Emergency preparedness, resilience and response guidance for UK hospital transfusion teams

Abstract Objectives To present Emergency Preparedness, Resilience and Response (EPRR) guidance for Hospital Transfusion Teams on behalf of the National Blood Transfusion Committee emergency planning working group. Background The Civil Contingencies Act 2004 requires healthcare organisations to demonstrate that they can deal with major incidents while maintaining critical services. Recent mass casualty events and the use of transfusion‐based resuscitation have highlighted the evolving role of the Hospital Transfusion Team. Methods This multi‐disciplinary advice is informed by recent global and national experience, the 2018 NHS England clinical guidelines for Major Incidents, and stakeholder workshops. Guidance Transfusion staff should be familiar with local EPRR plans including casualty type and numbers. Staff should be exercised as part of wider Trust preparation, with documented roles and responsibilities. Transfusion support should be proactive and include blood issue, regulatory compliance and sample handling. Robust LIMS‐compatible emergency identification systems are essential to minimise errors. Emergency stock management requires rapid assessment of existing stock and estimated demand before re‐ordering. Initial demand should be based on 2 to 4 red blood cells (RBC) per patient admitted. Patients with significant haemorrhage may require further red cells and early haemostatic support. Where “universal” components are demanded, they should be gender appropriate. Senior staff should lead the response, log and communicate key decisions, and prepare for post‐incident recovery. Conclusions Transfusion teams have an important role in ensuring continuity of transfusion support. Teams should develop their EPRR plans based on local plans and national guidance. Emergency preparedness should include post‐incident debriefing for ongoing staff support and future service improvement.


| BACKGROUND
The Civil Contingencies Act 2004 1 requires NHS organisations and the providers of NHS funded care to demonstrate that they can deal with major incidents while maintaining critical services. The healthcare community refers to this national programme of work as emergency preparedness, resilience and response (EPRR). 2 The programme is overseen locally by the NHS England regional EPRR teams and together with global events, have highlighted the need to revisit national transfusion emergency preparedness. 3 The group was reconvened in late 2017.
In 2018, new clinical guidelines for use in Major Incidents and MCE were developed by NHS England following a period of multiple incidents. 4 The incidents had presented a range of challenging clinical scenarios, such as blast injury and penetrating injury, unlike those seen in day-to-day practice. The organisational guidance and care pathways were developed to establish and share best practice using recent experience from both military and civilian healthcare. Transfusion support is now recognised as an essential element of modern trauma resuscitation with a move to earlier use of blood in major trauma. 5 The primary purpose of this document is to provide revised guidance for Hospital Transfusion Teams to prepare for, and respond to, conventional Major Incidents and MCEs. It is designed to complement the NHS England clinical guidelines. However, other emergencies such as wide-scale disruption of computer services and adverse weather may also significantly disrupt transfusion laboratory function and necessitate a broadening of scope. The guidance therefore considers the transfusion EPRR for both Major Incidents and large-scale disruption due to other causes.

| Working group and writing process
The multi-disciplinary working group was selected to represent the wider transfusion community together with academics and key users with recent experience of major incidents. The final guidance format was based on the framework of an existing hospital-based plan and further developed using feedback from Regional Transfusion Committees' study days and workshops. The guidance is designed to provide the foundation for local policy and practice.

| DEFINITIONS
Each healthcare organisation should have in place plans for Major Incidents, Mass Casualty Incidents (MCIs), Critical Incidents and Business Continuity Incidents. Definitions for each may vary but the following definitions may be useful: • Major Incident (MI): Any occurrence that presents a serious threat to the health of the community, disruption to service, or causes (or is likely to cause) such numbers or types of casualties as to require special arrangements to be implemented.
• MCI/MCE: NHS England defines an MCI for the health services as an incident (or series of incidents) causing casualties, on a scale that is beyond the normal resources of the emergency and healthcare services ability to manage.
• Business Continuity Incident: An event or occurrence that disrupts or might disrupt normal service delivery to below acceptable predefined levels, requiring special arrangements to be implemented until services can return to an acceptable level.
The decision to activate any pre-prepared incident plan should follow a decision-making framework. The triggers for activation and escalation will depend on the nature of the incident and the capability and capacity of the healthcare organisation.

