Emergency blood management arrangements, NHSGGC policy

The overall aim of the Emergency Blood Management Arrangement (EBMA) is to ensure prompt reaction to a national blood shortage.

The main aims are to ensure:

• Blood is available for all essential transfusions to patients equally across Scotland.
• National pool of blood is available to support essential transfusions.
• Overall blood usage is reduced to ensure that those patients with the greatest clinical need are treated.

The plan deals only with a shortage of red cells. SNBTS is currently defining the stock levels in relation to the blood shortage plan as:

It is envisaged that this plan could be activated under a variety of circumstances including:

• Blood shortages resulting from short lived events such as bad weather. Following an outbreak of Influenza. Implementation of security measures that adversely affect blood donation. The introduction of additional measures designed to reduce the risk of Transfusion Transmitted Infections.

A key principle of the plan is that the incidences of blood shortages can be significantly reduced by optimising blood usage, avoiding inappropriate transfusions and reducing wastage.

• The Green phase applies to “normal” circumstances when blood supply meets demand. Hospital actions in this phase relate to the successful implementation of the Better Blood Transfusion Team, which is coordinated by the Hospital Transfusion Committee (HTC). The key principle in this phase is that blood shortage can, in most cases, be avoided by reducing current usage of blood.
• SNBTS continually monitors blood stocks and takes appropriate action to maintain these. However, if blood stocks fall, SNBTS will take action to increase collections from donors. If these actions prove unsuccessful, SNBTS will declare a blood shortage and communicate a move to the Amber or Red phase.

• The SNBTS trigger point for amber is currently set at approximately two days stock. This may apply to a single blood group or to all blood groups.
• The stockholding of blood in hospitals, according to wastage rate status, will be immediately reduced to approximately 67% of the average stockholding and of the percentage reduction in usage required will be achieved by reducing ordering to replace stock to the lower level.
• If the shortage is more prolonged, SNBTS will communicate the need to reduce usage. 
• Where the required reduction in usage will exceed that which could be achieved through the efficient use of blood in accordance with the BBT measures the EBMG may have to consider cessation of procedures for patients in Category 3. (see Table1 for more details)

• SNBTS will declare a red level shortage if there is a severe, prolonged shortage of blood, e.g. a 50% loss of donors, or, if an imminent severe threat of blood supply is identified.
• SNBTS will communicate the required actions which in the first instance will be to reduce stockholding in hospitals to approximately 40% of the normal stockholding level. This may be accompanied by a further reduction in usage. In this case, it is likely that only patients in Category 1 (see Table 1 for more details) of the categorization of clinical need will be treated.

The EBMG is responsible for:

• Reviewing, updating and amending the plan and following any blood shortage incident.
• Considering the impact on the arrangements of new guidance, procedures and recommended changes as a consequence of national guidance, incident reports or judicial enquiries.
• Activating the plan in times of blood shortage and ensuring the hospital meets the required reduction in blood usage.
• Ensuring 24/7 availability of themselves or a deputy.

Emergency Blood Management Group Members and Deputies –Pan Glasgow

 EBMA group members and deputies for individual hospital sites see (Appendix 2)

ACTIVATION OF EBMA BY SNBTS

The SNBTS will inform the hospital Transfusion Laboratory that the national blood stocks have reduced to the level where hospitals should implement their Amber or Red status contingency plan. The communication will indicate that stocks should be reduced to the pre-determined level & whether a percentage reduction in usage is required. The Transfusion Laboratory Manager or deputy will immediately contact the Consultant Haematologist with responsibility for Transfusion.

SNBTS will also notify the pan Glasgow EBMG group who would then send off pre determined e-mail informing all clinical staff of the blood shortage status (Appendix 3). The EBMA group will notify the Chief Executive and the Medical Director, who will notify relevant personnel. 

ACTIVATION OF HOSPITAL ARRANGEMENTS

The Consultant Haematologist will authorise the activation of the Hospitals Amber EBMA and initiate the communication cascade (see Appendix 1). The Consultant Haematologist will confirm the time for the first EBMG meeting and inform the chair of the EBMG who will contact all members regarding the shortage status and the time of the first meeting of the EBMG.

• Flowcharts outlining the hospital plan are shown in Figure 1. Arrangements must be in place for this to operate in and out of regular hours. The process is the same for both Amber and Red.
• The critical difference between Amber and Red is the clinical prioritisation of patients. In order to simplify the management of this process, national guidance has been provided which suggests dividing patients into three broad categories. See table 1 below:

Table 1. Guidance for red cell use:

*Emergency – patients likely to die within 24 hours without surgery

** With the exception of poor risk rupture aortic aneurysm patients who rarely survive  but may require large volumes of blood                       

*** Urgent – patient likely to have major morbidity if surgery not carried out

**** Planned stem cell transplant or chemotherapy should be deferred if    possible

It is advised that senior clinicians be involved in the decision to use blood during shortages and provide guidance to their staff. In the Red phase – all requests will require approval by Consultant staff.

