Transfusion support in mass casualty events: lessons for hospital and pathology preparedness from the Bourke Street Mall incident

An integrated approach that includes a central role for pathology laboratories is necessary

Mass casualty events (MCEs) are defined as events or other circumstances “where the normal major incident response of one or several health organisations must be augmented by extraordinary measures to maintain an efficient, suitable and sustainable response”.1 Haemorrhage is a leading cause of mortality in MCEs, accounting for almost 50% of deaths in the first 24 hours,2,3 and transfusion emergency preparedness is increasingly recognised as a critical element of an integrated approach to MCEs,4 with timely availability and appropriate delivery of blood components being an essential part of management.

On 20 January 2017, an MCE occurred in Melbourne, Victoria, when a car struck pedestrians in the Bourke Street Mall in the central business district, killing six people and injuring more than 30. The injured were taken to various adult and paediatric hospitals around Melbourne, including designated trauma centres and non‐trauma hospitals, both public and private. A Code Brown was activated at some of these hospitals. This is a hospital alert activated internally when notification of an external incident is received, usually by emergency services or health departments, which requires mobilisation of additional capability and capacity within that facility to receive an influx of patients.5

In Victoria, the users of blood products, including public and private hospitals and pathology laboratories, are represented by the Victorian Blood User Group. The Blood User Group meets quarterly with Australian Red Cross Lifeblood (previously Australian Red Cross Blood Service) to discuss issues relevant to the use and supply of blood products. In February 2017, Blood User Group members highlighted concerns with communication during the Bourke Street incident. Poor communication from hospitals to their pathology laboratories was noted during activation of hospital Code Brown alerts. There was also uncertainty and lack of transparency surrounding supply of blood components from Lifeblood to hospitals in Victoria, not only to those involved in the incident but also those awaiting delivery of routine blood inventory.

In response to these concerns, the Blood User Group held a forum in August 2017 to discuss these issues and to make recommendations to assist planning for future incidents. Blood User Group representatives and invited guests, including National Blood Authority representatives, heard presentations from the Victorian Department of Health and Human Services, Lifeblood and four hospitals that received patients, outlining issues and learnings from the incident, followed by further discussion. A summary of recommendations was circulated to forum attendees. This article highlights issues and recommendations pertinent to hospitals and associated pathology laboratories, in particular their haematology and transfusion laboratories.

Recommendations

Pathology staff must form part of hospital critical incident management teams

In some hospitals, the associated pathology laboratory is not part of the critical incident management team, and when these hospitals were notified of the Bourke Street MCE by emergency services, this was only communicated to the pathology laboratory via public address systems or other informal means. Updates received by hospitals from emergency services throughout the event were similarly not always communicated in a planned way. Key pathology representatives in some hospitals also attended their emergency departments in person, which was invaluable for communication but occurred on an ad hoc basis rather than being part of a documented protocol. Without streamlined communication, pathology representatives can often only respond to blood component requests and transfusion specimens when they arrive, leading to potential delays in blood product provision.

As transfusion support remains a core component of management in MCEs, a key recommendation is that pathology staff must form part of any hospital's critical incident management team. This should be documented in the critical incident protocol, and involves active pathology staff participation during critical incidents. Further formalised pathology roles, such as physical attendance at critical sites in the hospital (eg, emergency department) to streamline communication with the laboratory, are also encouraged. This ensures that pathology services receive adequate notification of critical events, and enables direct involvement in ongoing management of the incident in a systematic way with clear lines of communication. It also allows pre‐emptive action such as pre‐thawing of clinical plasma, and review and management of current inventory including appropriate use of emergency blood components.

Implement safe, non‐sequential allocation of unit record numbers for consecutive emergency patients

One hazard noted at the forum was a lack of specific labelling protocols for identifying patients presenting to some emergency departments, resulting in potentially dangerous patient identifiers being used; for example, consecutive unit record numbers for consecutive patients, or the same prefix on all patients. This may facilitate clerical errors and patient misidentification. It is recommended that institutions ensure that allocation of unit record numbers for consecutive unknown patients is performed in a safe way, which minimises the risk of patient misidentification.