| EMERGENCY PREPAREDNESS
Hospital Trusts must include the Pathology Department and the Hospital Transfusion Team in Major Incident planning. The role of the Transfusion Team is to provide transfusion support throughout the incident within their Trust to both optimise patient care and make best use of resources.
NHSBT is responsible for ensuring the supply of critical biological products, including blood, together with related clinical services. NHSBT acts as a Category 1 responder with authority to enable blue-light vehicles to make emergency deliveries. See resilience and mutual aid section.
The Ambulance Service is the lead for the delivery of pre-hospital healthcare. It is unlikely that blood will be used at scene during largescale incidents, where the priority is rapid triage and transport of casualties Examples include the ED, resuscitation areas and operating theatres.
Members of the extended transfusion team may be used to assist in a range of supporting activities, 6 including: transfusion triage, emergency issue of blood, the handling of blood samples and communication with the laboratory. The use of staff will be dependent on staffing levels and trust configuration together with individuals' background and experience. All staff should be appropriately trained, competed and rehearsed for their role.
Hospital transfusion laboratories may consider moving stocks of blood components to key clinical areas for use in a Major Incident.
Where blood is moved, secure systems should be in place for blood selection, maintaining the cold chain and traceability records.  A log should be started to record key decisions and handovers of senior staff and shifts. The following key areas should be considered.

| Staffing
An initial assessment of current laboratory staffing should be undertaken along with determining the need for additional personnel. Other transfusion staff should be redeployed according to departmental plans. Off-duty staff should not report for duty until advised to do so. Staff reporting for work should use the pre-determined hospital check-in points according to Trust plans.

| Blood stock and critical consumables
Stock levels of blood components within the laboratory and in remote fridges, that is, ED, theatres and satellite fridges should immediately be assessed, as should the availability of other critical consumables, including reagents and transport containers. Stock levels should be enough to maintain business continuity during and after the event.
The total available internal bloodstocks should be quickly determined before arranging additional supplies from NHSBT.
The priority component required is expected to be Group O red cells. It is assumed that approximately 3 units are required per patient admitted with trauma. 7 The initial blood order should take into consideration the hospital admissions expected, the total stock of group O already held, and the group O needed for non-disaster related needs. An example of a calculator to estimate the requirement is shown in Figure 1.

| Stock movement
Trusts should initiate the movement and discharge of patients to receiving areas and create capacity for the reception of patients from the incident to ED, theatres and critical care areas. Routine surgery and some day care patient activity may be suspended. Blood already issued may no longer be immediately required for those cases. Consideration should be undertaken to de-reserve and re-centralise blood before re-issuing to emergency areas to meet the potential surge in demand.

| Plasma
It is assumed that Trusts will hold enough frozen blood components to meet their planned admissions for the first hour. Plasma may be prethawed and stored for 5 days for use in traumatic haemorrhage; however, cryoprecipitate is rarely routinely pre-thawed. Hospitals that do not routinely use pre-thawed plasma may wish to have procedures and training in place to enable staff to pre-thaw plasma in preparation for urgent issue.

| Platelets
Early consideration should be given to the demand and storage for platelets, especially if Trusts are located some distance from NHSBT and do not routinely stock platelets. However, the current literature suggests that platelets are rarely routinely required in MCEs, except for the most severely injured patients.

| Pre-hospital transfusion
In the context of Major Incidents, Transfusion Laboratories should anticipate the requirement for pre-hospital transfusion and the implications for blood stock management.

| Blood service
NHSBT will respond to hospital orders from its national pre-donated bloodstock. Current planning anticipates that several hospitals may order blood from the same stock holding unit/blood centre following an incident.
It is assumed that most blood will be ordered as universal components and used within the first 6 hours. However, some patients may have an ongoing demand for blood, especially where repeat surgery may be necessary.

| Documentation
Major Incidents may be caused by criminal acts and are likely to be subject to subsequent investigations. All key decisions should be documented, and all documentation should be clear, accurate and timely. All documentation (electronic and paperwork) must be preserved. White boards should be photographed before cleaning. No material or details should be shared with unauthorised persons.

