordinating Network (ORBCoN) and Vice-Chair and Chair of the Ontario Contingency Planning Working Group.

On May 16th, 2018 at approximately 0900 EDT, Ontario hospitals received a fax notification from CBS signaling that a Provincial Blood Shortage Simulation Exercise was underway. The scenario involved contamination of a lot number of the additive solution in red blood cell units (saline-adenine-glucose-mannitol or SAGM) and resulted in an immediate Red Phase blood shortage across the province. Because the issue was with the additive solution, the shortage, in this scenario, only affected red blood cells and not any other components.

Three CBS centres were involved (Ottawa, Brampton and Winnipeg) along with 157 hospital sites across Ontario. Three CBS teleconferences (one by each of the CBS sites) were held to provide an update to participating hospitals and allow for some discussion on how the exercise was progressing. During these calls it became evident that there was a significant delay from when some hospitals received the initial notification compared to others. Lags up to an hour or more were reported in some regions.

The exercise proceeded throughout that day and into the following day. A Recovery Phase notification was issued from CBS at approximately 1430 EDT on May 17th from both the Ottawa and Brampton facilities but unfortunately was not issued from the Winnipeg site. Therefore, twelve hospitals in the Northwest part of the province were not aware that the exercise had ended until the following day when the post exercise survey was issued from ORBCoN.

During this exercise, the Ministry of Health and Long-Term Care tested out a fairly new provincial communication tool. This tool, the Emergency Management Communication Tool (EMCT), can be used  to share information on an emergent situation rapidly across many facilities. It has the advantage of not being dependent on individual email addresses to relay information as it uses a ‘dashboard’. As long as a person is logged on and monitoring the system, they receive notification of uploads and alerts. The major drawback to this system is that if a hospital does not have a dedicated person monitoring it, the information alerts will not be received. In the post exercise survey we asked hospitals about EMCT and 87% responded that they were now aware of this tool.

One hundred and thirty-nine hospitals reported that they participated in this provincial blood shortage exercise representing 89% of the hospital sites with transfusion services in the province. A total of 93.5% of hospitals that participated in this exercise answered that their hospital has a hospital specific blood shortage plan and 78% had updated it to the most recent version of the Ontario Contingency Plan for Managing Blood Shortages (version 3) released in February of 2017.

As part of the exercise, we asked hospital participants to perform a mock triage on their red blood cell requests during the time that the exercise was ‘live’. About half of hospitals did this and reported that a total of 931 units would have been deferred over this time period. If we estimate the number of units (on average) that would have been transfused in a 30 hour period in Ontario, this would represent about 75% of total red cell use that could have been deferred if we had been in a real Red Phase shortage situation.

Despite only half of hospitals reporting their deferral decisions, this represents a significant decrease in demand that could be achieved if we are faced with a critical shortage of red cells. One respondent commented that after going through the simulation of triage for the exercise, they would review their routine blood use to determine if they could reduce it at their hospital.

It was encouraging that more hospitals appeared to be working together regionally to effectively pool inventory across a number of sites (an example of this is described in the following article). This would facilitate better management of limited resources to help ensure equitable care for patients across a region during a blood shortage.

Table 1 – What progress has been made since our last blood shortage exercise?

*Note: the 2014 Blood Shortage Exercise simulated a shortage of platelets therefore fewer hospitals participated

The biggest take-away from this exercise was that work still needs to be done to improve communication – from the notification process by CBS through to the internal hospital notification and methods used by the MOHLTC to provide updates and guidance during a blood shortage, challenges were reported.

Following this exercise, CBS has begun to investigate an automated solution to address the issues encountered with the fax notification process and the MOHLTC will be discussing how recommendations and guidance provided by the Ontario Emergency Blood Management Committee should be communicated to hospitals during a blood shortage.

Overall, participation in this exercise was overwhelmingly positive and Ontario is doing very well. We should feel very proud of the progress that has been made over the past decade and all the work that has gone into ensuring we will be prepared if we face a situation of severe blood shortage.

