On the Road to a Provincial Massive Hemorrhage Protocol (MHP)
By: Stephanie Cope, Administrative Project Coordinator, CE ORBCoN
All Ontario patients, including those that are massively bleeding, deserve quality, equitable and coordinated care. Previous studies have shown that there is inter-institutional variability across all aspects of a MHP. In order to understand Ontario practices, a baseline survey was sent November 30th 2017, to Transfusion Medicine (TM) Medical Directors/TM Leads at all Ontario hospitals with a transfusion service* (n=150) with an aim of determining the proportion of hospitals with a formal, implemented MHP and the components included. The survey question categories included; hospital demographics, activation criteria, communication, teams, blood draws, laboratory test menu, patient temperature management, transport, transfusion medicine, and quality metrics.
The survey received a 100% response rate with a total of 132 completed responses (17 hospitals provided a verbal response that they did not have a MHP and one partial response was received).
Ninety-seven hospitals (65%) had a MHP implemented although wide variation in practices was observed. There were at least ten different names given to a MHP, with “massive transfusion protocol” the most commonly used name at 68% of hospitals. One of the key goals of the provincial initiative is to eliminate the confusion of having multiple and varying protocols amongst Ontario hospitals as many healthcare professionals (e.g. medical trainees) have to rotate through or work at multiple hospitals.
The most common method of protocol activation was with a call to hospital locating at 87% followed by a call to the Transfusion Medicine Laboratory in 78% of hospitals.
There was wide variability in the triggers for MHP activation which included:
- Volume of blood loss (70%)
- Number of red blood cell (RBC) units transfused (60%)
- Hemodynamic instability (32%)
Laboratory tests routinely drawn during protocol included:
- Group & Screen
- Blood gas
- Ionized calcium, and calcium
Four hospitals also included ROTEM (although the test is available at nine hospitals) while no hospital utilized TEG for their protocol (although this is available in two hospitals).
Fibrinogen testing was available in 66% of hospitals.
The monitoring of patient temperature was included in 65% of protocols with warming blankets being the most common method (61%) to achieve normothermia.
The majority of hospitals reported transporting RBCs and plasma in containers validated to maintain acceptable temperatures whereas only 33% of platelets and 29% of cryoprecipitate issues were reported as being transported in validated containers. Components maintained in appropriate storage temperatures may be returned into inventory if not used which may help reduce wastage.
A significant gap was noted in the in-hospital transfer of products and samples with only 33% of hospitals using Porters for this role.
Group O Rh- negative RBCs are given to all patients with unknown blood group in 36% of hospitals. The remaining hospitals use O Rh-negative RBCs in the following patients:
- Females <45 years (60%)
- Patients with a history of anti-D (27%)
- Females <50 years (20%)
- All children (14%)
- Women of child bearing age (11%)
- Females <46 years (5%)
Fifty-nine hospitals reported having predefined blood/trauma ratio based packs with most using a ratio of 4:0:0:0; red blood cells: plasma: platelets: cryoprecipitate respectively in pack one. There was marked variability in subsequent blood packs.
Tranexamic acid (TXA) was included in 70% of MHPs.
The survey found that 69% of hospitals with a MHP do not track any quality metrics. The 31% of hospitals that do such tracking only did so for select cases.
A Delphi-method exercise was completed by a multidisciplinary panel that brought together experts from various disciplines including: emergency medicine, trauma, ICU, obstetrics, pediatrics, anesthesia, hemostasis, transfusion medicine, pre-hospital transport, nursing, and patients to name most. The purpose of the exercise was to reach consensus on recommendation statements for inclusion in a provincial MHP toolkit. The survey results and supporting literature for the recommendations were presented at ORBCoN’s Transfusion Committee Forum April 20, 2018. The presentations can be found at https://transfusionontario.org/documents/?cat=transfusion-committee-forum.
We know that one size does not fit all, but we know that standardized protocols do work. That is why we are working towards a multi-part provincial MHP protocol that will include policies and procedures, checklists, training and educational materials and much more, for the benefit of both large and small hospitals, and both adult and pediatric populations.
ORBCoN would like to thank all hospitals for their participation in the survey; it is this collaboration that allows us to do our job. We would also like to thank Victoria Chin, Dr. Calvin Yeh and our expert panel members for their dedication to this undertaking and, last but not least, to Drs. Jeannie Callum and Katerina Pavenski for leading us in this provincial initiative.
