Transfusion Associated Circulatory Overload TACO Clinical Perspectives

Transfusion Associated Circulatory Overload TACO Clinical Perspectives by Sarah Hal – November 2022

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RBC Transfusions Historical vs Best Practices by Dr Jacob Pendergrast – November 2022

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Massive Hemorrage Protocol Adult by Alison Armstrong – November 2022

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Documenting Transfusion Dotting the i’s, Crossing the t’s by Donna Berta – November 2022

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In This Issue

  • Transfusion Related Roles for Nursing Officers
  • Blood in a Canadian Armed Forces Theatre of Operations
  • Blood on Board Program saving lives and time in first year
  • Announcements
    • Tech Assessment
  • Featured Resources
    • Bloody Easy 5
    • Purolator Healthcare indicators
    • Dispensary and administration toolkit
  • Upcoming Events
    • Transfusion Medicine Boot Camp for Nurses
    • Upcoming UofT TM Round

Transfusion Related Roles for Nursing Officers

Maj Amy Godwin, RN
Blood Program Manager
Canadian Armed Forces

CAF Nursing Officer Transfusing
CAF Nursing Officer Transfusing

Canadian Armed Forces Nursing Officers are licensed Registered Nurses employed in various domains of nursing including direct patient care, clinical training, personnel management and strategic policy. A few of the specialities within the direct patient care domain include Medical-Surgical, Critical Care, Operating Room and Aeromedical Evacuation. Within each of these specialties, Nursing Officers may be called upon to fill blood management and transfusion roles. 

To achieve clinical readiness for deployed missions, Nursing Officers receive trauma training to prepare them for roles in Damage Control Resuscitation (DCR). This training, amongst many other topics, includes familiarization with blood and blood products, Massive Hemorrhage Protocols and transfusion principles. Additionally, select Nursing Officers are designated as Blood Management Nurses and receive specialized training to lead the collection of fresh whole blood (FWB) in a deployed setting.

Despite detailed analysis and planning, circumstances may arise in deployed medical facilities where clinical demand for blood and blood products surpasses available resources and resupply timelines. In these extremis situations, FWB collected in theatre from a pre-screened volunteer donor offers an additional clinical capability towards the goal of life saving resuscitation. Once collected, FWB remains at room temperature for up to 24 hours prior to refrigeration and is not separated into components.

A deployed Nursing Officer assigned as the Blood Management Nurse will move from their primary duties to this role when an order is received to initiate screening for FWB. The Nurse assembles their team and commences recalling of pre-screened donors. Pre-screened donors are tested in Canada prior to a deployment by Canadian Blood Services and must meet the same eligibility criteria as any other Canadian blood donor. This stringent screening ensures FWB collected in a deployed setting is as safe as possible for immediate transfusion.

Once the donor is recalled to the medical facility, the Nurse and team complete another screening assessment including verbal attestations and collection of blood samples for testing by the lab. Upon receipt of lab results, the Senior Medical Authority decides whether a unit of blood is to be collected from the donor. The Blood Management Nurse is responsible for collection of the unit and documentation throughout the process. The lab then takes over responsibility of issuing the FWB unit to the trauma team for transfusion to a casualty.

FWB is most often collected during mass casualty events, meaning the facility is being overwhelmed and stretched beyond its capacity limits. The Blood Management Nurse needs to rely on their extensive training prior to the deployment to remain calm and deliberate while leading their team through the FWB collection process, most likely concurrently collecting from multiple donors. Errors made during the screening and collection phase could result in transfusion related reactions, including death. Training, ongoing practice and standardized approaches are used to minimize the potential for errors, in addition to the selection of a Nursing Officer with appropriate experience and skills to fill the vital Blood Management role.

Nursing in the CAF is an exciting job that offers unique clinical opportunities. The recruiting doors are open! Please reach out to Maj Godwin (AMY.GODWIN@forces.gc.ca) if you’re interested in learning more.

Blood in a Canadian Armed Forces Theatre of Operations

Warrant Officer Jeff Scott, BSc, MLT
Canadian Armed Forces Blood Program

Massive hemorrhage is the leading cause of potentially survivable death on the battlefield (1). The North Atlantic Treaty Organization (NATO) Allied Joint Medical Doctrine (2) has outlined expected medical care timelines for casualties in a theatre of operations using the 10-1-2 standard:

a. 10 minutes: Trained military personnel in Tactical Combat Casualty Care to provide immediate life saving measures;
b. 1 hour – Damage Control Resuscitation (DCR) initiated to restore homeostasis and prevent coagulopathy, hypothermia, and acidosis often with aggressive hemostatic resuscitation; and
c. 2 hours – Damage Control Surgery (DCS) to focus on surgical interventions to those with life threatening injuries (3).

