How I Came to Be? Saturday@7:36am Hi Elsa, The BCC speaker for the Monday night dinner dropped out, and we are looking for another speaker.    Would you be interested in giving the trauma presentation to our group in Santa Barbara?   It’s the Blood Centers of CA CEO group.   Saturday@7:36am

Flow Chart Question 1 Why was she sending an e-mail so early on a Sat? Why was I reading my e-mail? How did she know I would be reading it? ANSWER: Type A Personality

Flow Chart Question 2 What Monday? ANSWER: This Monday (kind of figured otherwise why the question on Sat)

Flow Chart, cont. Question 3 YES or NO?

Flow Chart, cont. If I answer NO: Back from 2 weeks in Hawaii. Just asked for another week off….. hmmmmmm…….. She is the BOSS..... Hmmmmm again My yearly evaluation is due… Answers that ????

Massive Transfusion Protocol What’s it all about? Elsa Tsukahara, MT(ASCP)SBB Ronald Reagan UCLA Medical Center 7

Bleeding to Death! Give me “everything” you have! “Massive Hemorrhage” Bleeding to Death! Give me “everything” you have! We all have either heard this or will hear this sometime in our career. And of course we have a picture in our mind of what this means. But give me everything you have?

Cornucopia of Blood Products Whole Blood Red Blood Cells Platelet Concentrates Single Donor Platelets 5 Day Plasma Fresh Frozen Plasma Single Unit Cryoprecipitate Pre Pooled Cryoprecipitate Factor Concentrates In the good old days there was only 1 or 2 products to chose from. So Give me Everything maybe was more meaningful. But now days it ain’t so simple. There are multiple different products that can be utilized. So what in the heck they actually need. Any maybe they don’t even know what they need?

Definition of “Massive Hemorrhage” Acute Loss of 6-10 units of RBC Emergency Intervention is required to Control Life-Threatening Bleeding Sudden loss of LARGE amounts of blood. With the 2nd definition of “bleeding to death” is really accurate.

Damage Control Structured intervention that begins immediately Prediction of Massive Transfusion Address the Vicious Cycle Immediately Minimize the use of crystalloids Treatment of acidosis, hypothermia and hypocalcemia Surgical control of bleeding Early transfusion of RBC, Plasma, and Platelets J Trauma. 2007 Feb;62(2):307-10. Basic concept with a MTP is Damage Control. A key words are “Structured”, “Immediate”, “Predictive” Military routine is “Scoop and Run”. Control bleeding and get the patient to a site that can do more. Do not waste time trying to start an IV. Part of this is also the situation that they are in. They need to leave an area

Mortality by Plasma to RBC Ratio Military Experience Retrospective Review of the Military Experience Baghdad from Nov. 2003 – Sept. 2005 Mortality by Plasma to RBC Ratio J Trauma. 2007 Oct;63(4):805-13. A lot of what got us started on talking and doing was based on the militaries experience in the middle east.

“1:1:1 Ratio of RBC:Plasma:Platelets” Military Experience January 2006: U.S. Army Surgeon General issued a field medical recommendation that resuscitation of the massively injured be conducted with a “1:1:1 Ratio of RBC:Plasma:Platelets” Limitations of the study: Retrospective review, narrow patient demographic, 1:1 = fresh whole blood J Trauma. 2007 Oct;63(4):805-13. In review of this paper comments were made about the fact that is was retrospective study, it was based on a specific type of patient and type of injuries, and what they were approximating was basically Whole Blood. But…. Does a MTP actual improve outcomes….

MTP Improvement in Patient Outcomes All patients Blunt Trauma Penetrating Trauma J Trauma 2009:66:1616-24 Solid Column are patients treated with MTP protocol. Looking at percent Mortality. There is decreased mortality in all types of trauma if a MTP is utilized both within 24 hours and overall . From this particular study you can see that the biggest impact appears to be in blunt traumas.

What is the Optimal Ratio? Texieria: J Trauma 2009;66:693-7

What is all this saying? Trauma is the leading cause of death worldwide 30-40% of trauma patients die secondary to bleeding and coagulopathy A MTP may reduce mortality Optimal ratio is not known

Approach to MTP A system that allows for early and aggressive component transfusion that approximates whole blood Optimize ‘Communication’ between the transfusion service and the patient team Optimize delivery of blood products Standardize patient care High Risk but Low Volume – Standardize the transfusion service practice

Food for Thought Identify patients at risk quickly Communication Provision of “Uncrossmatched” RBC Involvement of “Key” personnel Trauma MD Transfusion Medicine MD Training of Staff

No Wasted Motion

Massive Transfusion Protocol The Ronald Reagan UCLA Trauma MTP

Ronald Reagan-UCLA Stats 100 Trauma Patients admitted annually that fall into our “Hi” end Tier System 23 patients were massively transfused 725 RBC (32 units / pt) 557 Plasma (24 units / pt) 84 Platelets (3.5 units / pt) RBC:Plasma ratio range of 0.20 – 1.1

Trauma Refrigerator Trauma Refrigerator in the “Trauma Bay” Maintained and monitored by the Blood Bank Contains at least 4 O Neg RBC RBC are prelabeled with generic transfusion forms Alarm is activated in blood bank when the refrigerator door is opened.

