Blood Bank

How I Heard

Terry, above top left: In the early morning of June 12, 2016, I received a phone call from Mark Jones, president of Orlando Health Orlando Regional Medical Center (ORMC). He informed me of a mass shooting in Orlando, and I immediately got ready and headed to the hospital. I knew our Blood Bank would be affected by the incident. When I arrived, I encountered road blocks and police everywhere.  I was stopped by the police, who told me I could not be on campus due to a possible shooter in the Emergency Department who fled to the nursing units. I said I was in charge of the laboratory and needed to get there as quickly as I could. They followed me in with their lights flashing to the main entrance of ORMC.

Lourdes, above top right: Early that morning, I received a phone call from the Blood Bank department at ORMC informing me that a mass casualty was in progress. The team requested help. I didn’t recognize the voice and it took me a few seconds to realize what the person was saying. In the background, I heard the lab assistant saying, “We need help.” I proceeded to call in team members and prepare to report immediately to ORMC. The senior technologist called me minutes later to explain the situation. At this point, I was wide awake. I continued to support the team over the phone and continued to reach out to team members for assistance. I remember waking up my husband and saying, “I need you to take me to work. There’s been a shooting and it is bad and I don’t know when I will be back.” There were two medical technologists on the way to the hospital. I left a message for three other team members, making sure that they understood this was not a drill, this is a mass casualty and I needed them to report to work as soon as possible.

Lori above center: That night I did not have my cell phone in the bedroom, so I didn’t hear it or the home phone ringing. The Blood Bank supervisor, Lourdes Miller, and the customer support lead in the main laboratory had both called to notify me. Later that morning when I checked my phone, I saw a text that said, “My thoughts are with you at this time and hope everything is OK.” I had no idea what that meant. There also was a call from Terry Roberts, corporate lab manager. Just by the calls, I knew something was wrong.  I called Terry and he explained the situation. My first thought was, Oh, no, the blood bank.  The feelings while driving to the hospital were, No way and This can’t be real. Surreal is the word.

Synopsis

Lourdes: At the time, the Blood Bank department was undergoing a major renovation. We had only half the workspace available and only one pneumatic tube station functional. We typically have two pneumatic tube stations available to send and receive products within ORMC and to a sister facility on the same campus.

On a typical Sunday, we dispense on average about 35 blood products and maybe one massive transfusion protocol (MTP). On a busy day we dispense on average 75 to a 100 blood products with two to three MTPs. During the Pulse mass casualty, we had seven MTPs going throughout that day. More than 500 blood products were received and tested/processed by the ORMC Blood Bank. The blood products included RBC units, platelet units, FFP units, Cryo units. The Blood Bank dispensed 441 blood products on that single day.

With the help of a nearby sister facility, the ORMC Blood Bank team was still able to provide routine and stat blood bank laboratory testing and transfusion services for the OR, ED routine transfusion or emergency transfusions, critical care patients and pre-admit surgeries.

Lori: The Blood Bank on a typical day can be very busy with any variety of situations: traumas, surgeries, critical patients and special patient work-ups. The night shift is staffed with the fewest technologists and has a call person in the case of traumas.

One specific memory sticks in my mind from that day: The continuous overhead pages for “Person Down — North Tower” were heartbreaking because I knew someone had just gotten bad news about a loved one.

My other role is Operations Manager for the laboratory phlebotomy team that goes to various inpatient nursing units to collect early morning lab tests. This team reports to the nursing units at 2:00 am. They already were on campus before patients arrived, but they were affected by the “active shooter” overhead pages. This required part of the team on a specific unit to hide in closets and patient rooms. As managers, we need to understand how such massive events can affect team members and consider the possibility of PTSD or existing PTSD that may be triggered.

Preparation

Lori: One advantage for the ORMC Blood Bank is that the team is exceptional at handling multiple MTPs at the same time. Not at the magnitude of the Pulse event, but the skills are used daily by each team member.

Lourdes: The Corporate Emergency Management team participates in the community-wide drills and the Blood Bank is an active part of the response to specific types of emergencies. A drill in March 2016 involved an active-shooter scenario with patients coming in two waves. During this drill, the emergency department sent a test request on paper asking for Type/Screen or Type/Crossmatch. The Blood Bank went through the process of locating the specimens to perform the testing. The exercise allowed us to walk through the process with the information received from the ED. The drills were beneficial not only in defining a process within the Blood Bank, but also in defining the process between the ED and the Blood Bank.  Although it is great practice, the drill does not fully prepare the team for the emotions and stress of the actual event. While it provides a backbone for responsiveness, managers need to be able to improvise as the situation dictates.