In order to meet the one hour DCR standard, it is imperative that blood products are available pre-hospital in case medical evacuation from the point of injury to a medical treatment facility is delayed or unavailable. From a laboratory perspective, there are numerous challenges and considerations with respect to managing blood products in a deployed setting, namely cold chain and inventory.

The process of maintaining the appropriate temperature of blood products, no matter the location is the Cold Chain. This is achieved by employing passive temperature controlled devices (coolers) or active temperature controlled devices (portable refrigerators or freezers). Advance planning needs to be employed to ensure that cold chain can be maintained in uncertain or adverse conditions. Without sustainable cold chain, blood products would be unavailable when needed most.

Another challenge is maintaining an inventory of blood products in theatre. The Canadian Forces Health Services’ (CFHS) mandate is to ensure CAF members receive the same full-spectrum high quality health care abroad as they would in Canada (4). One of the biggest differences in a deployed theatre of operations compared to a civilian hospital in Canada is the availability of platelets. The short shelf life of platelets makes them logistically impractical to maintain in a deployed setting. This limiting factor means that due consideration needs to be made on deployments for the scope of care that can be provided.

The CFHS has identified whole blood as the preferred hemostatic agent for traumatic hemorrhage. Whole blood is never fractionated into its components; it contains all required components and is the only source of platelets available in an austere environment. Whole blood provides blood to the casualty in the same ratio that it’s lost. Deploying CAF members can volunteer to be pre-screened by Canadian Blood Services for potential fresh whole blood donation in a theatre of operations. The member undergoes the same donor qualification process as a civilian donating blood, but does not donate the unit of blood at the time of screening. If eligible, they donate whole blood when the need for whole blood arises while in theatre. This practice of collecting pre-screened fresh whole blood for a named patient in theatre is termed an Emergency Donor Panel (EDP).

Cold chain and inventory management are just a couple of the unique challenges and considerations with providing full spectrum health care in a deployed setting. An EDP is unique to the military environment and plays an extremely important role in providing lifesaving blood products.

  1. Eastridge BJ. Death on the battlefield (2001-2011): implications for the future of combat casualty care. J Trauma Acute Care Surg. 2012 Dec;73(6 Suppl 5):S431-7. doi: 10.1097/TA.0b013e3182755dcc. Erratum in: J Trauma Acute Care Surg. 2013 Feb;74(2):706. Kotwal, Russell S [corrected to Kotwal, Russ S]. PMID: 23192066.
  2. North Atlantic Treaty Organization. Allied Joint Publication 4–10(A) Allied Joint Medical Doctrine. 2011.
  3. Fisher, Andrew D. “Damage Control Resuscitation (DCR) in Prolonged Field Care (PFC) (CPG ID:73).” Joint Trauma System Clinical Practice Guideline (JTS CPG), 1 Oct. 2018.
  4. (The Canadian Forces Health Services (CFHS) Overview)

Disclaimer: reposted with permission from Hospital News

Blood on Board Program saving lives and time in first year

By Joshua McNamara

A car crashes on a rural highway, 60 minutes from the closest hospital. Ornge’s Operations Control Centre receives a request from the Central Ambulance Communications Centre to respond to the scene with an air ambulance helicopter. Local paramedics work to stabilize the lone occupant as the fire department works to extricate them from the mangled wreck. The driver is trapped in the car during a lengthy extrication, their pelvis pinned by the dashboard with significant bleeding from a lower extremity injury. As the patient is extricated, a tourniquet is applied by the paramedics to stop the bleeding, but they remain profoundly hypotensive.

Ornge lands at the scene of the crash as the patient is being wheeled toward the land ambulance. The Ornge paramedics exit the helicopter and assume care of the patient as they are loaded into the awaiting helicopter, blades still turning and ready for a quick departure. Every minute counts. The patient will be transported by Ornge to a lead trauma hospital based on the Field Trauma Triage Standards. On route, Ornge Critical Care Paramedics are able to transfuse blood to the patient, thanks to the Blood on Board program, improving the drivers blood pressure and perfusion on the way to definitive care.

