Newfoundland and Labrador Emergency Blood Management Plan For Blood Component Shortages

Transcription

1 Newfoundland and Labrador Emergency Blood Management Plan For Blood Component Shortages

2 TABLE OF CONTENTS Definitions....4 Acronyms Introduction Authority Purpose and Scope Key Participants and Stakeholders Principles and Assumptions Plan Structure Overview Phases of Inventory Availability...7 Framework (of Emergency Blood Management) Plan Actions Required in Response to Phases of Inventory Shortage Green Phase Amber Phase Red Phase Recovery Phase Key Participants - Stakeholders Roles and Responsibilities Canadian Blood Services Minister of Health and Community Services CBS Provincial /Territorial Blood Liaison Committee Member National Advisory Committee Member Provincial Blood Coordinating Program (PBCP) PBCP Blood Reference Advisory Group Provincial Emergency Blood Management Committee Chief Executive Officers Regional Health Authorities Regional/Hospital Emergency Blood Management Committee Patient Advocate Ethics Committee Representative Communications/Public Relations Representative Communications Network Training and Education Page 2 of 27

3 5.2 Testing the Provincial and Regional Emergency Blood Management Plans Ongoing Maintenance of the Plan Conclusion References Supplemental Materials.26 Flow Chart (NL Emergency Blood Management Plan) Toolkit: Emergency Management Plan for Blood Component Shortages Emergency Framework for Rationing of Blood for Massively Bleeding Patients During a Red Phase of a Blood Shortage - Synopsis for Triage Team Page 3 of 27

4 DEFINITIONS For the purposes of this document, the following definitions apply. Blood component(s): a therapeutic part of blood intended for transfusion that includes red blood cell concentrates, platelet concentrates, frozen plasma, cryoprecipitate, cryosupernatant plasma, apheresis components that include apheresis platelets and apheresis plasma. Blood product(s): products prepared from the manufacturing of human blood that includes albumin, immune globulins and coagulation products. Disaster: any domestic disaster or act of terrorism that temporarily restricts or eliminates the Canadian Blood Services ability to provide blood components to its hospital customers or sudden requirements for a much larger inventory of blood components than usual. Short Term Regional Shortages: Events that impact the provincial blood collection center; a local disaster, weather disturbances and/or transportation interruptions that result in a short term gap between supply and demand. Short Term National Shortages: Events that impact more than one Canadian Blood Services collection/production site or a large CBS collection/production site with the potential to negatively impact the national blood supply due to, but not limited to major labor disruption, information system failure that affects testing or traceability of blood components or failure of the transportation network. Prolonged Shortage: Pandemic influenza or other illness that severely reduces blood donor collection and/or Canadian Blood Services personnel, donor criteria/deferral policies that affect a large proportion of eligible blood donors, contracted manufacturer supply problems, and/or prolonged labor disputes that result in a longer term to severe discrepancy between demand and supply. ACRONYMS BRAG- Blood Reference Advisory Group CBS Canadian Blood Services CBS P/T BLC- Canadian Blood Services Provincial/Territorial Blood Liaison Committee CEO Chief Executive Officer CSA Canadian Standards Association CSTM Canadian Society for Transfusion Medicine COO Chief Operating Officer DHCS - Department of Health and Community Services EBMC Emergency Blood Management Committee EBMP - Emergency Blood Management Plan Page 4 of 27

5 ICU Intensive Care Unit MHCS Minister of Health and Community Services MSBOS Maximum Surgical Blood Ordering Schedule NAC National Advisory Committee on Blood and Blood Components P/T Member CBS Provincial/Territorial Blood Liaison Committee Representative PBCP Provincial Blood Coordinating Program PEBMC - Provincial Emergency Blood Management Committee PEBMP Provincial Emergency Blood Management Plan R/H Regional/Hospital RHA Regional Health Authorities TMAG Transfusion Medicine Advisory Group TML Blood Bank or Transfusion Medicine Laboratory 1.0 INTRODUCTION 1.1 Authority The National Advisory Committee on Blood and Blood Products (NAC) was requested by the Canadian Blood Services Provincial/Territorial Blood Liaison Committee (CBS P/T BLC) to develop a national plan to manage blood shortages. A working group was convened and a National Plan for the Management of Shortages of Labile Blood Products has been developed (referred to hereafter as the National Plan). As an adjunct to the National Plan, NAC also convened a working group of experts to develop an Emergency Framework for Rationing of Blood for Massively Bleeding Patients during a Red Phase of a Blood Shortage- Synopsis for Triage Team (a supplement to this document), for dealing with patients who require massive blood transfusions during a Red Phase shortage. Provincial Blood Coordinating Programs, where they exist, have been charged to develop a Provincial Emergency Blood Management Plan (PEBMP) that is congruent with the National Plan in order to provide continuity of service within the provinces in times of severe shortages. Blood components and blood products are supplied to the provinces (except Quebec) and the territories by CBS through voluntary donations from dedicated donors. The availability of blood components and blood products is an essential element of patient care in emergency, surgical and medical settings. The Newfoundland and Labrador Provincial Blood Coordinating Program, consistent with the Program mandate, blood component and blood product utilization, has developed a Provincial Emergency Blood Management Plan. Page 5 of 27