| The hospital response to a major incident
Each hospital on activation should initiate their local command and control arrangements, including a central control room, to manage the overall response to the incident. The initial information available may be incomplete but situational understanding should evolve over time. Factors to be considered when determining the overall response include: • Type of incident The 2018 Patient Safety Alert has provided further guidance for temporary identification to accommodate hospital transfers, which cover names, temporary numbers and options for indicating age. 9 It is recommended that Transfusion teams discuss this alert and have local clinical agreements in place, which are compatible with their LIMS.
Baseline blood samples for pre-transfusion testing should be obtained before administration of any blood components. A second confirmatory sample for transfusion should be taken as soon as possible and labelled independently from the first sample to confidently determine the patient's ABO and D group. 10 The use of group-specific blood is normally recommended once the patient's blood group has been confirmed. There are advantages both to the individual patient and the wider population if the patient can be safely transfused with group-specific blood components. However, it is recognised that in some chaotic situations this may not be possible, and the initial use of group O blood may be the safest option.
The gender of the patient should be included on both the blood sample bottles and request forms to optimise blood group selection.
Individuals of childbearing potential are at risk of developing atypical antibodies following blood transfusion which may harm future pregnancies.
These patients therefore should receive D negative and K negative red cells. Pathology disciplines should default to the female gender in the event of an unidentified casualty where the gender has not been specified.
Request forms should include treatment priority, age or estimated age and special requirements if known. Distinguishing children from adults enables age-related criteria to be applied to component selection.

| Guidance for clinical blood use
Major Incidents may not result in many casualties with traumatic haemorrhage. In incidents classed as MCEs, current national EPRR planning is based on triage systems in which Priority 1 (P1) require immediate life-saving intervention, P2 require intervention that could be delayed, and P3 are "walking wounded" or with minor injuries. 4,11 It is anticipated that only the P1s and P2s will require admission to hospital however priorities may change.
Reviews of past MCEs recommend planning for a red cell demand of 2 to 4 units for each casualty admitted with bleeding. [12][13][14] An early estimate for more severely injured casualties admitted to trauma centres, that is, P1 casualties with massive haemorrhage, is near 6 units of RBC in 24 hours. 15 Many of these patients may also require plasma, platelets and cryoprecipitate as guided by Major Haemorrhage protocols. 8 Trusts should ensure that they have a policy for the management of massive haemorrhage and massive transfusion and this should be incorporated into the Major Incident plan in order to promote prompt and appropriate use of haemostatic blood components in this setting. 16 Transfusion support should be optimised using the principles of Trusts should have contingency plans for major blood shortages incorporated into Major Incident plans. National integrated blood shortage plans include guidance for the clinical prioritisation of red cells 17 and platelets. 18

| Selection and issue of blood components
All patients admitted to hospital should have a baseline sample taken for transfusion testing of blood group (ABO and D) and atypical antibody screen. However, blood grouping should be initially prioritised to the most urgent cases (P1 and P2 cases), that is, those who are bleeding and most likely to require blood components. Laboratory procedures should be in place to prioritise and handle emergency samples. Age-appropriate components should be used wherever available.
In emergency situations, it may not be possible to meet all additional paediatric specifications. In these situations, the selection of substitutions should follow national guidance. 20 Tracking blood components once they have been issued may be challenging, especially if sent to multiple areas. Consideration should be given to the use of paper logs or whiteboards to record the issue of blood components, shock packs or other deliveries.
Arrangements must be in place for the traceability of blood sent to other hospitals and the Ambulance Service. Hospital Transfusion Laboratories should be able to provide details of blood and blood component usage following a Major Incident to NHSBT within 72 hours, to guide the management of patients and bloodstocks in relation to future events.

| REGULATORY REQUIREMENTS
Transfusion support in the context of an incident should comply with legislation (BSQR, 2005) and best practice. Records should be retained for both regulatory and forensic purposes.
Due consideration must be given to securely maintaining the cold chain of any blood components stored and transported during an incident.
Special care is required when Hospital Transfusion Laboratories move "stock" of blood components to treatment areas in a Major Incident.
Hospital Transfusion Laboratories should have protocols for the timely thawing and issue of plasma together with the option of postthaw storage of FFP at 4 C for up to 5 days. 21 The use and disposal of any blood component must be docu- Major Incidents can be traumatic events, which cause stress, whatever their source or scale. Staff may need some psychosocial support in the time following the incident. In some circumstances, those affected may need additional support for a considerable period.
Debriefing may help individuals and support the transfusion team.
At the command "Major Incident Stand Down" the transfusion team should hold a short "hot debrief" meeting drawing out issues that presented problems or where improvements can be made.
Debriefs may also contribute to psychosocial support. Debrief should be repeated for each new shift and provided to individuals as required.
A representative from the transfusion department should attend their hospital hot debrief meeting which is normally initiated by the director leading the Gold control team. The time should normally be no later than a few hours after the incident.
Any documentation and experience from the incident should be used to capture lessons identified, and feedback to other stakeholders including NHSBT to support service improvement.