Response

Terry: When I arrived, I ran into ORMC’s chief operating officer (COO) and told him I was on my way to the Laboratory Blood Bank. I immediately saw the frantic situation in the Blood Bank, with the technologists moving as fast as they could work up the MTPs. At this point, I still did not know how bad the situation was. I asked the supervisor what I could do. She said to take these MTPs to the Trauma Intensive Care Unit and when I came back to take more to the ED Trauma Room. After that I called the vice president of One Blood, Inc., the blood supplier for the Central Florida area, and said to keep 60 units of blood coming every hour until I told them to stop. They did, until about 6:00 pm. I kept communicating to the team. I went to Incident Command, giving updates of supplies and getting information of what had happened so I could keep my team informed.

Lourdes: We were able to triple our staff from two medical technologists and one laboratory assistant to nine team members in house. As team members arrived, I assigned different tasks to ensure that all were handled and there was no duplication of efforts. Assigned tasks included: receiving blood product (RBCs, PLTs, FFPs and Cryos) into our computer system for tracking; retyping RBC units; irradiating platelet units; and specific patient MTPs. We kept ourselves organized by using clipboards for each of our MTPs. Our planning had to include a replacement team because this was going to last more than 12 hours. We received staffing assistance from our other satellite hospitals. Throughout that day we supported seven MTPs as well as all other blood-product needs. MTPs continued on and off through Sunday night and into Monday, as surgeries were scheduled.

Lori: The laboratory has a corporate model, which means all of the laboratories in the system have the same instrumentation, policies and procedures, as applicable. This was a huge advantage because we could call on the Blood Bank staffs at four additional facilities, during that Sunday and in the following days.

One Blood, Inc. continued to provide unprecedented amounts of blood products throughout the day and evening. The Blood Bank team systematically tested each product, as normal protocol. Several times during the day and evening, there would be a stack of three 2’x 4’ boxes of blood products next to the one technologist doing the validation testing and documenting of the products.

My role during the event was to ensure the team had what they needed to do their job, but also to provide opportunities for them to step away for a break. Terry and I went to the cafeteria and spoke to the managers about getting pizzas and drinks up to the laboratory for the staff to have a meal. The food service managers provided multiple pizzas and water/drinks to our conference room for the team.

Another advantage of a corporate laboratory system is that another facility on our main campus was able to assist in performing the routine blood bank requests for patients not related to the mass casualty. This prevented delays for surgeries or any other patient-care issues. The location and availability of a pneumatic tube system allowed the other facility to assist with the thawing of blood products, which is limited by space and takes approximately 20 minutes. This enabled us to provide units much faster.

Lessons Learned

Lourdes:

• Expect the unexpected. Don’t expect the mass casualty to go exactly like the drills — be flexible. Even though the ED may have experienced two distinct waves of patients, the Blood Bank continuously supported existing patients as the second wave came.
• Have a staff communication plan that will work at any time. This mass casualty occurred during the shift of lowest staffing levels.
• Ensure there is a clear communication plan between the Blood Bank and ED.

Lori:

• Make sure that each shift has a call list with updated phone numbers available.
• Provide routine updates to the staff so they are aware of the situation.
• Have a plan for back-up staff coverage, depending on the length of the event.
• Have a defined contact in the Emergency Department.

What We Changed

Lori: A code for “Mass Casualty standby” was established for emergencies involving more than 5 patients being transported to the Emergency Department. The Blood Bank response to this code is to begin preparing 10 O Pos and 10 O Neg units of Pack Red Blood cells to have available in case emergency release is needed.

Conclusion

Lori: A mass casualty situation of this magnitude was something that never entered my mind here in Orlando. I never imagined that we would use our mass casualty procedures for a mass shooting. The Blood Bank and the supervisor demonstrated great poise and strength during the very active hours early in the incident, as well as through the rest of that week and month. The ED did not have to wait on blood products. There was also a great coordinated effort with our blood supplier, One Blood, Inc.

The established processes in the Blood Bank held strong in a situation that tested the limits. Teamwork between our blood bank and sister departments at the other facilities was beyond expectations.

Lourdes: June 12, 2016, is a day that will never be forgotten because of the lives that were saved and lost. Communication and a plan are keys to success, but the teamwork is the shining star for success. The support from the system’s executives, the community and from other states was overwhelming.

Key Takeaways

Lourdes:

1. Be ready to thaw large quantities of plasma.
2. Staff for 24 hours or more.
3. Have a plan for handling routine work.
4. Plan for getting large quantities of blood products from blood supplier and processing them.
5. Reroute unnecessary phone calls away from the Blood Bank.

Lori:

1. Be prepared for the unexpected.
2. A communication plan is a necessity.
3. Team members care and they are affected by the events that occur around them. They need support and flexibility through and after such events.