MASSIVE TRANSFUSION PROTOCOL Shands at University of Florida DEVELOPMENT & IMPLEMENTATION

Transcription

1 MASSIVE TRANSFUSION PROTOCOL Shands at University of Florida DEVELOPMENT & IMPLEMENTATION

2 MASSIVE TRANSFUSION: Joint Anesthesia, Surgery, CCM Morbidity and Mortality Conference 15 February 2006 University of Florida COM

3 Massive Transfusion Case Presentations Necrotizing Pancreatitis Blunt Abdominal Trauma Physiology and Management of Massive Transfusion Requirements Gordon Gibby, MD The Blood Bank and Massive Transfusion Juan Scornik, MD Discussion

4 Time Line 2 March 2006 Plans to form rapid process QI Team 24 February 2006 Urgent meeting of subgroup to address possible immediate stopgap interventions Measures suggested Identify PST whose only purpose is blood/sample transport during MTP Identify person whose only purpose is communication with BB during MTP istats available in OR Get OR BB refrigerator on line Increase staffing in BB

5 2 March 2006 Time Line Planning Meeting for MTP QI Team Set goals Pick team and leaders Team Leader: Alan Reed Process Owner: Georgiann Ellis Facilitator: Sue (CQI) Jones Members: broad representation of those involved Formation of 3 pre-meeting sub-groups Flow charting subgroup Stat Lab/Satellite BB subgroup Scientific subgroup

6 MTP Team Members Alan Reed, MD - Leader Georgiann Ellis - Process owner Sue Jones - Facilitator Elizabeth Beierle, MD - Pediatric Surgery Bette Brotherton - Quality Management Michele Brunges, RN - Operating Room Pam Clevenger, RN - Operating Room Paula Davis, RN - Emergency Department William Gair - LifeSouth Catherine Garrison, MD- Sr. Surgery Resident Monique Huggins - Blood Bank Kathy Langer, ARNP - SICU Lawrence Lottenberg, MD - Trauma Surgery Richard Lottenberg, MD - Hematology/Oncology Tisha Netzel, MD - Clinical Pathology Cheryl Urban, RN - Risk Management Michele Ziglar, RN, MSN - Trauma

7 GOALS To develop a single massive transfusion protocol Evidenced based Applicable across services Applicable to adults and children The MTP should Provide proper products to the proper site in a timely fashion Maintain homeostasis Prevent product wastage To enable the logistics of putting this plan into effect within the Shands at UF system: Who should enact? For what type of patients? How and to whom will the information flow? Determining necessary resources To define parameters for measurement and concurrent review

8 Implementation Time Line 8 March 2006 First full team meeting 15 April 2006 Final full team meeting 8 May 2006 Stakeholder s Meeting Bypass the physical barriers ER phone lines Keyed elevator Purchase coolers and stencil them First draft of policy ready to review, then legal Form through forms process Completed MTP through policy committee Present to the Shands HC Quality Committees Prepare educational materials Present at a variety of venues 4 June 2006 Transfusion Committee 7 July 2006 Legal/Risk Management 15 September 2006 Policy Committee 1 December 2006 Go Live..

9 Analysis The most important concept is communication Focus on defined roles Insist on, and enable, constant dialogue There is little science to go on Proximity of BB to OR and ER Transport of blood and blood products It is surprising what is actually happening when you think you know what is happening

10 Policy Nuts and Bolts Recognizes MTP differs at 3 different sites OR ED ICU At each site, there are well defined roles Nurse communicator/scribe Blood runner (on-line education) Communication is emphasized New phone lines in ED Emergency BB line Part of the expected process The process is standardized Type and XM samples Use of ER and OR Refrigerators Coolers Product delivery Route of travel for runners Handoffs (RN to RN) Lab monitoring (istat)

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12 Policy Nuts and Bolts Recognizes MTP differs at 3 different sites OR ED ICU At each site, there are well defined roles Nurse communicator/scribe Blood runner (on-line education) Communication is emphasized New phone lines in ED Emergency BB line Part of the expected process The process is standardized Type and XM samples Use of ER and OR Refrigerators Coolers (Michele Ziglar) Product delivery Route of travel for runners Handoffs (RN to RN) Lab monitoring (istat)

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14 Policy Nuts and Bolts Recognizes MTP differs at 3 different sites OR ED ICU At each site, there are well defined roles Nurse communicator/scribe Blood runner (on-line education) Communication is emphasized New phone lines in ED Emergency BB line Part of the expected process The process is standardized Type and XM samples Use of ER and OR Refrigerators Coolers Lab monitoring (istat) Product delivery Route of travel for runners Handoffs (RN to RN)

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16 Policy Nuts and Bolts Recognizes MTP differs at 3 different sites OR ED ICU At each site, there are well defined roles Nurse communicator/scribe Blood runner (on-line education) Communication is emphasized New phone lines in ED Emergency BB line Part of the expected process The process is standardized Type and XM samples Use of ER and OR Refrigerators Coolers Lab monitoring (istat) Product delivery Route of travel for runners Handoffs (RN to RN)

17 Schedule for Massive Transfusion Protocol Shipment Red Blood Cells Plasma Platelet Dose/ APH Cryo **rfvlla *1 10 (O-Neg) 4(AB) rfviia rfviia *Shipment 1 is located in the Satellite Blood Bank Refrigerator, located in the ED and OR. ** Suggested; see policy for specifics.

