From Battlefield to Back Home: A Current and Future Look at the Armed

Services Blood Program

COL Audra L. Taylor

Division Chief, ASBP

Speaker Name

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ASBP Mission

Provide quality blood products and support to

military healthcare operations worldwide.

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Organization• The Armed Services Blood Program (ASBP) transitioned to the Defense

Health Agency (DHA) in August 2017

• The ASBP is comprised of the following:

o Armed Services Blood Program Division (ASBPD) at DHA/CS

o Service Blood Program Offices (SBPOs): Three Food and Drug Administration (FDA) Licenses

o 20 Blood Donor Centers (BDCs)

₋ FDA Licensed, AABB and College of American Pathologists (CAP) Accredited

o and over 60 Transfusion Service (TS) Activities

₋ FDA Registered, AABB and CAP Accredited, and Joint Commission (JC)

o Armed Services Whole Blood Processing Laboratories (ASWBPLs) –Air Force/Air Force Medical Research Agency (AFMRA)

o Theater Operations

o Joint Blood Program Officers (JBPOs)

Expeditionary Blood Transshipment Centers (EBTC)

Blood Product Depots (BPDs) – Army/Navy

Blood Support Detachments (BSDs) - Army

Medical Treatment Facilities (MTFs) – Army, Navy, Air Force

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Service Blood Program Directors and Joint Blood Program Officers

Service Blood Program Directors

• Army Blood Program

• Navy Blood Program

• Air Force Blood Program

Joint Blood Program Officers

• CENTCOM

• AFRICOM

• EUCOM

• INDO-PACOM

• SOCOM

• NORTHCOM

• SOUTHCOM

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Coordination & Distribution System

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Available Blood Products

Red Blood Cells - Liquid

o Expiration: 35 or 42 days

o Storage Temp: 1-6oC

o Shipment Temp: 1-10oC

Red Blood Cells - Frozen

o Expiration: 10 Years frozen

o Storage Temp: < -65oC Shipment Temp: < -40oC

o Post thaw/deglycerolization 14 days @ 1-6oC

o Prepositioned in some theaters & shipboard

Plasma (Fresh Frozen / Frozen Within 24 hrs)

o Expiration 1 Year

o Stored/Ship Temp @ < -18oC

o Type A used for emergencies

Cryoprecipitateo Expiration: 1 Yearo Store/Ship Temp: @ < -18oCo Infuse w/I 4 hrs of thaw/pool

Platelets – Liquido Expiration: 5 Days o Store/Ship Temp: @ 20-24oCo Not available for shipment to theater.o Performing in-theater platelet apheresis

collections (not fully tested)

Low Titer Group O Whole Bloodo Expiration: 21 or 35 dayso Storage Temp: 1-6oC o Shipment Temp: 1-10oC

Liquid Plasmao Expiration: 26 or 40 dayso Storage Temp: 1-6oC o Shipment Temp: 1-10oC

Cold Storage Platelets

Freeze Dried Plasma

COVID-19 Convalescent Plasma

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Blood Donor Centers (BDCs)

• Collect from volunteers (Active Duty, Active Duty Dependents, DoD Civilian & Federal employees and Contractors)

• Provides blood products to meet continuing operational requirements & military healthcare support needs

• Requires Command support to encourage donations

• All BDCs licensed by the FDA and AABB Accredited

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Systematic Process

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Armed Services Whole Blood Processing Laboratory (ASWBPL)

Functions:

• Receive blood from the BDCs

• Confirm ABO/Rh Types & Product Labels

• Contingency storage capability

• Freeze/Store Frozen Red Blood Cells (RBCs)

Locations:

• ASWBPL East, Joint Base McGuire-Dix, NJ

• ASWBPL West, Travis AFB, CA

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Expeditionary Transshipment System (EBTS)

• Single “modular” system

• U.S. Air Force Operated: Usually located at a secured theater airfield Inventory managed by the Joint Blood Program Officer (JBPO)

• Functions: Central receiving point in theater

• Inspect blood products, re-ice blood products, store blood products

• Issue blood products to Blood Support Detachment (BSD) units and any adjacent Medical Treatment Facilities (MTFs) as directed

• Send reports to Area Joint Blood Product Officer/JBPO

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Blood Product Depot (BPD)• Service Component Operated (Army and Navy)

• Inventory managed by designated JBPO

• Function:

o Receive & Store Frozen Blood

o Thaw & Deglycerolize Frozen Blood:

- Activate 24 hrs/day for 3 - 10 Days

- Slow process: 1 unit/machine/hour (2-3 machines/Tech)

- 14 Days post-thaw expiration (ACP 215)

o Distribute deglycerolized Red Blood Cells

• Locations: Okinawa, Korea & Sigonella

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Blood Support Detachment (BSD)

Component Operated – U.S. Army

Functions:

• Receive/Inspect Blood Products

• Store and Re-ice Blood Products

• Issue Blood Products to MTFs within Area of Operation:

o Transportation Assets Vary with Unit Designated

• May Operate with a Blood Product Depot (BPD)

