Meeting blood requirements following terrorist attacks: the Israeli experience

Characteristics and Motivational Factors of Whole Blood and Convalescent Plasma Donors during the SARS-CoV-2 Pandemic in Israel

Demands for whole blood (WB) and COVID-19 convalescent plasma (CCP) donations during the SARS-CoV-2 (COVID-19) pandemic presented unprecedented challenges for blood services throughout the world. This study aims to understand the motivating factors that drive WB and CCP donations in the context of the pandemic. This cross-sectional study is based on data extracted from surveys of the two volunteer donor cohorts. The findings reveal that when compared to CCP donors, WB donors were more likely to view donation as a form of social engagement (97.7% vs. 87.1%, p < 0.01), advantageous in the workplace (46.4% vs. 28.6%, p < 0.01), advantageous in their social network (58.6% vs. 47.0%, p = 0.01), and view their donation in the context of positive self-satisfaction (99% vs. 95.1%, p = 0.01). The average age of CCP donors was 7.1 years younger than those who donated WB (p < 0.01). Motivational factors were also analyzed by sex and religiosity. In conclusion, whereas both donor groups showed a high motivation to partake in these life-saving commitments, WB donors were more likely to be motivated by factors that, when better-understood and implemented in policies concerning plasma donations, may help to increase these donations.

Managing blood supplies during natural disasters, humanitarian emergencies, and pandemics: lessons learned from COVID-19

INTRODUCTION

The COVID-19 pandemic has resulted in a historic public health crisis with widespread social and economic ramifications. The pandemic has also affected the blood supply, resulting in unprecedented and sustained blood shortages.

AREAS COVERED

This review describes the challenges of maintaining a safe and sufficient blood supply in the wake of natural disasters, humanitarian emergencies, and pandemics. The challenges, which are accentuated in low- and high-income countries, span the impact on human capacity (affecting blood donors and blood collections personnel alike), disruption to supply chains, and economic sustainability. COVID-19 imparted lessons on how to offset these challenges, which may be applied to future pandemics and public health crises.

EXPERT OPINION

Pandemic emergency preparedness plans should be implemented or revised by blood centers and hospitals to lessen the impact to the blood supply. Comprehensive planning should address the timely assessment of risk to the blood supply, rapid donor recruitment, and communication of need, measures to preserve safety for donors and operational staff, careful blood management, and resource sharing.

Transfusion support during mass casualty events

Transfusion support is an essential element of modern emergency healthcare. Blood services together with hospital transfusion teams are required to prepare for, and respond to, mass casualty events as part of wider healthcare emergency planning. Preparedness is a constant collaborative process that actively identifies and manages potential risks, to prevent such events becoming a 'disaster'. The aim of transfusion support during incidents is to provide sufficient and timely supply of blood components and diagnostic services, whilst maintaining support to other patients not involved in the event.

Exploring Peaks in Hospital Blood Component Utilization: A 10-Year Retrospective Study at a Large Multisite Academic Centre

Peak demand analysis is common in industries such as the energy sector, but can also be applied to the field of transfusion to characterize the nature and timing of peak days in hospital blood utilization. This information can be used to forecast future peak days or to inform hospital emergency preparedness plans. The aims of this study are to characterize peak days in red blood cell (RBC) utilization over the past 10 years at our hospital, and to compare RBC peaks with peaks in platelet, plasma, and cryoprecipitate utilization. This was a retrospective cohort study of RBC, platelet, plasma, and cryoprecipitate transfusions in the inpatient and emergency department setting between May 2009 and April 2019 at a large academic hospital, containing regional trauma and cardiovascular surgery centers. For each blood product, a peak in utilization was defined as a day with a ≥50% increase in the number of units transfused compared to the previous 90-day average. Descriptive and inferential analyses were performed to characterize peak days. There were on average 20,501 RBCs transfused per year and 56 RBCs transfused per day over the 10-year period. A total of 134 peaks in RBC utilization occurred over the study period, with an average of 14 peaks per year. RBC peak days required on average 69% more RBC units compared to nonpeak days (P< .0001). 77% of RBC peaks were caused either solely or in part by surgical bleeding, 34% were caused entirely or in part by trauma, and other causes were infrequent. RBC peaks occurred most often on Fridays and least often on weekends (P< .0001). While there were 134 RBC peaks over the study period, there was a larger number of platelet (n = 292), plasma (n = 467), and cryoprecipitate peaks (n = 579). RBC peak days often coincided with plasma peak days, but less frequently with platelet and cryoprecipitate peaks. More studies are needed to determine whether analysis of peak usage will be of value to hospital blood banks for emergency planning and blood inventory management.