6 1.2 Purpose and Scope In the event that the blood supply is negatively impacted and blood component/blood product shortages are experienced due either to pandemic flu, emergency scenarios, disease, disaster, terrorism, adverse weather conditions, or supply chain issues, a PEBMP is required to ensure that patients have equitable access to essential blood components on the basis of greatest clinical need and the likelihood of survival. Although the plan addresses blood components, blood products may also fit into this plan. The PEBMP is a proactive approach to inventory management which will assist Regional Health Authorities (RHAs) to identify actions to be taken in the event of short term or prolonged regional and national shortages, to ensure that blood components and blood products are available to patients in urgent situations. The PEBMP guides RHAs in maintaining a regional blood shortage management plan. Regional plans should incorporate strategies to address shortages in the event of local disasters including but not limited to industrial accidents. These plans must be shared with the relevant stakeholders. Hospitals require communication and management strategies to respond to such events. The PEBMP guides RHAs in maintaining a regional blood shortage management plan. The Regional Health Authority will notify the PBCP immediately, in the event of any identified short term regional blood supply shortage. This will occur simultaneously with notification of CBS. 1.3 Key Participants and Stakeholders The PEBMP, which aligns with the National Plan, shall be used by the Department of Health and Community Services (DHCS), the Provincial Blood Coordinating Program (PBCP), Canadian Blood Services (CBS) Newfoundland and Labrador Centre, and the RHAs. The PEBMP shall be utilized to assist RHAs in the development of a RHA/Hospital Emergency Blood Management Plan which aligns with the Provincial Plan. The RHA shall be responsible for the maintenance of its plan. Validation of the plan shall occur annually in a mock framework in conjunction with key participants and stakeholders. An Emergency Blood Management Committee (EBMC) shall be formed at the Provincial and RHA/Hospital level to develop and support the EBMP. 2.0 PRINCIPLES AND ASSUMPTIONS The development of the PEBMP is based on the principles and assumptions outlined in the National Plan. The PEBMP has been developed in compliance with the Canadian Standards Association (CSA) Z Blood and Blood Components Standards. Page 6 of 27

7 The PEBMP is based on procedural values of fairness, knowledge, accountability and responsiveness as well as those substantive values of equality, trust, solidarity and respect for human dignity. These statements apply: The PEBMP operates within existing blood system structures, legislative and regulatory frameworks. All efforts to increase the blood supply have been exhausted. Collaboration to ensure allocation of product is optimal and transparent. Ethical principles are identified and adhered to. Previous and ongoing work with the PEBMP is refined and amended regularly. Potential legal liability is acknowledged. All areas of the country served by CBS would be equally affected, while at the same time addressing provincial/regional differences. Acknowledgement of the diversity of Canadian geography and expertise in Transfusion Medicine. The PEBMP is based on the following planning assumptions: CBS will determine the nature and extent of the shortage based on local or national inventory levels. The RHA/Hospital Emergency Blood Management Committee (R/H EBMC) has developed Emergency Blood Management Plans that encompass the four phases of the plan. RHAs maintain compliance with the CSA Standards, Canadian Society for Transfusion Medicine (CSTM) Standards for Hospital Transfusion Services and the Provincial Policy on Blood Component and Blood Product Administration. RHAs invoke Provincial Emergency Blood Management Plans upon declaration of Amber/Red Phase. RHA will notify the PBCP of ongoing shortages or difficulty in achieving minimum inventory levels. 3.0 PLAN STRUCTURE OVERVIEW The PEBMP considers the four phases of inventory availability defined below. Roles and responsibilities of the key participants are described in Section Phases of Inventory Availability The PEBMP considers four phases based on blood component inventory levels Green, Amber, Red, and Recovery. These phases align with the National Plan and shall be maintained throughout RHA/Hospital Plans. The phase may apply to one or more Page 7 of 27

8 components. As well different components may be in varying phases. (e.g. red blood cells could be at Amber Phase while platelets could be at Red Phase). It is also possible to go directly from a Green Phase to a Red Phase depending on real or perceived impacts to the blood supply. Blood conservation strategies should be implemented at the RHA/Hospital level as a means to mitigate a more serious blood component inventory situation. Allocation of blood components in times of severe shortage will be determined by CBS in consultation with National and Provincial/Territorial Blood Emergency Committees. During a Red Phase of blood shortage, reference should be made to the Emergency Framework for Rationing of Blood for Massively Bleeding Patients. FRAMEWORK OF PLAN Phase Inventory Supply Level Hospital Impact and Actions Green Amber Red Normal blood component inventory levels are able to meet demand. Includes range of inventory levels from ideal inventory to periodic temporary shortages. Short term shortage of inventory, may apply to single blood component /group / blood product / lot number or may result from a large unexpected need for products due to local /regional disaster. Inventory levels are insufficient to continue with routine transfusion practice and require measures to reduce blood component usage. Severe and / or prolonged shortage of inventory or imminent severe threat to blood supply. Inventory levels are insufficient to ensure that patients with non-elective indications for transfusion will receive required transfusion(s). Normal utilization activities Report hospital inventory to Canadian Blood Services on product request form. Canadian Blood Services will notify hospitals Order fill rate may be less than 100% of request RHAs must communicate shortages to PBCP if order/fill rate impacts normal operations. Triage blood orders, reduce or delay transfusion activity. Inform Canadian Blood Services of current inventory on request order form Continued shortage may progress to Red Phase Improvements in inventory may progress to Recovery Phase Canadian Blood Services will notify hospitals Order fill rates reduced to levels defined by CBS RHAs must communicate shortages to PBCP if order/fill rate impacts normal operations. Hospital plans must define how to respond to request for decreased utilization Hospitals report inventory levels to Canadian Blood Services on the order request form with each request for product Perform Inter-Hospital Transfer where necessary Page 8 of 27