REVIEW OF REQUESTS FOR BLOOD COMPONENTS

All requests for blood components will be reviewed by Blood Bank staff and assessed using the information given on the request form.

Blood Bank staff will review the request and prioritise the issue of blood following discussion with the Haematologist and take into consideration:

• The Hospitals Maximum Surgical Blood Order Schedule (MSBOS)
• Patient category (Categories 1-3 table 1)
• Blood group of the patient and availability of compatible blood
• Need for additional platelet and plasma support
• Referral to Haematologist as required

In the event of difficulties in decision-making the Consultant Haematologist (or EBMG chair) will be the final arbiter. 

The roles of the different staff groups are summarised below.

SNBTS

Responsible for:

• Provision of relevant and timely information of shortage status to Blood Bank via fax.

LAB MANAGER OR DEPUTY

Responsible for: 

• Informing Consultant Haematologist of shortage status.
• Assisting with roles described for Blood Bank staff.

CONSULTANT HAEMATOLOGIST

Responsible for:

• Informing Chair or Deputy of EBMG of shortage status.
• Initially (i.e. before the EBMG sits), reviewing and restricting outstanding requests for transfusion in conjunction with the Laboratory Manager/ Local Blood Bank Managerand with input from the Chairman of the EBMG if required.

CHAIRMAN/DEPUTY OF THE EBMG

Responsible for:

• Informing members of the EBMG of the shortage status.
• Chairing the EBMG.
• Monitoring of the integrity of the plan.
• Acting as an advisor in the formulation and maintenance of the plan.
• Making final decisions where areas of conflict exist.
• Review impact of shortages.
• Collating lessons learnt.
• Producing the final report following recovery to normal service.

BED MANAGEMENT TEAM

Responsible for:

• Leasing with the Consultants/Divisional operations staff to stop elective admissions based on clinical priorities and potential blood requirements.
• Collection and correlation of cancelled operations and feedback of this information to Duty Managers

DUTY CONSULTANTS

Responsible for:

• Reviewing and restricting blood requirements as per algorithms, MSBOS and EBMA criteria.
• Liaising with relevant members of the clinical and management teams.
• Feedback to Bed Management Team re clinical priorities/cancellations of patients.
• Feedback regarding the impact of restrictions to EBMG via Surgical and Medical representatives.

BLOOD BANK STAFF AND TRANSFUSION PRACTITIONERS

Responsible for:

• Return of blood from satellite fridges that have reached the 12-hour dereservation period.
• Production, maintenance and control of a current log of bloodstocks, detailing group and age of units and provide this information at the EBMG.
• Collation of blood requirements as received in the laboratory prior to the EBMG. To prioritise these with reference to time required. For requests required prior to the EBMG meeting, to provide supporting evidence of appropriateness of request i.e. whether patient is bleeding, Hb level etc, and present this information to the Consultant Haematologist.
• To make available a meeting room for the EBMG on a daily basis during shortage and contact all members of the EBMG and notify them of the details of the meeting.

• On recovery from shortage, SNBTS will inform the Transfusion Laboratory that stocks have risen to a level where hospitals can move to AMBER or GREEN status.
• Local EBMGs will inform the pan Glasgow EBMG when stocks have returned to normal and they will inform the Chief Executive and Medical Director.
• The SNBTS will adopt a phased return to normal issue levels.
• The Hospitals will adopt a phased return to normal activity levels; in particular, elective surgery backlogs should not be compressed into the immediate post recovery period.
• The EBMG will convene to review the effect of the blood shortage and amend the Emergency Blood Management Arrangements as necessary.

Emergency Blood Management Group Members and Deputies

WIG/GGH

*Mobile numbers only to be used for EBMA

GRI

Yorkhill

VIC/ SGH

Clyde

To all staff in GG&C :

National blood stocks have fallen to very low levels and unfortunately it has become necessary to implement the National Emergency Blood Management Arrangements (EBMA) with immediate effect.

These detail restrictions in blood use that are required and will be co-ordinated by the hospital’s Emergency Blood Management Group (EBMG) which will oversee implementation of the arrangements. Further information will follow but each individual must play their role in carrying out the plan and ensuring that blood supplies are maintained for the most essential transfusions.

Staff will be kept up to date with the situation and will be informed when the shortage is over.

Yours sincerely

On behalf of the Emergency Blood Management Group.