Mass Casualty Shootings and Emergency Preparedness: A Multidisciplinary Approach for an Unpredictable Event

Mass casualty events (MCE) are an infrequent occurrence to most daily healthcare systems however these incidents are the causation for new hospital preparedness and the development of coordinated emergency services. The broad support and operational plans outside the hospital include emergency medical services, local law enforcement, government agencies, and city officials. Modern-day hospital disaster preparedness goals include scheduled training for healthcare personnel to ensure effective and accurate triage for a high-volume of injured patients. This MDT collaboration strengthens the emergency response to optimize the delivery of life-saving care during MCEs. This review identifies the clinical importance of the interdisciplinary team interactions and the lessons learned from past MCE experiences, strengthening healthcare system readiness for such critical incidents.

Blood bank preparedness for mass casualty incidents and disasters: a pilot study in the Piedmont region, Italy

BACKGROUND AND OBJECTIVES

Blood is a critical resource for responding to mass casualty incidents (MCI). The main framework for transfusion preparedness is the American Association of Blood Bank (AABB) Disaster Operation Handbook. A disaster preparedness plan for co-ordinated blood supply was issued in Italy in 2016.

AIM

To assess the level of preparedness of the Transfusion Centers (TS) in the Piedmont region, to evaluate the applicability of AABB checklist and to evaluate the application of the Italian plan.

MATERIALS AND METHODS

We surveyed all the Regional Transfusion Centers (TS) using the AABB checklist, addressing 74 priority action items grouped according to 16 preparedness domains. The Italian 2016 plan has been considered the regulatory cut-off and hospitals were stratified based on the type and the TS workload. A principal component analysis (PCA) was conducted to summarize the variance among centres.

RESULTS

Twenty-one out of 25 TS agreed to participate. Eighty-one % were at high and 18% were at medium level of preparedness. All but two centres were above the cut-off determined by the Italian law. A significant better preparedness was found in medium size hospitals compared to bigger and smaller hospitals. Other than that, the different TS showed a quite homogeneous distribution of preparedness variance.

CONCLUSIONS

This study demonstrated a good level of preparedness in the Piemonte TS, above the Italian law requirements in the majority of TS. The AABB checklist could be used to highlight gaps and needs in the regional TS networks in case of emergency crisis.

Managing the surge in demand for blood following mass casualty events: Early automatic restocking may preserve red cell supply

BACKGROUND

Traumatic hemorrhage is a leading preventable cause of mortality following mass casualty events (MCEs). Improving outcomes requires adequate in-hospital provision of high-volume red blood cell (RBC) transfusions. This study investigated strategies for optimizing RBC provision to casualties in MCEs using simulation modeling.

METHODS

A computerized simulation model of a UK major trauma center (TC) transfusion system was developed. The model used input data from past MCEs and civilian and military trauma registries. We simulated the effect of varying on-shelf RBC stock hold and the timing of externally restocking RBC supplies on TC treatment capacity across increasing loads of priority one (P1) and two (P2) casualties from an event.

RESULTS

Thirty-five thousand simulations were performed. A casualty load of 20 P1s and P2s under standard TC RBC stock conditions left 35% (95% confidence interval, 32-38%) of P1s and 7% (4-10%) of P2s inadequately treated for hemorrhage. Additionally, exhaustion of type O emergency RBC stocks (a surrogate for reaching surge capacity) occurred in a median of 10 hours (IQR, 5 to >12 hours). Doubling casualty load increased this to 60% (57-63%) and 30% (26-34%), respectively, with capacity reached in 2 hours (1-3 hours). The model identified a minimum requirement of 12 U of on-shelf RBCs per P1/P2 casualty received to prevent surge capacity being reached. Restocking supplies in an MCE versus greater permanent on-shelf RBC stock holds was considered at increasing hourly intervals. T-test analysis showed no difference between stock hold versus supply restocking with regard to overall outcomes for MCEs up to 80 P1s and P2s in size (p < 0.05), provided the restock occurred within 6 hours.

CONCLUSION

Even limited-sized MCEs threaten to overwhelm TC transfusion systems. An early-automated push approach to restocking RBCs initiated by central suppliers can produce equivocal outcomes compared with holding excess stock permanently at TCs.

LEVEL OF EVIDENCE

Therapeutic/care management study, level IV.