9 Triage all urgent blood order requests based on prioritization of need and reference to the Emergency Framework for Rationing of Blood for Massively Bleeding Patients during a Red Phase of a Blood Shortage. Recovery Blood component inventories have begun to increase and are expected to be maintained at a level that would enable hospitals to move from Red to Amber and subsequently to the Green Phase or from Amber to Green. Canadian Blood Services will notify hospitals when inventories have returned to normal. Hospitals increase blood usage /activity slowly and gradually increase inventories. Note: Refer to the National Plan for guidelines for use of Red Blood Cells and Platelet transfusions in the various phases. 3.2 Actions Required in response to Phases of Inventory Shortage Green Phase Normal Levels of Activity and Requests for Blood Components Inventories of blood components are sufficient to meet demands. Inventory levels may range from ideal inventory to periodic temporary shortages that can still be managed with collaboration between CBS and hospitals. CBS will develop communication strategies and plans to inform hospital Transfusion Medicine Laboratories when inventories do not meet CBS satisfactory levels. CBS inventory levels for various blood components are defined in the Amber phase and the Red phase of the National Plan. Correspondence from CBS indicating reduction in blood orders must be defined in the plans and communicated to hospital Transfusion Medicine Laboratories (Blood Bank). Hospitals must define minimum/maximum blood inventory levels to ensure normal requests for blood components/products can be met. These may be determined based on historical blood component/product usage and should align with the levels defined by the PBCP based on average daily use. The table below may serve as a guideline where applicable and appropriate. Other blood components have varying acceptable inventory levels to meet the CBS national requirement. Refer to the National Plan. Phase Green Amber Red Inventory Levels for Red Blood Cells Optimal inventory -greater than 3 days average daily use 2-3 days average daily use Less than 2 days average daily use Page 9 of 27

10 Consideration shall be made for transportation and unexpected patient requirements. Inter-Hospital Transfer practices should assist in balancing inventories at each site as well as outdates and discards. RHAs/Hospitals shall have agreements in place to address sharing inventories, outlining policies and procedures for transfer and storage with appropriate documentation that ensure standards are met. Maximum Surgical Blood Ordering Schedules (MSBOS) and a Massive Blood Transfusion Policy are recommended to assist in improving blood utilization. Inventory management tools assist in determining required actions in response to requests for reduction of blood use. During the Green Phase, the RHA/Hospital Transfusion Medicine Laboratory shall develop an internal Emergency Blood Management Plan (EBMP) Amber Phase Inventory shortage may be short term or prolonged Amber Phase implies that inventories of identified blood components are unable to meet routine transfusion requirements in the short term or for a prolonged period. Specific measures may be required by RHAs/Hospitals to address these moderate, extended temporary shortages. The necessity to enact Amber Phase may act as a predictor of a more extensive shortage requiring corrective action to mitigate the shortage. *Note: Amber Phase may be activated in the event of a regionally identified shortage or a CBS identified inventory shortage. The PBCP and CBS shall be notified of a regional/local shortage that impacts normal operations. Official Amber Phase communication will only be initiated by CBS. CBS shall recommend verbally or in writing to the Provincial/Territorial Blood Liaison Committee representative (P/T Member) that PEBMC be convened and determine when the amber phase is initiated based on CBS defined inventory levels. CBS shall notify all hospitals by fax when an amber phase is initiated. Upon receipt of the fax at the hospital, the Medical Director or consultant for Transfusion Medicine Laboratories (Blood Bank) must be notified. The Amber phase of the EBMP must be activated. This shall include: Notification to technical, administrative, medical, and nursing staff of the situation; Reduction and/or monitoring of inventory levels of affected blood group, blood component or blood product; Triage of blood order requests to ensure patients in the most urgent need will receive blood components; Transfer blood components to hospitals with the greatest need; and Delay of elective procedures and non-urgent transfusions including notification to patients and families impacted by delays. Page 10 of 27

11 CBS shall communicate regularly with Transfusion Medicine Laboratories to provide status reports of CBS inventory levels and anticipated recovery times or if inventories are continuing to drop. Once the inventory levels return to optimal levels (Green Phase), the CBS shall notify the Transfusion Medicine Laboratories Services by fax. Hospitals shall report daily inventory levels to the PBCP and CBS. Recovery of hospital inventories should be slow and gradual to ensure overall inventory does not return to shortage levels. CBS shall continue with regular communications to hospitals during this time. If inventory levels fail to recover in the short term, CBS shall make a decision to move from the Amber Phase to the Red Phase. CBS shall communicate in writing to the Provincial/Territorial Blood Liaison Committee representative (P/T Member) that CBS inventory supply level is moving from the Amber Phase to the Red Phase prior to release of communications. Communications and media announcements shall be coordinated by CBS Red Phase Severe shortage of inventory (prolonged or short term) Red Phase implies that inventories of identified blood components are unable to meet requirements for patients in non-elective indications, resulting in deferral and cancellation of elective procedures in order to ensure patients in life threatening situations may have access to required blood components. *Note: Red Phase may be activated in the event of a Regionally identified shortage or a CBS identified inventory shortage. The PBCP and CBS shall be notified of a regional/local shortage that impacts normal operations. Official Red Phase communication will only be initiated by CBS. CBS shall notify hospitals immediately informing them of the change from amber phase to red phase by fax. CBS shall fill orders at rates ranging from 10% to 50% or more. Upon receipt of the fax at the hospital, the Medical Director or consultant for Transfusion Medicine Laboratories shall be notified. The Red Phase of the EBMP shall be activated. This shall include: Notification in writing by the Medical Director of Transfusion Medicine Laboratories or consultant to senior administrative, medical, technical and nursing staff of the situation; Reduction to critical inventory levels of affected blood group, blood component or blood product Triage of blood order requests according to criteria defined in the RHA/Hospital EBMP and/or in reference to the Emergency Framework for Rationing of Blood for Massively Bleeding Patients during a Red Phase of Blood Shortage. Communication between medical staff, Medical Director/consultant of the CBS, and the Medical Director/consultant of the Page 11 of 27