18 Policy Nuts and Bolts The Blood deliveries are standardized BB empowered to make appropriate choices On-site MTP un-crossmatched blood refrigerators Documentation Tool (Kathy Langer) Process flow sheet Becomes the order when signed Serves to collect data

19 Massive Transfusion Protocol Documentation Form

20 When Does Need for Blood Become an MTP? Definition: Presumed need of at least 10 units of PRBC for an adult patient At least 5 units for a child Short time period (i.e. within 2 hours)

21 Who Can Initiate MTP Attending Physician Fellow Chief Resident, acting Chief Resident R4 and above

22 MTP Process Shands at UF Attending, Fellow, Chief Resident Acting Chief Resident initiates MTP & notifies designated RN Designated RN**: Calls BB to unlock refrigerator Logs out blood from MTP refrigerator & delivers Sends designated MTP Runner to BB with cross & match ED/OR MTP site? ICU Designate RN (ICU Charge Nurse): Calls BB with MTP alert Sends designated MTP runner to BB with cross & match ** ED = Nurse Scribe OR = Circ. RN notifies Charge Nurse END NO MTP runner delivers blood products to designated RN Designated RN assures blood administered per MD order Is more MTP needed? Designated RN assures blood administered per MD order YES END Designated RN sends MTP runner for more blood Designated RN transports blood with pt. to location (OR/ICU) YES Is pt. to be transported with blood? NO END

23 START ED Attending, Fellow, or Chief/ Acting Chief Resident initiates verbal order to ED Nurse Scribe MTP Process For Shands UF Emergency Department END ED Nurse Scribe: Calls BB on BB phone to unlock MTP refrigerator Gives pt. info. to BB Tech. END NO Pt. to be transported with blood to OR or ICU? YES ED Nurse Scribe: Transports blood with pt. Hands off to accepting RN Documents on MTP form Blood Bank tech: Unlocks MTP refrigerator Notifies BB supervisor of MTP ED Nurse Scribe Calls BB to cancel MTP & documents on MTP form NO Is more MTP needed? YES ED Nurse Scribe sends CCT to BB for next delivery & documents on MTP form ED Nurse Scribe: Alerts the OR& ICU of MTP Designates CCT as MTP runner Sends runner to BB with pt s cross &match specimen ED Nurse Scribe: Logs out blood products from MTP refrigerator Labels units Administers per MD order CCT delivers blood to ED Nurse Scribe

24 START OR Attending, Fellow, or Chief/ Acting Chief Resident initiates verbal order to Circulating Nurse MTP Process For Shands UF Operating Room OR Circulating RN notifies Charge Nurse of MTP PST delivers blood to OR Charge Nurse OR Charge Nurse calls the BB to unlock OR s MTP refrigerator; &gives pt. info. to BB Blood Bank tech: Unlocks the OR s MTP refrigerator Notifies BB supervisor of MTP BB prepares 2nd blood product order for pick up OR Charge RN notifies BB; & sends PST for next delivery YES END OR Circulating RN: Transports blood with pt. Hands off to accepting RN Documents on MTP form YES OR Charge Nurse logs out blood products from MTP refrigerator; & delivers blood to OR Room Is more MTP needed? NO Pt. to be transported with blood to ICU? OR Charge Nurse designates PST as MTP runner & sends to BB with pt s cross & match specimen NO END

25 START OR Attending, Fellow, or Chief/ Acting Chief Resident initiates verbal order to ICU Charge Nurse MTP Process For Shands UF Intensive Care Units ICU Charge Nurses uses designated BB phone # to alert BB of MTP & gives BB pt. info. ICU Charge Nurse notifies OR of MTP ICU Charge Nurse designates CCT as MTP runner; & sends runner to BB with pt s cross & match specimen CCT delivers blood to ICU Charge Nurse BB prepares 2nd blood product order for pick up END ICU Charge Nurse: Transports blood with pt. Hands off to accepting RN Documents on MTP form CCT delivers blood products to the ICU Charge Nurse ICU Charge RN notifies BB; & sends PST for next delivery YES YES ICU Charge Nurse assures that pt s bedside RN receives the units Is more MTP needed? END NO NO Pt. to be transported with blood to the OR?

26 Quality Review Indicators Measuring the Process Shands Transfusion Committee would act as the reviewing body All instances of MTP initiation to be reviewed for Appropriateness of initiation Timing of Deliveries Product usage Product Wastage Outcomes (survival) MTP Team to meet at 6 months after policy implementation to review data

27 Committee/Educational Presentations Committees Transfusion Committee 6/4/2006 PSQEC 10/4/2006 QSEC 10/19/2006 BQC 10/25/2006 Surgery M&M 11/29/2006 Trauma Quality Management Committee Nurses/others OR/ED blood refrigerator in-services Specimen transport education in-service On-line education for all users? Physicians CME? ED? CCM? Medicine?