On behalf of the Provincial Contingency Planning Working Group, we sincerely thank all of those who participated in the planning of this exercise and took the time to participate and provide feedback. Together we can continue to improve Ontario’s preparedness!

Blood Shortage Mock Exercise – EORLA Experience

By: Hakan Buyukdere MD FRCPC, Alan Tinmouth MD FRCPC, Antonio Giulivi MD FRCPC Hematopathology/Clinical Hematology, The Ottawa Hospital

On May 16-17, 2018 all Ontario hospitals, including 19 acute care hospitals under Eastern Ontario Regional Laboratory Association (EORLA) structure, participated in a province-wide blood shortage mock exercise. This event was led by both the Ontario Regional Blood Coordinating Network (ORBCoN) and Canadian Blood Services (CBS). All participating hospital Transfusion Services received notification from CBS about a red blood cell shortage affecting all blood groups resulting in a red phase shortage. Although it was not the primary method of communication, the provincial Emergency Management Communication Tool (EMCT) was also used to communicate the mock shortage to each hospital.

Following the Provincial Blood Shortage Plan, all EORLA sites then activated their local blood shortage protocols and started adjusting their red cell inventory levels according to the provincial and local emergency blood management plans. The sites which had Emergency Blood Management Committees (EBMC) notified their members and asked them to be available for an emergency meeting, and/or mock triaging of red cell transfusion requests and reviewing surgery lists for possibility of cancellations as outlined in their local plans. For hospitals without an EBMC, the local Transfusion Committee was contacted for similar purposes. Locally, the head of transfusion service or the transfusion committee chair worked with the manager/supervisor of the transfusion medicine laboratory to simulate triage of red cell transfusion requests and review elective surgery lists to determine which surgeries would be cancelled if this was a real situation. All EORLA transfusion services chose to review transfusion requests and surgery lists in real-time rather than performing the review retrospectively. Decisions regarding issuing red cell units and surgery cancellations were documented and then, with the exception of the Children’s Hospital of Eastern Ontario (CHEO), the decisions were sent to the Regional Transfusion Committee Chair at The Ottawa Hospital – General campus. The regional report as well as CHEO’s report were then sent to ORBCoN independently.

Reported results from participating EORLA Transfusion Medicine services indicated there was a total of 272 units of red blood cells ordered during the shortage exercise. Of these, 72 units were for surgical procedures and 200 units were requested for ward patients & outpatients. Of the 87 units ordered for outpatients, 70 would have been deferred in real shortage. Of the 113 inpatient red blood cell requests, 66 units would have been deferred.

Of the 72 surgical blood transfusion requests, 33 units would have been cancelled; 21 of these surgeries were orthopaedic, 8 were abdominal, 2 vascular and 2 abdominal procedures.

On the first day of the exercise, CBS organised a teleconference which gave opportunity to each hospital to express their concerns and feedback.

There were several lessons learned from this exercise:

1- Importance of having Transfusion Medicine committees and/or EBMCs for each hospital and proper designation of roles and responsibilities for each committee’s members. This needs to be reviewed periodically.

2- Effectiveness of current communication channels between CBS and regional hospitals, also between EMCT and local hospitals. A few sites reported short delays in receiving notifications from CBS in comparison to others. We also tested our regional communication among our sites.

3- Benefits of using Provincial and National Emergency Blood Management Guidelines and Toolkits for ongoing guidance.

4- Strategic value of pre-surgical or peri-operative transfusion evaluation by surgical team by analysing patient’s latest Hemoglobin, planned surgical technique and extent of procedure, underlying comorbidities and any previous transfusion history.

5- Deciding when to transfer patients from peripheral hospitals to more central major sites. After close discussions, we all agreed that patient transfers during a real blood shortage should be based on patient’s overall health status rather than their requirement for a blood transfusion. Clear communication on the transfer needs to occur between referring and receiving hospital physicians.

All EORLA sites reported very positive outcomes and member hospitals expressed their gratitude for regional collaboration. Surveys sent by ORBCoN were completed by each EORLA Transfusion Medicine service and reported back to ORBCoN.

We would like to thank all member hospitals for their continuous dedication and commitment to collaborative excellence.