12 hospital Transfusion Medicine Laboratory is necessary to ensure patients in the most urgent need will receive blood components; Transfer blood components to hospitals with the greatest need; and Delay of elective activities and non-urgent transfusions shall include notification to patients and families impacted by delays. CBS shall communicate regularly with Transfusion Medicine Laboratories to provide status reports of inventory levels and anticipated recovery times or advise if inventories are continuing to drop. Once the inventory levels return to normal (Green Phase), CBS shall notify the Transfusion Medicine Laboratories by fax. The Transfusion Medicine Laboratories medical and technical staff should be involved in the communications; Hospitals shall report inventory levels daily to PBCP and CBS. Recovery of hospital inventories should be slow and gradual to ensure overall inventory does not return to shortage levels. Prioritization of need will continue until inventory levels return to normal levels and can be sustained. Scheduling of elective procedures should be gradual so as to prevent a return to shortage levels during the Recovery Phase. CBS shall continue with regular communications to hospitals during this time Recovery Phase Recovery Phase implies that identified blood component inventories are increasing such that transitioning from Red to Amber to Green is anticipated and inventory levels will be maintained at a level which facilitates the resumption of transfusion activities. It is important that during the Recovery Phase at both CBS and the hospital Transfusion Medicine Laboratories, that blood component inventories are carefully monitored and distribution is cautiously managed to prevent a return to an inventory shortage. CBS to facilitate restoration of internal activity through continued communication with RHA/Hospital EBMC containing key messages recommended by the NEBMC. Slowly replace inventory and emergency stock components to levels previously determined as appropriate for effective recovery. Hospitals slowly review and reinstate medical/surgical procedures/transfusions on the basis of urgency on advice provided by the responsible EBMC. Participate in debriefing to review and revise CBS, National, Provincial and RHA/Hospital plans as a process of continued improvement. 4.0 KEY PARTICIPANTS / STAKEHOLDERS ROLES AND RESPONSIBILITIES CBS is the blood supplier for all provinces (except Quebec) and territories in Canada. RHAs including the Department of Health and Community Services are responsible for emergency preparedness, response, and recovery. The PBCPs mandate is to provide Page 12 of 27

13 consultation and communication on provincial blood issues, policy planning and program implementation while supporting transfusion medicine within NL. The Blood Reference Advisory Group acts in an advisory role through the PBCP to the Minister of Health and Community Services. This section outlines the roles and responsibilities of the key participants and stakeholders in the development and implementation of the Plan. Canadian Blood Services (CBS) Provincial Minister of Health and Community Services (MHCS) CBS Provincial/Territorial Blood Liaison Committee Representative (P/T Member) Provincial Blood Coordinating Program (PBCP) PBCP Blood Reference Advisory Group (BRAG) Provincial Emergency Blood Management Committee (PEBMC) Chief Executive Officer (CEO) Regional Health Authorities Regional/Hospital Emergency Blood Management Committee (R/H EBMC) Patient Advocate Ethics Committee Representative/Specialist Communications/Public Relations 4.1 Canadian Blood Services (CBS) CBS is the blood supplier for Canada, with the exception of Quebec. CBS provides blood components and blood products to the province of Newfoundland and Labrador. In the event of a blood shortage, an advisory shall be issued in writing from CBS to the Transfusion Medicine Laboratory Manager/designate in each hospital in the province and to Program Manager of the PBCP at the Department of Health and Community Services. CBS in consultation with the NEBMC also determine the distribution of blood components in accordance with the phase of criticality. 4.2 Minister of Health and Community Services (MHCS) The Minister of Health and Community Services is responsible to ensure the development of a PEBMP to manage blood component shortages including the establishment of a Provincial Emergency Blood Management Committee (PEBMC) and its terms of reference. The PEBMP should be aligned to Provincial Emergency Preparedness Plans. The MHCS shall be notified in writing of all blood shortages other than those that are identified by CBS as short term. A representative of the MHCS shall consult with the CBS Provincial/Territorial Blood Liaison Committee representative (P/T Member) and the PBCP Manager to provide communications and recommendations to the Regional/Hospital EBMC (R/H EBMC). Page 13 of 27

