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May 2024

In This Issue

  • Experience of MHP Implementation in 16 small rural hospitals
  • Massive Hemorrhage Protocol Implementation at Small Hospitals: Challenges, Possible Solutions, and Opportunities
  • Featured Resources
    • 19th Annual TM Education Web Symposium (Archive)
    • Ontario MHP: Guidance for small/remote hospitals
    • Implementation Checklist (MHP Toolkit) – Adult
    • Patient Transport (MHP Toolkit)
    • MHP Quality Metrics Portal
  • Upcoming Events
    • CSTM 2024
    • Transfusionists Talks
    • U of T Rounds

Experience of MHP Implementation in 16 small rural hospitals 

Dr. J. Radigan, FRCPC, Pam Vansteelandt, MLT, BSc., CLQM, MBA, Tasha Vandervliet, RN, BScN, Deanna Wright MBA, BSc, MRT(T) 
Stratford General Hospital-Interhospital Laboratory program, Stratford, ON 

The Interhospital Laboratory Partnership (IHLP) is a lab-partnership of 16 small, rural community hospitals in Southwestern Ontario. We have one blood bank hub site that does antibody identification, 8 sites that do basic blood banking and crossmatching, and 7 dispensary sites which only carry emergency O PRBCs onsite. 

Since the release of the MHP Toolkit in 2020, we have been transitioning from a lab-based Massive Transfusion Procedure to a Hospital-based Protocol. After some delays due to COVID and Health-human resource shortages, our sites have been either refining existing processes, or actively developing their Hospital/Alliance-specific MHPs. 

A multidisciplinary team including nursing, nurse educators, lab staff, pharmacy, and maintenance have contributed their expertise and experience to make implementation successful.  We have utilized the resources from the provincial MHPs. We have utilized the resources from the provincial MHP toolkit, and have attempted to optimize plans for unique local conditions.  Small rural sites have specific challenges that were not clearly addressed in the MHP Toolkit such as, the types and quantity of blood products available on site, staffing levels, and availability of transport.

Given the limited lab staffing at rural sites, we have opted to utilize prothrombin complex concentrates (PCC), instead of plasma. This enables nursing to remove the product from the lab and reconstitute; avoiding ABO incompatibility issues, thawing requirements and product ratio tracking. For similar reasons, we have also implemented the use of fibrinogen concentrate (FC) across the region as a replacement for cryoprecipitate.

To validate the proposed MHP processes before finalizing them, Mock Code Transfusions were held in various rural EDs and key care areas. This not only garnered stakeholder buy-in but also enabled the multidisciplinary team to assess necessary process changes at each level to align with protocol goals. These simulations underscored the importance of prioritizing transfers to larger centers and provided valuable practice opportunities for nursing staff in reconstituting and administering PCCs and FCs, as well as utilizing blood warmers and warming blankets.

Physician education is continuous. Given the diverse care provided by our medical staff, training for less common protocols competes with other priorities. The MHP undergoes review by the Medical Advisory Committee before approval. Transfusion training is integrated into Grand Rounds and other educational opportunities for medical staff.

We have been successful in consistent early administration of Tranexamic acid (TXA). We have recently involved local paramedics, with the objective to incorporate pre-hospital TXA administration, where possible.

Knowing the expectation for quality metrics has been helpful in the process, thus we took the approach of evaluating MHPs in terms of these quality metrics.  Quality data will be useful in both process improvement and optimizing future blood product inventory levels.

With guidance and data provided by ORBCoN and CBS, we envision walking this fine line of balancing responsible resource management while still ensuring effective MHPs at all our rural hospital sites.

Massive Hemorrhage Protocol Implementation at Small Hospitals: Challenges, Possible Solutions, and Opportunities 

Talal Mahdi, MD, FRCPC 
Hematopathologist, Eastern Ontario Regional Laboratory Association, The Ottawa Hospital 

Massive hemorrhage protocols (MHPs) are vital tools designed to expedite the provision of blood components in emergent situations based on best practices for the management of massively bleeding patients. These best practices include early identification of the massively bleeding patient, rapid provision of blood components and products, and a coordinated human resource response aimed at rapid identification of and control of bleeding. 

While all hospitals that contain emergency departments, operating rooms, and/or obstetrical services should have MHPs, there are certainly challenges that may come with their implementation. These can include engaging and educating clinical partners, staffing limitations, limited inventories of blood components and products, limited laboratory test variety, and the ability, or rather, the inability to offer definitive hemorrhage control. However, amidst these obstacles lie potential solutions to optimize MHP implementation and efficacy, and ultimately, improve patient care.  

Potentially the most significant obstacle to effective MHP implementation at small hospitals is the engagement and education of clinical colleagues. It is crucial that all individuals involved in carrying out the MHPs are engaged throughout the process, and all educated to be on the same page, as the MHPs require a rapid, coordinated team response. This can be done through the creation of specialized subcommittees as well as holding regular education and review sessions for all those who may be involved in the implementation.  

At the heart of MHP efficacy lies the timely identification of massively bleeding patients and the rapid provision of necessary blood components or products. However, staffing limitations pose a significant hurdle in this process. To address this, hospitals can implement after-hours working policies and procedures. By empowering physicians and nurses to obtain blood units with appropriate documentation outside regular hours, hospitals can bolster their ability to respond promptly to hemorrhage cases. 

Moreover, tailoring blood tests to match available resources during after-hours shifts can further streamline the process. Utilizing point-of-care instruments for this allows for efficient testing, enabling swift decision-making regarding blood component provision.  

If patient transfer is necessary, proactively preparing for such events can be accomplished by establishing clear criteria for MHP activation. Additionally, due to the scarcity of MHP activation in most centers, running regular mock MHP activities can help maintain staff competency and ensure readiness to execute protocols effectively when the need arises.  

Retrospective learning is a valuable tool as well, and implementing regular audits provides valuable insights from previous MHP activations, facilitating compliance with regulations and driving continuous quality improvement. 

Lastly, when faced with unavoidable blood components and product inventory limitations, it is important to foster communication and collaboration with nearby hospitals. This can bolster support during blood component and product shortages and patient transfers, forming a network of assistance in times of need.  

While challenges in implementing MHPs persist, proactive measures and innovative strategies offer pathways to surmount these obstacles. By leveraging adaptive solutions, maintaining a network of support with one another, and fostering a culture of continuous improvement, hospitals can enhance their capacity to respond swiftly and effectively to cases of massive hemorrhage, ultimately improving patient care. 

Featured Resources

19th Annual TM Education Web Symposium

Ontario’s MHP: Guidance for small/remote hospitals

Implementation Checklist (MHP Toolkit) – Adult

Patient Transport (MHP Toolkit)

MHP Quality Metrics Portal

Note: Each Ontario hospital will need to determine where the data for the metrics is housed within their facility and who will be responsible for gathering and entering the data.

Capture MHP Quality Metrics data, Auto-generate reports, Assess and improve specific metrics. Get more info at transfusionontario@gmail.com

Upcoming Events

Transfusionists Talk

CSTM 2024

U of T

June 20, 2024 @12pm-1pm

MLT Session – Interesting serology cases

Subscribe to U of T Transfusion Medicine Rounds mailing list to get registration details