*Defined as a licensed laboratory transfusion service that receives blood components/products directly from Canadian Blood Services and may also provide blood components/products to another facility for either storage and administration, or administration only.
Bloody Easy Nursing Transfusion Medicine Boot Camp: Lab to Bedside
By: Leonor De Biasio, Clinical Project Coordinator, Transfusion Safety Nurse, CE ORBCoN
Transfusion is a familiar therapeutic practice in health care institutions, and nurses have an active involvement in transfusion practices. In Ontario, basic blood transfusion education usually begins in nursing schools and the education should continue throughout a nurse’s career. It has been noted by front line nursing staff that most of the training is minimal and self-directed. Several studies have noted that nurses need to have more extension in transfusion knowledge and skills to perform their responsibilities safely and effectively.
Ontario Transfusion Medicine (TM) clinicians identified that nurses have a vast amount of influence in their daily practices in the areas in which they work. To achieve best practices and cultural change in TM, transfusion educational training sessions targeting the Ontario nursing population would assist in cultivating transfusion knowledge. In 2017, the Ontario Regional Blood Coordinating Network (ORBCoN) considered the need for TM education for Ontario nurses. As a result, a working group was established to assist in the development of a pilot four-hour province wide educational videoconference geared for the nursing audience. On March 26, 2018, the event occurred at no cost to the participants.
The working group and speakers consisted of patient blood management (PBM) coordinators, transfusion safety officers (TSO), TM physicians, and an ORBCoN clinical project coordinator-transfusion safety nurse. The TM experts created an educational event to enhance the learning and build capacity in TM for Ontario nurses. The topics in the curriculum included:
- Pretransfusion Testing: How quickly can we get blood?
- Transfusion Guidelines: Less is Best
- Best Practices: Hemoglobin Optimization
- Administration Process: Informed Consent, Patient Preparation and Administration Procedures
- Recognition, Management and Prevention of Transfusion Reactions and Errors
The Bloody Easy Nursing TM Boot Camp: Lab to Bedside event not only enhanced the knowledge and skills of Ontario nurses but it provided them with the ability to interact with TM experts across Ontario through webcasting capabilities via Ontario Telemedicine Network (OTN) from their institutions.
Prior to the event a pre assessment knowledge survey and registration through LimeSurvey™ was distributed to laboratory contacts and the nursing leadership teams throughout Ontario hospitals. The survey results presented 507 registrants. During the event, 59 institutions accessed the videoconference through OTN and 23 groups utilized webcasting capabilities from their home or office. After the event, a post assessment knowledge survey comprised of the same ten questions as the pre assessment knowledge survey, and an evaluation was distributed to all registrants and all respondents were to receive a certificate of attendance at completion. The post videoconference results indicated 92 respondents received and completed the post assessment knowledge survey and evaluation. One of the challenges noted after distribution of the post assessment knowledge survey and evaluation through LimeSurvey™, was several mail delivery failures. Reasons associated with the mail delivery failures were network security issues within the hospitals or inaccurate email addresses provided during registration.
The data received from both pre and post assessment knowledge surveys exhibited on average:
- 57% of the participants answered the pre assessment questions correctly
- 75% of the participants answered the post assessment questions correctly
The data below indicate some of the significant results from the evaluation survey.
Overall rating of videoconference:
- Excellent 34% (31)
- Very Good 48% (44)
- Good 4% (4)
- Neutral 2% (2)
- Poor 1% (1)
Will their practice change after attending the videoconference:
- Most likely 58% (53)
- Likely 25% (23)
- Unlikely 7% (6)
Common themes that were revealed when asked about future topics:
massive hemorrhage, pediatrics, transfusion reactions
It is evident that the data captured from the surveys demonstrate that it is essential and there is a demand for continuous TM education for nurses. I would like to acknowledge the Ontario MOHLTC for their support; UHN, NBRHC, and LHSC for being the on-site host sites; and to the working group members and the speakers for volunteering their time and effort in making this event a success. Finally, thank you to all the health care professionals for their interest and participation in the event.
If you have not received the link to the post assessment knowledge survey and evaluation or received your certificate, please contact: firstname.lastname@example.org.