14 4.3 CBS Provincial/Territorial Blood Liaison Committee Member (P/T Representative) The CBS Provincial/Territorial Blood Liaison Committee representative (P/T Member) provides advice and support to the Deputy Minister and Minister of Health on issues affecting the blood system. The P/T member participates on the NEBMC and plays a leadership role in facilitating internal and external communications between stakeholders at both the federal and provincial levels. The P/T member shall have a central role in the establishment of a Provincial Emergency Blood Management Committee. The P/T member shall convene the PEBMC in the event of a blood component shortage. The P/T member shall ensure compliance by testing the plan annually and shall monitor compliance levels within the RHAs. 4.4 National Advisory Committee Member The provincial representative on the National Advisory Committee (NAC) on Blood and Blood Products participates on the NEBMC and may be consulted in the development and implementation of the PEBMP. The Chair of the NAC shall chair the NEBMC. 4.5 Provincial Blood Coordinating Program (PBCP) The PBCP is responsible for the maintenance of the PEBMP by revision and distribution on the PBCP website. The PBCP supports the P/T Member with the development of Provincial and Regional Plans and communications in the event of a blood component shortage. The PBCP will provide representation on the RHA/Hospital Blood Emergency Management Committee (R/H EBMC). The PBCP shall provide the secretariat for the RHA/Hospital EBMC and disseminate communications and recommendations of the RHA/Hospital EBMC to the MHCS and subsequently to the RHAs. 4.6 PBCP Blood Reference Advisory Group The Blood Reference Advisory Group (BRAG) shall serve as active members of EBMC and provide guidance in the decision making processes that may impact the RHAs ability to deal with blood shortages. The BRAG shall also provide support in the development of the RHA/Hospital EBMC and liaises with the Regional Transfusion Committees. 4.7 Provincial Emergency Blood Management Committee (PEBMC) The MHCS is responsible for the development of a PEBMC to work collaboratively with the NEBMC and the RHA/Hospital EBMC. The core membership of this committee shall include the P/T member and Provincial NAC member(s) in addition to the: Director of Acute Health Services and Emergency Response Page 14 of 27

15 Provincial Blood Coordinating Program Medical Advisor, Program Manager, Utilization Coordinator and Transfusion Practice Coordinator Medical Director (VP Medical) of the Regional Health Authorities Clinical Chief of Children s Health Managers of Regional Transfusion Medicine Laboratories Transfusion Safety Officers Medical Director of Canadian Blood Services Canadian Blood Services Director of Product and Hospital Services, and the Hospital Liaison Specialist Terms of Reference shall be established for the committee and shall include: 1. The responsibility to deal with urgent or emergent threats to the blood supply. 2. Development of a response plan in order to minimize the provincial impact of such shortages. 3. The responsibility to work in accordance with the guidelines of the National Plan. 4. Assurance that the decisions and recommendations of the NEBMC are appropriately communicated and adhered to in times of blood shortages. 4.8 Chief Executive Officers (CEOs) Regional Health Authorities The Chief Executive Officers (CEOs) shall be responsible for ensuring that the RHA/Hospital EBMC develops and executes the PEBMP when invoked. The CEOs shall ensure that communication lines include personnel directly impacted by such blood component shortages. The CEOs shall be notified in writing when the Phase of inventory shortage transitions from Amber to Red Regional/Hospital Emergency Blood Management Committee (RHA/Hospital EBMC) The RHA/Hospital EBMC is tasked with the development of the RHA/Hospital EBMP. The Plan shall identify lines of responsibility, decision making processes, and effective lines of communication to enable the RHA/Hospital EBMC to respond appropriately to a blood component shortage. The RHA/Hospital EBMC shall ensure that key stakeholders are represented so that input and decision making strategies required provide the best utilization practices during the time of the shortage. Suggested personnel, consultants, or representatives on this committee should include but are not limited to: Regional Chief Executive Officer /representative Hospital Transfusion Medicine Medical Director/Consultant Page 15 of 27 Manager of Transfusion Medicine Laboratory Transfusion Safety Officer

16 Chair of Transfusion Committee Chief of Anesthesiology Chief of Surgery Chief of Internal Medicine Chief of Critical Care Chief of Hematology/Oncology Chief of Obstetrics and Gynecology Chief of Emergency/Trauma Director of Nursing Risk/Emergency Manager Quality Manager Director of Public Relations Patient advocate Ethics Committee representative Director of Communications / Public Relations The RHA/Hospital Plans shall be based on and comply with the requirements in the National Plan. The standardized phasing system of inventory availability (Green, Amber, Red, and Recovery) shall be adopted by all RHA/Hospital Provincial Emergency Blood Management Plans. The RHA/Hospital EBMP shall be developed during the Green Phase so that it is available should a shortage occur. Minor shortages are usually managed by the Transfusion Medicine Manager and the Medical Director by triaging requests for blood components as they are received. Severe shortages of the blood supply shall be communicated to professional staff outside the Transfusion Medicine Laboratories to ensure a coordinated response to the shortage is achieved through prioritization of the available blood components to patients in the most urgent need. Hospitals within the RHAs in the province shall have a consistent approach to ensure equitable access to supply. The RHA/Hospital EBMP shall have a communication strategy to notify personnel at various Phases of the inventory shortages, notify patients and family impacted by the blood shortage and notify the public. Personnel impacted by the inventory shortages shall become familiar with the Phases and their implications. The Amber Phase may require notification of the Transfusion Medicine Laboratories Medical Director and specific services, such as Emergency, Intensive Care Unit (ICU) or Oncology, but may expand to other services if shortages impact elective procedures. The Red Phase shall require notification to the CEO and all senior Medical and Nursing Staff. A mechanism is needed to define: Categories of patients to prioritize need for blood components Ethical considerations in decision making Triaging blood order requests (pre-defined criteria, use of patient categories, direct medical approval) Monitoring blood component utilization at the Transfusion Medicine Laboratory. Page 16 of 27