Going for gold: blood planning for the London 2012 Olympic Games

The Olympics is one of the largest sporting events in the world. Major events may be complicated by disruption of normal activity and major incidents. Health care and transfusion planners should be prepared for both. Previously, transfusion contingency planning has focused on seasonal blood shortages and pandemic influenzas. This article is the first published account of transfusion contingency planning for a major event. We describe the issues encountered and the lessons identified during transfusion planning for the London 2012 Olympics. Planning was started 18 months in advance and was led by a project team reporting to the Executive. Planning was based on three periods of Gamestime. The requirements were planned with key stakeholders using normal processes enhanced by service developments. Demand planning was based on literature review together with computer modelling. The aim was blood-stock sufficiency complimented by a high readiness donor panel to minimise waste. Plans were widely communicated and table-top exercised. Full transfusion services were maintained during both Games with all demands met. The new service improvements and high readiness donors worked well. Emergency command and control have been upgraded. Red cell concentrate (RCC) stock aged but wastage was not significantly increased. The key to success was: early planning, stakeholder engagement, service developments, integration of transfusion service planning within the wider health care community and conduct within an assurance framework.

Defining the need for blood and blood products transfusion following suicide bombing attacks on a civilian population: a level I single-centre experience

INTRODUCTION

Knowledge of patterns of blood use in the care of mass casualty settings is important for preparedness of medical centre resources and for maximising survival when blood supplies are limited. Our objectives were to review of our experience with the use of blood products and define the utilisation of blood transfusion following suicide bombing attacks.

PATIENTS AND METHODS

We conducted a retrospective analysis of blood and blood product transfusion following civilian bombing attacks at a level I trauma centre in Jerusalem, Israel from 2000 to 2005. The study group consisted of 137 patients who were admitted following 17 suicide bombing attacks which were carried out in Jerusalem during the 5-year period. Demographic data, number of units of blood and blood products transfused and the need for massive transfusions were recorded and analyzed.

RESULTS

Fifty-three patients received blood transfusions (38.7%). There were 33 males (62.2%) with a median ISS of 13 (range 4-25). These 53 patients received 524 PRBC, 42 WB, and 449 FFP. The mean number of PRBC transfused/admitted patient was 3.82 units (range 0-59). Thirty patients (21.9%) received 236 PRBC (45% of total PRBC) at the first 2h. The ratio of ordered to transfused blood was 946:524. The FFP:PRBC ratio for all transfused patients was 1:1.17. The number of PRBC transfused per attack correlated with the number of patients admitted per attack. The most commonly transfused blood type was A (52.3%). Only 18 units of uncrossed-matched blood were transfused (3.3% of total). 14 patients (10.2%) received massive transfusions. These patients received 399 PRBC (76.1% of total units transfused) and the average number of PRBC transfused was 28.5/patient (10-59).

CONCLUSIONS

More than 1/3 of casualties admitted following civilian bombing attacks received transfusions, most in the first 2h. Large-scale attacks will require more blood and blood products than small-scale attacks. Twice the number of PRBC ordered than transfused reflects a known trend for over-triage during the initial assessment following bombing attacks. One tenth of patients received massive transfusion.

Hemotransfusion in Combat Trauma

The collaboration of blood transfusion service in the management of severely combat-injured individuals has proved to be an essential factor for the successful treatment of these patients. While the operating and anesthesiology teams are engaged in maintaining the vital signs and controlling blood loss of the injured, the transfusion service representatives follow the information on the amount of blood products given and the latest laboratory tests, as well as provide consultations regarding further blood component requirements on the basis of data obtained. A major effort of the treating team should be aimed at diagnosis and correction of coagulopathy, acidosis, and hypothermia. For the massively bleeding combat trauma injured, which can amount to as high as 8% of all trauma patients, a generous use of plasma at a one-to-one ratio with packed cells, along with the early addition of platelets and cryoprecipitates, should be considered. Early point-of-care thromboelastography is helpful for identification of coagulopathies. The use of a preset massive transfusion protocol is beneficial; however, it should be tailored according to the patient’s actual needs, depending on the type of injury and the individual’s general condition.

Investigating the factors affecting blood donation among Israelis

AIM

This study examined whether the Theory of Planned Behavior adds significantly to the prediction of intention and actual blood donation of the general Israeli population.

BACKGROUND

In most developed countries and in Israel in particular there is a chronic shortage of blood for transfusions. This raises questions about methods of increasing blood donations.

DESIGN

This is a correlational quantitative study.

METHODS

A questionnaire was created based on a review of the literature and the Theory of Planned Behavior. The questionnaire was distributed among a convenience sample of 190 Israeli Jewish men and women, aged 17-60.

RESULTS

Israelis' perceived behavioral control of their blood donations, their subjective norms and their attitude regarding blood donation, predicted their intention to donate blood. It seems that intention predicted actual blood donations. A conspicuous finding is that members of the Ethiopian Jewish community displayed an extremely limited intention to donate blood.

CONCLUSIONS

The results of this study show that a number of various educational and practical strategies may be used to encourage the population to donate blood. These include: reducing perceived barriers, directing interventions specifically at the population most likely to donate blood and forming a reserve of regular donors.