This intervention and outcome is the direct result of the Blood on Board program, a collaboration between Ornge the Division of Transfusion Medicine & Supply Bank at Sunnybrook Health Sciences Centre, an academic health sciences centre fully affiliated with the University of Toronto and a Level One trauma centre. Launched in August 2021, the program reached its 12-month milestone on August 31, 2022. Over the last 12 months, the program has transfused 63 units of blood to 38 patients ranging from interfacility trauma and medical calls to direct from scene trauma cases like the story above.

“For patients experiencing a life-threating injury or catastrophic hemorrhage, an emergency transfusion to replace lost blood can be life saving,” says Dr. Bruce Sawadsky, Chief Medical Officer for Ornge. “Research shows the faster that lost blood is restored with a transfusion, the better the patient outcome. This new program will lead to improved and faster access to blood products as a life-saving therapy.”

As a result of this program, the time to first transfusion for patients picked up directly from scene has been cut in half. These improvements don’t only occur for direct scene calls, similar improvements were seen for patients retrieved from regional and community hospitals. These reductions in delays to the first unit of transfused blood are significant and are directly attributable to the Blood on Board collaboration.

Ornge paramedics have received this initiative positively. “Paramedic crews report a great sense of accomplishment and patient advocacy in having the ability to provide this treatment modality in the field,” says Justin Smith, Chief Flight Paramedic at Ornge. “This allows our paramedics to provide the right care, for the right patient, at the right time.”

Sunnybrook and Ornge have been fortunate to speak about the team’s experience developing a Blood on Board program at regional, provincial and national conferences. Additionally, the team is part of the newly formed Canadian Prehospital and Transport Transfusion (CAN-PATT) group, a multi-disciplinary group of transport and transfusion programs from across Canada.

“Launching ‘Blood on Board’ has been a true team effort for everyone involved, from our partners at Ornge to the lab technologists in our blood bank,” says Dr. Yulia Lin, Division Head, Transfusion Medicine & Tissue Bank at Sunnybrook. “We look forward to helping other hospitals across the province join the program in the near future.”

As the program continues to develop, Ornge is looking to other Ontario regional transfusion programs to build partnerships to expand the reach of the Blood on Board program across the province. The goal is to be able to bring blood to the patients that need it in the prehospital and transport environment across all of Ontario.

Joshua McNamara works in communications at ORNGE


Announcement


Tech Assessment

The Tech Assessment program, Basic, Advanced and Dispensary Site will be launching in November 2022!


Featured Resources


Bloody Easy 5

Purolator Healthcare Indicators

The Plasma Protein and Related Products (PPRP) redistribution program is adding the use of Purolator Healthcare Indicator labels in order to further identify our shipments as Healthcare/Hospital related and to avoid possible delays in redistribution of PPRP shipments. Notification and implementation for the use of the labels on the J82, E38 and MTS EMT shipping containers was sent on October 24th.

Updates to the following documents in our Redistribution Toolkit have been made to reflect this change:  

Changes to the following documents will follow soon:

  • Redistribution Hospital User Guide: Plasma Protein and Related Products Redistribution Hospital User Guide
  • Narrated PowerPoint: Plasma Protein and Related Products (PPRP) Online Reporting Training Video

For questions or concerns please contact one of your ORBCoN or FCRP coordinators.

Dispensary and administration toolkit

ORBCoN has created a set of tools that can help the Dispensary/Administration sites design and implement a transfusion program. These tools include: 

If you have any questions about setting up an administration site, please reach out at transfusionontario@gmail.com


Upcoming Events


Transfusion Medicine Boot Camp for Nurses

Join these speakers for this year’s Transfusion Medicine Boot Camp for Nurses, Nov 23rd

Upcoming UofT TM Round

November 24, 2022 @12pm-1pm

MLT Session – Interesting Serology Cases

Virtual Session Only

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In This Issue

Results of a Market Research Survey on Accessing ORBCoN Resources

Andrew Duyvestyn, Information Technology Analyst
Ontario Regional Blood Coordinating Network

This spring, ORBCoN conducted a market research survey to help ensure important resources and information continue to inform best practice in transfusion medicine in the Province of Ontario. We received 184 full responses containing valuable information; thank you to all those who participated. Below are some of the results from that survey.

Of the 184 full responses, the majority were technologists (61%) and nurses (22%), underscoring the need for us to reach other professional demographics in the transfusion medicine network. 