17 Daily monitoring of inventory levels supplied by the CBS and Transfusion Medicine Laboratories and communication of information throughout the hospital Blood conservation and transfusion alternatives that may be appropriate to reduce demand for blood and avoid anemia CBS status and possible Phase changes Coordinating surgical schedules related to deferred procedures Prioritization of patients / procedures during Recovery Phase to sustain recovering inventory Communications to hospital personnel, patients and families, and the general public. 4.9 Patient Advocate A patient advocate shall be selected from the blood component recipient community by the RHA/Hospital EBMC to provide input from the patient perspective as it relates to health matters dependent upon transfusion of blood components in either a chronic clinical setting or a surgical intervention setting. The patient advocate shall provide support to the RHA/Hospital EBMC for triage, ethical and the general public perspectives Ethics Committee Representative The Ethics Committee representative shall provide support during a blood shortage where decisions shall need to be made regarding the rationing of blood components. A fair and transparent process based on shared ethical values shall be developed to ensure acceptance and cooperation so that the public understands the values behind the decisions Communications/Public Relations Representative The communications/public relations representative shall be responsible to ensure messaging is consistent and appropriate throughout the various phases of the PEBMP and the RHA/Hospital EBMP. Communications shall be provided internally to Provincial, Regional and Hospital stakeholders in a timely manner. 5.0 COMMUNICATIONS NETWORK Coordination of strong, effective and timely communication is required to ensure prudent management during a blood shortage. Each organization shall work within its own communication infrastructure to promote alignment, consistency and collaboration during a potential crisis. The principal organizations involved in managing a blood shortage are: CBS, Provincial Territorial Ministries of Health, the Provincial Blood Coordinating Program and Regional Health Authorities/Hospitals. Page 17 of 27

18 Core Messages CBS, P/T Ministries of Health and local RHA/Hospitals should have an effective plan in place to ensure the safe, optimal and equitable supply of blood and blood products for Canadians in the event of a blood shortage situation. Core messages for specific jurisdictions are to be determined by provincial/local Plans. Additional Key Messages Additional key message development will be driven by CBS in consultation with the NEBMC according to inventory availability and individual circumstances. To ensure timelines of key message development, a smaller subset of CBS and NEBMC may be called upon to draft communications. Key Audiences Mutual key audiences will include CBS P/T Blood Liaison Committee, the National Advisory Committee, National Emergency Blood Management Committee, Provincial/Territorial Emergency Blood Management Committee and RHA/Hospital EBMCs. Key audiences may vary from Phase to Phase, and each organization will have its own specific key internal and external stakeholders to address. Key operational communication occurs between and among various organizations and internal audiences that include; Canadian Blood Services PTBLC/Health Ministries/RHAs Hema Quebec PHAC Jurisdiction-specific internal audiences determined by provincial and local Plans. Communication of information to external audiences must be coordinated and consistent and occur almost simultaneously. External audiences include; National associations/organizations; Transfusion Medicine physicians, nurses and allied health care workers; Transfusion Medicine and outpatient procedure clinics; Individual patients requiring blood; General public; and Media Page 18 of 27

19 A communications committee, appointed by the RHA Communications Director, shall consist of members representing both internal relations and public relations of the RHA. The committee shall ensure that there is input from all stakeholders (CBS P/T Blood Liaison Committee, the National Advisory Committee, National Emergency Blood Management Committee, Provincial/ Territorial Emergency Blood Management Committee and RHA/Hospital EBMCs); that all Phases of the Plan are considered; established networks for coordination of internal and external messaging are developed; media spokespersons are identified and consistent; and accurate communications material is developed for each Phase of the Plan that includes key messages and frequently asked questions and answers. Recommended Spokespersons Appropriate spokespersons need to be identified at each Phase, based on the shortage situation, the issue and jurisdiction. Provincial spokespeople should be decided by the PEBMC and may include: The P/T Minister of Health or designate P/T Blood Liaison Representative and/or Provincial Blood Coordinating Program Manager Provincial CBS Medical Director and/or NAC member. RHA/Hospital spokesperson(s) may include: Chairs of RHA/Hospital EBMCs RHA/Hospital Transfusion Medicine Directors CBS Medical Directors Public Affairs or Chair of local Emergency Response Team or designate RHA/Hospital spokesperson once briefed by the RHA/Hospital EBMC. Tactics Communication tactics will vary from Phase to Phase and use a variety of existing internal and external communication channels that each partner has at its disposal. The nucleus for all communications must be a common set of key messages that have been developed and endorsed by CBS and NEBMC. Phase Specific Inventory Communications Plan GREEN Phase Information Flow: Limited availability-routine order reduction. No change in clinical practice / No urgent public & media appeal. Although the operational plan only calls for activation of the NEBMC when considering moving to an Amber or Red Phase, activation of the NEBMC should be considered in the Green Phase when shipments to hospitals will be reduced Page 19 of 27

20 across-the-board for a period of greater than or equal to one week, and/or when CBS issues a mass public media appeal for donations. CBS communications about issues and activities related to the national blood inventory will occur through business as usual channels. The PT Blood Liaison will receive relevant information through regularly scheduled meetings and communications. Hospitals will receive information from Hospital Liaison Specialists, CBS Medical Directors and other CBS staff with whom they are typically in contact. Temporary Reduction of Hospital Order Fill Rates In the event of temporary reduction of hospital order fill rates, CBS will communicate to hospitals through business as usual channels. Should this situation extend greater than one week the following process is recommended: 1. CBS will communicate updated information through business as usual channels if no change in hospital inventory management practice is recommended. 2. Inventory updates will be distributed to P/T BLC, hospitals and other stakeholders via CBS business as usual channels. 3. These updates will be shared with the NEBMC members on a for your information basis. The CBS Chief Operating Officer (COO) will consult with the NEBMC Chair should the situation persist to convene the NEBMC prior to going to a public appeal for donors or discussing the potential of an Amber Phase to determine if there are changes to hospital inventory management practice which can assist with and/or improve the situation internally. Public Appeal for Donations In the event of a media appeal the following procedure should guide the information flow: 1. CBS COO advises NEBMC Chair that CBS will be issuing a public appeal within hours. 2. NEBMC Chair can offer input to CBS COO on actions. 3. CBS produces Inventory Alert with Key messages. 4. NEBMC Chair shares information with NEBMC members. 5. CBS cascades messaging to its stakeholders (P/T liaison committee, hospitals, patient groups, donors) via business as usual channels. Page 20 of 27