Why would young people donate blood? A survey-based questionnaire study

BACKGROUND AND OBJECTIVES

Different issues associated with blood donation among young donors were studied, towards building a large and consistent blood donor base.

METHODS

Data were collected from 221/285 donors in drives conducted among military personnel (response rate of 78%), through a self-administered questionnaire tailored to review knowledge, beliefs, attitudes and habits regarding blood and general donations. Data were then further analysed using a multivariate model.

RESULTS

The most significant factors related to blood donation were the donors' perception of approval from a superior (the commander's request to donate blood) and the participant's military rank or position (P < 0.0001 and P = 0.0019, respectively). Experienced blood donors comprised 71.9 % of all donors and more donations were noted among men (P = 0.0013).

CONCLUSIONS

The important role of a significant superior, and his or her personal involvement in the blood drive organization was elucidated. Various other factors, previously found to be related to readiness or reluctance to donate blood, were insignificant among the studied population. Our finding may assist blood centres in optimizing their efforts in recruiting and retention of young donors.

Fluids as oxygen carriers and the potential role in trauma resuscitation

Patients with major trauma present a challenge, often using large quantities of banked blood both at the time of injury and during their hospital stay. Blood transfusion is not without risk and is associated with high costs; it is immunosuppressive, rendering patients more susceptible to infection. In the western world, banked blood is fully screened and relatively safe; the same is not true in parts of the developing world, where high rates of HIV carriage make blood transfusion a risky undertaking. Additionally, blood transfusion as a vector for transmission of illnesses such as prion disease is a distinct possibility, for both the developed and developing world alike. The introduction of artificial blood substitutes would ameliorate some risk and also remove the cost of extensive blood testing. For trauma outside hospital, blood substitutes could compete directly with fluid resuscitation as donated blood is not usually available. Patients with prolonged transport times would appear to be the most obvious beneficiaries and volume expansion, along with improvement in oxygen-carrying capacity would be the ultimate goal. All clinicians confronted with the need for transfusion of homologous blood would welcome the development of a safe and reliable alternative to red blood cells in order to ensure oxygen transport to the tissues. However, even though research on red cell substitutes started more than 100 years ago, even now none of the heavily investigated compounds based on haemoglobin or perfluorocarbons has been released in Europe or the USA for routine clinical use.

Clinical review: the role of the intensive care physician in mass casualty incidents: planning, organisation, and leadership

There is a long-standing, broad assumption that hospitals will ably receive and efficiently provide comprehensive care to victims following a mass casualty event. Unfortunately, the majority of medical major incident plans are insufficiently focused on strategies and procedures that extend beyond the pre-hospital and early-hospital phases of care. Recent events underscore two important lessons: (a) the role of intensive care specialists extends well beyond the intensive care unit during such events, and (b) non-intensive care hospital personnel must have the ability to provide basic critical care. The bombing of the London transport network, while highlighting some good practices in our major incident planning, also exposed weaknesses already described by others. Whilst this paper uses the events of the 7 July 2005 as its point of reference, the lessons learned and the changes incorporated in our planning have generic applications to mass casualty events. In the UK, the Department of Health convened an expert symposium in June 2007 to identify lessons learned from 7 July 2005 and disseminate them for the benefit of the wider medical community. The experiences of clinicians from critical care units in London made a large contribution to this process and are discussed in this paper.

Transfusion medicine during the summer of 2006: lessons learned in northern Israel

In July 2006 a Hizballah attack erupted at the Lebanon-Israel border. Reported here is the experience of the Rambam Health Care Campus--a level I trauma center--during 33 days of warfare. Two hundred ninety-five soldiers and 209 civilians were admitted to the emergency department (ED). Forty-eight wounded soldiers (16%) and 12 civilians (6%) had transfusion. Twenty soldiers and 1 civilian had massive transfusions. The ratio between packed red blood cells and fresh frozen plasma (FFP) used for patients who had massive transfusion was 3:2. In these patients, the median prothrombin time international normalized ratio and partial thromboplastin time increased during the first 2 hours after admission from 1.29 to 1.51 and from 33.6 to 39 seconds, respectively. Twenty patients who had massive transfusion survived. Patients with an injury severity score of at least 16 had a higher need for blood products than others, with a lower severity score, with a mean packed red blood cells unit transfusion of 7 vs 4 (P = .03) and FFP transfusion of 13 vs 1.5 (P = .002), respectively. In conclusion, we observed that early transfusion of FFP to casualties with penetrating wounds requiring massive transfusion is needed to overcome the coagulopathy present. The presence of a transfusion service representative on-site in the ED is recommended to ensure proper identification and labeling of blood samples. Real-time consultations provided by a transfusion medicine physician in the operation theater was also found to be essential.