| Recovery phase from a major incident
Response and recovery are not two discrete activities but may occur simultaneously. The recovery team should begin to plan recovery activities at the onset of the incident. As soon as the initial response phase is over, the focus should be on returning to "Business as Usual," or normality, as soon as possible.
A Trust level recovery co-ordinator should be appointed to coordinate the response. The Transfusion Department is responsible for planning local recovery but will need to be aware of the wider Trust plan. The recovery strategy will normally cover some or all the key following objectives: • Managing the return to normal service delivery

| Business continuity threats including cyber security
Business Continuity is regarded as a separate process from Major Incident planning although it is recognised that there are potential overlaps. Business Continuity has its own strategy, alert and escalation process.
Local business continuity plans should be held in readiness in the Transfusion Laboratory as well as in the emergency planning and command control rooms. There are normally four levels of activation for a business continuity incident.
The main business continuity threats to Trusts which may impact the delivery of hospital-based transfusion services include: • Loss of staff due to illness such as pandemic flu or an infectious outbreak. Outbreaks may have a secondary impact with loss of staff due to childcare commitments or dependents' illness. Pandemic flu may have an impact on blood donation, resulting in blood shortage.
• Interruption to essential supplies other than blood. Examples may include blood products such as albumin and immunoglobulins. Departments should ensure that there is enough stock of critical consumables and be aware of the risks in the supply chain. Transfusion Laboratories may be required to work closely and proactively with pharmacy and other departments to ensure continuity of supply.
• Loss of building due to fire, bomb threat or contamination especially when dealing with potentially infective biological material.
Systems should be in place to safely handle known infective samples and to decontaminate where required.
• Interruption to a utility, such as electricity, gas or water (drought).
Specific consideration should be given to the maintenance of the cold chain. The cold chain may be compromised during hot weather if there is air-conditioning failure.
• Interruption/loss of telephone or IT system. Modern clinical laboratory services, including transfusion services, are highly dependent on the Laboratory Information Management System for all aspects of blood banking.
Business Continuity plans should be in place to maintain essential services in the event of an IT failure. Hospital Transfusion Laboratories should maintain the capability to use manual techniques for testing and nonelectronic record keeping. Procedures should be in place to update IT records during the recovery phase.
It is specifically recommended that nonelectronic records of regularly transfused patients with clinically significant antibodies and special requirements are regularly maintained to enable timely transfusion in the event of a cyber-attack or power failure.
Disaster planning and training should include cyber security, and the actions required to minimise impact. Trusts and pathology services should comply with cyber and data security good practice to reduce the risk of IT failure. Examples of current guidance and best practice are available via NHS Digital and the National Cyber Security Centre.

| Resilience and mutual aid
Mutual aid is defined as an arrangement between Category 1 and Category 2 responders and other organisations not covered by the Civil Contingencies Act 2004. 1 Mutual aid may occur within the same sector or across sectors and across boundaries, to provide and assist with additional resource during an emergency that may overwhelm the resources of a single organisation.
Where consideration is given to providing or requesting assistance from another NHS organisation, this should be agreed through local strategic command. The requirements, roles and responsibilities should be clearly set out in advance. Examples of mutual aid for transfusion might include movement of bloodstock and emergency use of fridges and freezers. NHSBT may be contacted through the Hospital Services department for mutual aid enquiries.
NHSBT aims to manage supplies of blood components and critical services to all customers during emergencies. Response to orders may be staged, and substitutions used where appropriate. Priority will be based on clinical need. Emergency deliveries will be made in NHSBT liveried vehicles, usually directly to the transfusion laboratory. It may be necessary for a rendezvous point to be established when the security of a hospital is compromised. In such circumstances, an individual should be designated as the point of contact for the receipt of blood products.
Guidance for the arrangements for specialist chemical and biological antidote services is provided by NHS England.