• May Collect Whole Blood (WB) in emergencies

• May Collect Apheresis Platelets

• May Deglycerolize Frozen RBCs

• Provide Blood Reports to JBPO

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Medical Treatment Facility (MTF)Component Operated:

• Functions:

o Receive/Inspect/Store Blood Products

o Role 3, Role 2, Role 1and Point of Care

o Crossmatch Blood (Role 3 MTF)

o Transfuse Blood Products

o May collect Whole Blood (WB) and Apheresis Platelets in emergency situations

• Blood Storage:

o 30-50 Units PRBC (Type O) for Forward Surgical Unit/Role 2

o 30-50 Units FFP/PF24 (Type AB) for Forward Surgical Unit/Role 2

o 480 Units PRBC (ABO Mix) for Role 3

o 100-150 FFP/PF24 (ABO Mix) for Role 3

• Blood Reporting is required daily

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Type A plasma is now being used in place of AB in emergencies.

Blood Products by Treatment Level: Deployed

TREATMENT

LEVEL

AVAILABLE

BLOOD PRODUCTS

ABO & Rh

GROUP

TRANSFUSION

SERVICE

PROCEDURES

MAXIMUM STORAGE

CAPACITY

BLOOD

SUPPLIER

FIRST

RESPONDERS

(L1)

Red Blood Cells (RBC)

Thawed Plasma (TP)

O, Rh Pos/Neg

Group AB NONE NONE Level II or III

FORWARD

RESUSCITATIVE

SURGERY

(L2)

Red Blood Cells (RBC)

Frozen Plasma (FFP/PF24)

Cryoprecipitate (CRYO)

O, Rh Pos/Neg

Group AB

O, A, B, AB

ABO TYPING

50 UNITS RBC PER MEDICAL

FIELD REFRIGERATOR

20 UNITS FFP/PF24

BSD, BTC

or MTF

THEATER

HOSPITALS

(L3)

COMBAT SUPPORT

HOSPITAL (CSH)

FLEET HOSPITAL

EXPEDITIONARY

MEDICAL SUPPORT

(EMEDS) + 25

SHIPS

Red Blood Cells (RBC)

O, A, B

Rh Pos/Neg

ABO/Rh TYPE AND

GROUP ON

PATIENT AND

DONOR RBCs. (1)

IMMEDIATE SPIN

CROSSMATCHES.

- 480 UNITS: CSH/FH

- 90 UNITS: EMEDS+25

- 500 UNITS: LHA/LHD

- 2000 UNITS: HOSPITAL

SHIPS

BSD or BTC

FROZEN/

DEGLYCEROLIZED

RBC

O, A

Rh Pos/Neg

ABO/Rh TYPE AND

GROUP ON

PATIENT AND

DONOR RBCs.

IMMEDIATE SPIN

CROSSMATCH

- 950 UNITS: LHA/LHD

- 2850 UNITS: HOSPITAL

SHIPS

BSD, BPD, or

BTC

Frozen Plasma (FFP/PF24)

O, A, B, AB

Rh Pos/Neg

ISSUE GROUP

COMPATIBLE 100 UNITS BSD or BTC

Cryoprecipitate

(CRYO)

O, A, B, AB

Rh Pos/Neg N/A 50 UNITS BSD or BTC

Platelets

O, A, B, AB

Rh Pos/Neg NONE TBD BSD or MTF

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Joint Blood Program Office (JBPO)

Command Surgeon’s Staff

Functions:

• Enforce DoD Blood Program Policies

• Coordinate Component Blood Programs

• Plan and Execute Blood Program Exercises and Operations

• Manage the Theater Blood Distribution System for their designated area

Theater Reporting System:

• JBPO establishes format and frequency

• Provides Blood Reports to ASBP Division

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Coordination for Theater Blood Support

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Logistical Coordination

Blood Support is a Joint Effort on the part of:

• Medical Logistics Personnel

• Operations & Plans Personnel

• Transportation personnel

• Blood Bank/Laboratory Personnel

• Primary Medical Care Providers

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Influences of Blood Support

• Blood Support in Theater is Influenced by:

o Stringent Storage & Handling Requirements

- Ship at 1-10°C for RBCs and ≤ 18°C for FFP

- Store RBCs at 1-6°C

- Room temp platelets; agitator

o Inventory Management Constraints

- Type O Blood, Rh Negative Blood

- Lack of AB Plasma

o Limited Potency Periods (Short Shelf-Life)

• Operational challenges:

o Blood movement and re-supply

o Equipment and personnel

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Additional Support in the Pre-Hospital Setting

Collaboration and Innovation

Cold Stored Platelets

Walking Blood Bank

Global Outreach

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Collaboration and Innovation

• Focus: Availability of Blood Products Far Forward• Whole Blood Transfusion 2001-2016 focused at R2/R3

• 90% of combat deaths occur before reaching R2

• 25% of combat deaths preventable

• 90% of preventable deaths – due to Hemorrhage

• TCCC Guidelines • Resuscitation fluids of choice:

• Whole Blood- not new; increased demand

• Plasma, red cells and Platelets in 1:1:1 ratio

• Active Involvement with Trauma Hemostasis and Oxygenation Research (THOR) Network and NATO Blood Panel

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Ongoing Efforts

• Continued production of Low Titer Type O Whole Blood (LTOWB)o Predominantly produce 35-day stored CPDA-1

LTOWBo Weekly production for Army, Navy and AF donor

centers

• Liquid (never frozen) Plasma – preferred by mobile surgical teams o Eliminates need for freezers / plasma thawerso Type A used as universal plasma / no titers

performed

• Continued collection of apheresis platelets in theater o Deployed Army and Air Force collection teams

• Expanded Walking Blood Bank Donor Pre-Screeningo Support emergency whole blood collectionso Achieve highest degree of safety possible

Remote | Austere | Limited ResourcesBlood Further Forward on Battlefield

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Cold Stored Platelets

• Collection of apheresis platelets in theater (deployed setting) initiated in Iraq (2004) and Afghanistan (2006)

• Cold Stored Platelet collections initiated in Afghanistan in 2016

• Successful validations using both MCS-9000s and TRIMAs for 3, 10 and 14 day CSP

• US Central Command now routinely producing 14 day CSP, both PAS and 100% plasma stored

• 218 Cold Stored Apheresis Platelets Transfused to 109 patients / Joint Trauma System reviewing outcomes

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Cold Stored Platelets

Army received FDA approval for 14-day CSP variance

• Variance is for all Army donor centers

• Covers both plasma and PAS stored platelets

• Way ahead: Identify center(s) to initiate CSP validation

AF and Navy Blood Programs working on FDA variance

Near Term: CSP can be utilized:

• DoD hospitals for massively bleeding patients

• DoD hospitals to help with inventory management

• May be shipped to support theater operations

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Cold Stored Platelet Licensure

• DoD Goal is FDA licensure for Cold Stored Platelets

• Integrated Product Team / Program of Record

• Participants are Joint Service, Industry, Regulatory

• Civilian partners

• Establish large clinical trials to review efficacy of Cold Platelets compared to Room Temp Platelets

• Multi-year, Randomized Controlled Trials

• Partnership with civilian hospitals, donor centers

• Final Product: BLA application for CSP along with manufacturer label changes for platelet bag storage

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Walking Blood Bank Screening

• Joint Trauma System Definition of WBB: Process by which personnel are screened for acceptability and donate non-FDA compliant whole blood during an emergency.

• Ideally, best to screen a potential donor before deploy…but screening can be performed after deployment

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Walking Blood Bank Screening Before Deployment

WBB Donor Screening consists of:

• ABO/Rh

• FDA required disease testing

• HHQ (abbreviated ASBP version)

• Titer testing type O only

ASBP has screened Special Operations Forces routinely, now emphasis is to expand screening to our conventional forces before deployment

To balance need for blood donations (hospital support / quota for overseas) and WBB screening, ASBP has emphasized tandem blood drive/pre-screen events

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Prescreening for WBB

• Tandem blood drive/pre-screen events aggressively used with Army’s 18th Airborne Corp

• Military unit is screened for WBB / ASBP receives WB Donations – WIN/WIN

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Prescreens & Titer Testing While Deployed

• If a Role 1 has a patient in hemorrhagic shock that they cannot evacuate immediately, there is now a contingency in place for them as they are trained to collect emergency whole blood from the universal donors we have identified.

• Ideally low titer O individuals are identified prior to deployment, but bringing the Walking Blood Bank training to the pre-hospital setting and adding the capability to perform anti A and B titers in a deployed setting has allowed us to fill the gap in FWB availability for conventional forces.

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Collection of Emergency Whole Blood

• Improves Blood availability far forward

• TMDS

• Pre-screened donor pool

• Must train a team and practice, practice, practice

• Chinook or Combat Medical Systems WB kit

• Vacutainer tubes and questionnaire completed again

• DIN labels; vary by location and by prescreen/WB collection

• Bag must be fuller than most medical personnel are used to

• Most infectious disease testing still complete with rapid testing; and

tubes sent stateside for further testing

• Provider consent/Letter of Understanding for emergency, non-FDA

tested whole blood units

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Whole Blood Collection & Transfusion Kit

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Transfusions

• All transfusions are tracked in TMDS and linked to donor

• Same paperwork required as stateside for transfusions

• Lookback procedures and product recalls are followed

• LTOWB is more expeditious and safer during Walking Blood Bank because donor and recipient blood typing is not required

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Global Outreach

Blood Safety Program: Enduring program of Blood Safety in Lao P.D.R., Vietnam and Cambodia since 2009

Purpose -

1. Builds host nation biosecurity and a sustainable blood program capacity in support of disaster response

2. Brings together civilian and military blood program stakeholders in Host Nations, paving the way for further civilian and military coordination

3. Program progression to include frozen blood products, nursing training, and linkages to Humanitarian Assistance construction projects for Blood Banks

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