21 6. NEBMC members share with their PEBMC. 7. PEBMC share with RHA/Hospital EBMC (if applicable). AMBER Phase (Serious) Information Flow: CBS or the RHA identify a shortage situation and escalate communication accordingly. CBS contacts the NEBMC Chair to convene a meeting of the NEBMC. NEBMC Chair calls a meeting of the NEBMC and designates via the use of , text messaging, fax and telephone fan-out call to reach members of the NEBMC within 24 hours. It is critical that confirmation of message receipt is achieved or another method of communication must be used until confirmation is obtained. The CBS COO with counsel from the NEBMC makes the final determination of the Amber Phase. The CBS COO and the NEBMC Chair will meet at a minimum weekly during an Amber Phase and when going into and out of each Phase. For updates and information between meetings that does not require a decision by the NEBMC, electronic memorandum will be distributed to the members from the NEBMC secretariat. Regular updates of all NEBMC decisions will be available for public members and NEBMC members on the NAC website. Hospitals will receive inventory bulletins. The NEBMC members will cascade communication decisions which are summarized and formulated by NEBMC Chair and CBS COO at the end of each teleconference to the PEBMCs and CBS internal and external stakeholders. Key messages from CBS should focus on the state of the inventory, a confirmation of the Phase, mitigation efforts being made to address the situation and when the group can expect further communication. Key messages from the NEBMC should focus on the impact on clinical practice and transfusion protocols, and the counsel being made to the Provinces, RHAs and hospitals on how to best triage the limited supply of blood they have available through existing hospital supplies, and supply expected from CBS. Cascading Communication The NEBMC will be the conduit to the PEBMC, via Inventory Alert. It is imperative that those involved in managing the shortage (CBS, NEBMC, PEBMC, RHA/Hospital EBMC) are informed prior to external outreach to stakeholder groups and media. Page 21 of 27

22 Process: 1. NEBMC approved key messages are distributed to the entire NEBMC, which includes the CBS representatives on NEBMC. 2. In parallel, key messages will be circulated to: 2.1 Key divisions and departments at CBS, including Business Continuity Infrastructure. CBS will communicate inventory status only (hospital action is to be communicated by the PEBMC) to hospitals via fax, and/or text messages. If available, other channels of information dissemination may be required to ensure communication has been received. 2.2 The Provincial/Territorial Emergency Blood Management Committee via either the P/T Blood Liaison Committee Representative or Provincial NAC representative or PBCP Manager. 2.3 The RHA/Hospital EBMCs via the PEBMCs. 2.4 The PEBMC will be given 8 hours to cascade information, after which time CBS will begin outreach to external stakeholder groups, donors and the media if appropriate. RED Phase (Critical) Information Flow CBS or the RHA identify a shortage situation and escalate communication accordingly. CBS contacts the NEBMC Chair to convene a meeting of the NEBMC. NEBMC Chair calls a meeting of the NEBMC and designates via the use of , text messaging, fax and telephone fan-out call to reach members of the NEBMC within 4 hours. It is critical that confirmation of message receipt is achieved or another method of communication must be used until confirmation is obtained. The CBS COO with counsel from the NEBMC makes the final determination of the Red Phase. The CBS COO and the NEBMC Chair ideally meet daily, at a minimum twice weekly unless there is consensus of the NEBMC to delegate meetings to a smaller subset of the NEBMC which must at a minimum include the NAC Chair and CBS COO. Page 22 of 27

23 For updates and information between meetings that does not require a decision by the NEBMC, electronic memorandum will be distributed to the members from the NEBMC secretariat. Regular updates of all NEBMC decisions will be available for public members and NEBMC members on the NAC website will be provided. Hospitals will receive inventory bulletins. The NEBMC members will cascade communication decisions which are summarized and formulated by NEBMC Chair and CBS COO at the end of each teleconference to the PEBMCs and CBS internal and external stakeholders. Key messages from CBS should focus on the state of the inventory, a confirmation of the Phase, mitigation efforts being made to address the situation and when the group can expect further communication. Key messages from the NEBMC should focus on the impact on clinical practice and transfusion protocols, and the counsel being made to the Provinces, RHAs and hospitals on how to best triage the limited supply of blood they have available through existing hospital supplies, and what is expected from CBS. Cascading Communication The NEBMC will be conduit to the PEBMC, via Inventory Alert. It is imperative that those involved in managing the shortage (CBS, NEBMC, PEBMC, RHA/Hospital EBMC) are informed prior to external outreach to stakeholder groups and media. Process: 1. NEBMC approved key messages are distributed to the entire NEBMC, which includes the CBS representatives on NEBMC. 2. In parallel, key messages will be circulated to: 1. Key divisions and departments at CBS, including Business Continuity Infrastructure. CBS will communicate inventory status only (hospital action is to be communicated by the PEBMC) to hospitals via fax, and/or text messages. If available, other channels of information dissemination may be required to ensure communication has been received. 2. The Provincial/Territorial Emergency Blood Management Committee via either the P/T Blood Liaison Committee Representative or Provincial NAC representative or PBCP Manager. 3. The RHA/Hospital EBMCs via the PEBMCs. 4. NAC website Members Section will be updated as new information is available Page 23 of 27

