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
UNCLASSIFIED OIF RBC TRANSFUSIONS PAST 12 MONTHS
UNCLASSIFIED Quarterly Analysis of MTF Inventories OIF MTF Bld TypesTarget Inv #JUNJUL MTFMixed200665636 week 1 246143 daily high 11937 daily low 21 week 2 124159 daily high 38 daily low 88 week 3 197120 daily high 5436 daily low 95 week 4 98214 daily high 2757 daily low 48
UNCLASSIFIED 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= 1.96 Z-score for 99% CI = 2.58 Solution = MINITAB!!
UNCLASSIFIED 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? NOYES Target Level Changes? NO Staff to TF MED BDE units with blood capabilities Staff to remaining MNC-I customers Concur? NOYES Resolve with MNC-I SURG Section Execute Proposed Target Levels Brief to MNC-I Surgeon
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)
UNCLASSIFIED 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
UNCLASSIFIED OEF RBC TRANSFUSIONS PAST 12 MONTHS 31% Increase in Monthly AVG RBC Transfusions from Jan 2008 to Jan 2009
UNCLASSIFIED 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
UNCLASSIFIED 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
UNCLASSIFIED 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 7 th day post collection
UNCLASSIFIED 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 379 th 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 ASWBPL East BTC Qatar HOA BSD Afghan BSD Iraq FEDEXTCN JMR 24 hrs48 hrs RBC Tracking: Days of shelf-life remaining RBC Tracking: Days of shelf-life remaining 42-3637-2932-2524-1830-0 BDCASWBPL East BTCBSD*MTF IDL #1IDL #2 RBCs must arrive at ASWBPL NLT Day 7 Channel Mission: Once/week opportunity 2-3 opportunities/week Kuwait Ships Bahrain NSA *MTFs MTFs Sun/Wed Mon/Thurs JMR Mondays Only As Needed JMR Jan 2008/ajh EUCOM ASBBC As Needed * 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 CHOKE POINTS
Inter-modal Distribution Lanes (IDL) CENTCOM – Blood Shipments RBC Tracking: Days of shelf-life remaining RBC Tracking: Days of shelf-life remaining 42-3637-2932-2524-1830-0 BDCASWBPL East BTCBSD*MTF RBCs must arrive at ASWBPL NLT Day 7 Channel Mission: Once/week opportunity 2-3 opportunities/week Jan 2008/ajh CHANGE - 1CHANGE - 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: 379 th 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-life remaining 42-3634-3128-2130-0 BDCASWBPL East BTCBSD*MTF RBCs must arrive at 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
UNCLASSIFIED AVERAGE AGE OF BLOOD (in Days) UPON ARRIVAL at Al Udeid Air Base
UNCLASSIFIED 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 – 332 nd AFTH Balad transfused RBCs that were only 7 days old
UNCLASSIFIED TRAUMA CENTERS % OF RBC TRANSFUSED (AGE in DAYS) NOVEMBER – DECEMBER – JANUARY 2007 vs 2008
UNCLASSIFIED 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
UNCLASSIFIED FROZEN BLOOD First Transfusion: 86 th 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 332 nd 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.
UNCLASSIFIED 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.
UNCLASSIFIED 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”
UNCLASSIFIED Implementation of Platelet Golden Hour Boxes
UNCLASSIFIED RESUPPLY 440 th 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
UNCLASSIFIED 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