Ensure adequate levels of pathology staff familiar with critical event management

Staffing levels were an issue at some sites during the Bourke Street MCE, owing to senior staff being on leave. Similarly, when critical incidents occur after‐hours, staffing is often limited and senior personnel may not be on site, resulting in less experienced staff enacting their critical incident management plans. Extra staff may be required and there may be difficulty of access to workplaces if the incident results in road closures. Working during the incident can be physically and emotionally tiring, and replacement staff will be required after the event.4,6 Therefore, it is recommended that all staff, irrespective of experience, should be familiar with their local critical incident management plan, and that consideration be given to how staffing levels are managed during and after a critical incident.

Include pathology staff in practice disaster scenarios

All hospitals should practise responses to disaster scenarios and involve pathology representatives. During the Bourke Street event, hospitals other than the major trauma centres received multiple casualties. “Walking wounded” may also present at nearby hospitals, irrespective of whether these have emergency departments. Performing practice scenarios is therefore important to familiarise staff with their critical incident plans. Limitations of these scenarios are recognised, as they often do not encompass the practical issues faced by pathology teams, such as time taken to run multiple pathology samples, perform multiple crossmatches and accept into inventory large numbers of blood products. Despite these limitations, it is recommended that hospitals perform practice disaster scenarios and involve pathology staff to highlight areas of potential weakness.

Consider standby phase in Code Brown responses

One hospital activated their Standby Code Brown during the Bourke Street MCE, when it was first notified by emergency services of the possible arrival of casualties, but before patient numbers or severity of injuries were known. This standby phase alerted the critical response areas of the hospital, including the emergency department and pathology services, to an external incident, allowing review of department response plans such as staffing levels and blood product inventory without activating a full Code Brown response. The standby code remained in place until the hospital was advised of further details of presenting patients.

It is recommended that hospitals incorporate such a standby phase in their emergency response plan. This alerts relevant departments to plan and prepare for escalation of an event when a critical incident is first notified to the hospital, but before further details are known or casualties have presented, without activating the full series of Code Brown activities which can be disruptive.

Discussion

Effective communication during MCEs is critical. It is common for many more blood components to be requested than are eventually transfused, and the overall requirement for products in these events is often lower than expected.7,8 Most blood use in MCEs occurs within the first 24 hours, particularly in the first 4 hours as the majority of severe casualties arrive within this time frame.2,7 Therefore, the key to managing these chaotic and rapidly evolving events is early, accurate and ongoing updated communication between emergency services, state health departments, hospitals, pathology laboratories and Lifeblood to ensure that blood components are urgently allocated to appropriate patients while limiting unnecessary ordering and cross‐matching of products.

Local communication between hospital departments and pathology laboratories can be improved by implementing the above recommendations, in particular by involving pathology laboratories in critical incident management. Hospitals may use existing communication channels including email, intranet and paging or other messaging services; however, the protocol for using these should be clearly documented in the critical incident management plan.

Broader statewide communication via health departments and Lifeblood would also allow other health care services to respond appropriately; for example, by managing blood inventory conservatively until the extent and impact of the MCE is known. This requires effective communication between health departments and Lifeblood, and it is imperative that information circulated via state jurisdictions and Lifeblood is consistent to avoid confusion. Forum attendees recommended that the National Blood Authority enable Lifeblood to disseminate information to pathology services through a web‐based blood product ordering system, BloodNet, which is used by transfusion laboratories throughout Australia. Health departments should similarly ensure that existing channels for communicating emergency information to hospitals, such as hospital personnel contact details, are current. Any communication must also be effective outside standard business hours. Fax or email messages are unreliably received after‐hours, and phone contact with appropriate hospital personnel may be more effective.

The Bourke Street Mall MCE highlighted the challenges involved in supplying blood components during such events. The recommendations are similar to those published in a previous review on transfusion preparedness for MCEs4 and recognise the requirement for an integrated approach that includes a central role for pathology laboratories. Incorporating the lessons learnt from this incident will allow for more organised responses and streamlined communications between all departments and institutions.