24 3. The PEBMC will be given 8 hours to cascade information, after which time CBS will begin outreach to external stakeholder groups, donors and the media if appropriate. Newfoundland and Labrador Specific Cascading Communications: 1. CBS or the RHA identify a blood shortage situation. 2. In the event of RHA/Hospital identified inventory shortage, the RHA/Hospital simultaneously notifies the PBCP and CBS. 3. CBS contacts the RHA/Hospital Emergency Blood Management Committee via fan out protocol (fax, or phone calls). 4. RHAs /hospitals report physical inventory to CBS and the PBCP within 2 hours of alert for each site, not using consolidated reports. 5. Inventory may be re-directed to other sites. Hospitals need to be prepared. 6. RHAs/Hospitals prepare to reduce transfusion requests and services. 7. RHA report status to CBS and NL PBCP. 8. Fax information must be acknowledged; communications have to be signed and returned to sender. RECOVERY Phase: 1. Recovery from Red to Amber: A meeting with NEBMC will be called to determine if the situation warrants upgrading to the Amber Phase. Communication to EBMC groups and other stakeholders will follow the communication process for the Amber Phase. 2. Recovery from Amber to Green: A meeting with NEBMC will be called to determine if the situation warrants upgrading to the Green Phase. Communication to EBMC groups and other stakeholders will follow the communication process for the Amber Phase. Subsequent communications will follow the process outlined in Green Phase. During this phase it is critical that all those involved in Emergency Blood Management at the national, provincial and RHA/Hospital level remain engaged and use consistent coordinated communications until the return to business as usual. Debriefing and Lessons Learned Within 48 hours or two working days of return to Recovery Phase, the RHA and the Provincial Blood Management Committees, and CBS will conduct debriefing to clarify and consolidate insights and lessons learned during the inventory Page 24 of 27

25 shortage. Findings from all Committees will be disseminated to stakeholders at the RHAs, the Provincial Blood Coordinating Program, and CBS. 5.1 Training and Education Staff training and education related to the RHA/Hospital EBMP and its relationship to the Provincial/National EBMP shall be the responsibility of the RHA/Hospital EBMC. 5.2 Testing the PEBMP and the R/H EBMP The Provincial Blood Coordinating Program shall facilitate the coordination of a date annually to test both the PEBMP and the RHA/Hospital EMBP. Testing shall be conducted in collaboration with the Department of Health and Community Services, Canadian Blood Services and the Regional Health Authorities and designated hospitals. A date suitable to all parties must be determined and the date filed with the Provincial Blood Coordinating Program six months in advance of the test activation of the EBMP. A final debrief report will be sent to all collaborators and NEMBC. 5.3 Ongoing Maintenance of the Plan The Provincial Blood Coordinating Program, in conjunction with the Regional Health Authorities and in consultation with Canadian Blood Services, is responsible for the annual maintenance and update of the PEBMP based on revisions to the National EBMP. The PBCP shall communicate revisions to the PEBMC and subsequently to the RHA/Hospital EBMC in order to revise/update the RHA/Hospital EBMP to ensure consistency across Regional Health Authorities. Regional Health Authorities shall collaborate with the Provincial Blood Coordinating Program to ensure that revised regional plans fit within the Provincial and National Plans. 6.0 CONCLUSION The Provincial Emergency Blood Management Plan shall be developed and followed in the event of blood shortages to ensure that patients who are most in need of transfusion will receive the blood components required in a fair and equitable manner in a safe health services environment. Page 25 of 27

26 7.0 REFERENCES American Association of Blood Banks, (2008). Disaster Operations Handbook Hospital Supplement, Coordinating the Nation s Blood Supply During Disasters and Biological Events. Retrieved from: British Columbia Provincial Blood Coordinating Office, (2009). Blood Contingency Project Plan. Retrieved from: Canadian Blood Service, (2007). CBS Blood Inventory Management Best Practices Guide. Retrieved from: ources/resourcelibrary/$file/blood_inventory.pdf Canadian Standards Association (2010). Standards for Blood and Blood Components CSA Z Mississauga, ON: Author. Ethical Issues in Transfusion Medicine. Macpherson CR, Domen RE, Perlin T. AABB Press, Bethesda, Maryland, National Advisory Committee on Blood and Blood Products (2012). National Plan for the Management of Shortages of Labile Blood Components. Retrieved from final.pdf Nova Scotia Provincial Blood Coordinating Program (2010). Nova Scotia Provincial Blood Contingency Plan. Retrieved from Transfusion Ontario Program, (2012). Ontario Contingency Plan for Management of Blood Shortages, Version 2. Retrieved from n_blood_shortages.pdf 8.0 Supplemental Materials NL Emergency Blood Management Plan Flow Chart Toolkit (EBMP for Blood Component Shortages) Emergency Framework for Rationing of Blood for Massively Bleeding Patients During a Red Phase of a Blood Shortage--Synopsis for Triage Team Page 26 of 27

27 Newfoundland and Labrador Emergency Blood Management Plan Page 27 of 27