Of those working in a field that involves transfusion medicine and safety, 33% indicated daily involvement in policies regarding Transfusion Medicine. Seventy percent (70%) indicated at least weekly involvement.

When asked to think about the format that respondents prefer to learn about transfusion medicine, they overwhelmingly indicated that they somewhat prefer or completely prefer digital resources and eLearning modules with 85% and 80%, respectively. Healthcare websites and live webcasts are trailing not far behind at 68% and 64%, respectively. Social media was the least preferred format with only 16% selecting somewhat prefer or completely prefer. 

The top three reasons respondents had visited the transfusionontario.org website was to find a resource/toolkit related to transfusion (56% of respondents), to find information about an upcoming event (34% of respondents), and to find information about an eLearning program (25% of respondents).

When respondents were asked about their recent experiences on the transfusionontario.org website, the three statements they most agreed with were:
1.    “I trust the ORBCoN website”
2.    “I would refer a colleague to the ORBCoN website”
3.    “I was able to find what I was looking for”
The statement they least agreed with was: “I liked the design of the website”. 

When respondents were asked about the resources they accessed when visiting the transfusionontario.org website, the statement they most agreed with was: “The resources provided were reliable”. The statement they least agree with was: “The way resources were categorized made sense”.

Social media of all platforms were seen as largely unreliable. YouTube and LinkedIn were the   most reliable with 30% and 17% of respondents indicating they find them somewhat or completely reliable, respectively.

We asked respondents on a scale from 1 to 10 how likely they would be to recommend the Ontario Regional Blood Coordinating Network to a colleague, and to our delight, 80% of respondents chose either 8, 9, or 10. 
 
ORBCoN has taken the feedback from this market research and has started to apply some of the feedback to our resources. We will be looking at how our resources are categorized and will continue to offer as much digital engagement as possible.

Do any of these results spark questions or ideas? Join the conversation on LinkedIn or reach out to us at transfusionontario@gmail.com.

Bonus: Quick Survey

Are you part of a hospital in ON that has added “Code Transfusion” to their hospital Emergency Codes (badge)? If so, can you share what colour you use or how you distinguish this from the other emergency codes i.e. code red?


Announcement


UofT Monthly Transfusion Medicine Round

The University of Toronto Monthly Transfusion Medicine Rounds is held on the fourth Thursday of each month 1200-1300 EST. Each year there is a wide range of topics which provides continuing education opportunities for stakeholders in the field of Transfusion Medicine.

The 2022-2023 academic year will be a hybrid of virtual and onsite sessions. The onsite sessions will also have a virtual link available. The monthly communication will indicate the session platform and/ or location, registration link, speaker and topic.

Bloody Easy 5

Tech Asses

Tech Assess is a competency program which consists of a series of tests intended to provide Medical Laboratory Technologists in Ontario with a mechanism to assess and build on their technical and theoretical knowledge in Transfusion Medicine.

  • Registration in ORBCoN eLearning portal
  • Categorized into modules- different areas of subject matter
  • Two levels of difficulty – Basic and Advanced
  • Each question contains answers with rationale once the assessment is submitted.
  • Retake test if you did not receive a passing grade
  • Print Completion Certificate
  • Supports hospitals in meeting compliance with required standards for competency assessment

Tech Assess Basic, Advanced and Dispensary Site will be launching Fall 2022.


Featured Resources


PPRP Resources

The Plasma Protein and Related Products (PPRP) online reporting system officially launched September 27, 2021 with a bi-monthly survey comprised of three sections:
1) Hospital Information
2) PPRP to Report for Redistribution and
3) Summary. The survey may be utilized to report products for redistribution. Disposition data is now reported to Canadian Blood Services.

There are two resources for training and/or refresher purposes:

For questions or concerns please contact one of your ORBCoN or FCRP coordinators.


Upcoming Events


Transfusion Medicine Boot Camp for Nurses

Upcoming UofT TM Round

October 27, 2022 @12pm-1pm

The EPIC Experience
Mr. Michael Angers
Dr. Christine Cserti-Gazdewich
Dr. Michelle Zeller

Onsite and Virtual TGH Medical Education Room 025/026

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This Handbook provides practical information on Transfusion Medicine in a concise booklet format. It is designed to enhance knowledge of physicians, nurses, and technologists on the clinical use of blood transfusions and blood alternatives. Revised October, 2022.

Access the references here.

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https://transfusionontario.org/wp-content/uploads/2022/10/Bloody-Easy-5-EN.pdf

coming soon

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