Pre-Thawed Plasma Inventory Blood Bank Maintains Pre-thawed Plasma 5 group O 5 group A All blood types will be thawed if multiple victims from a disaster are expected

The “Trauma Phone” – ‘Hot Line’ A direct line from the ED to the Blood Bank Blood Bank phone Wireless Distinctive Ring Each OR room has this “unique #” posted

Trauma Coolers 3 Trauma Coolers are maintained in the Blood Bank for Urgent Usage 2 Coolers with 4 O Neg RBC each 1 Cooler with 4 O pos RBC Used for ALL male traumas

Trauma Coolers Color Coded Red – RBC Yellow – Plasma Validated for 8 hours of storage with a max. of 6 units Can be transported with the patient Temperature Monitor Note: Since moving the our hospital we now employee a full time blood courier 24/7.

Switching Rh(D) Blood Groups The “D” antigen is very immunogenic …BUT…… Rh Neg RBC inventory is limited Most Traumas are Young Males Rh Neg inventory should be reserved for Women of childbearing age to avoid HDFN Patients with preformed anti-D to avoid HTR

Identify the Patients at Risk Trauma Team developed a method categorizing patients at risk using predictive algorithms A “Tier Designation” was Designed Communication Standardization of Transfusion Orders Transfusion Packet Developed Minimize delays in registration Contains all paperwork/labels required for ID bands, radiology, lab, and blood bank

Safety of Uncrossmatched Blood Fatal hemolytic transfusions reactions due to NON-ABO antibodies are rare In trauma setting with large blood loss this would be extremely rare Most result ONLY in Delayed Hemolysis Exsanguinate vs Delayed Hemolysis?

Tier I Patient is stable Transfusion is NOT expected Blood Bank Actions Perform a STAT Type and Screen Prepare Blood Products ONLY on request

Tier II Patient MAY require transfusion or surgical intervention Blood Bank Actions Perform a STAT Type and Screen Crossmatch 4 RBC Prepare 4 Plasma Send Blood Products upon request Maintain a “Keep Ahead” of 4 RBC and 4 Plasma

Tier III Patient unstable. Requires IMMEDIATE transfusion Blood Bank Actions Perform a STAT Type and Screen / 10 unit XM Prepare and send 10 plasma Maintain a ‘Keep Ahead” of 10 RBC and 10 Plasma at ALL times Send 1 Platelet / 1 Hemostatic Dose of Cryoprecipitate with EVERY 10 Plasma

Why 10:10:1? The 10 RBC / 10 Plasma system was already being utilized for our Liver Transplants Easy to remember 1:1:1 = 10:10:1

Training of Staff On going – Huddles, Staff Meetings Discuss each “incident” to improve Liaison with the ED team to discuss problems Blood Bank has a representative on the Trauma Committee

Turn Around Time (TAT) for Trauma Specimens GOAL: Verified T&S Result within 60 min of receipt of 90% of specimens from Trauma Patients

Initial TAT Data January – December, 2006 Average Goal Met: 77% Low: 55% High: 89%

Action Plan Monthly Data e-mailed to all staff Incentive for meeting the goal

Follow up TAT Data January – December, 2007 Goal Met on Avg: 89% High: 94%

Additional Action Plan Communicate at Daily Huddles / Staff Mtg Provide more detailed information Manual vs Automated TAT Reminders to “Verify” the result

2 months when the Goal was NOT met! The Latest…. January 2008 – March 2010 2 months when the Goal was NOT met! (88% and 89%)

Metrolink – Sept. 12, 2008 Background ~Things never quite workout like you plan~ We had recently moved to our new facility at RRH It was a Friday Afternoon First NOTIFICATION of a Problem Manager contacted by Blood Supplier Recruitment asks if we should open on Saturday?

Fate…… Staffing on that Friday 5 CLS (routinely only 4) 2 Supv (routinely only 1) Lab Director Processing Staff Blood Bank Resident 1 Full Time dedicated “Blood Courier”

Inventory 50 O Pos RBC had just been delivered for routine stocking Blood Suppliers contacted us frequently to determine what we needed Trauma Refrigerator stocked with additional O= RBC Thawed all ABO group plasma Decision early on to switch RH= males to RH+ RBC (prior to our change in policy)

When crisis strikes, the best in all of us shine…. Blood Supplies provided what we needed and gave us ETA’s on delivery. YOU called us…. Patient care floors stopped ordering blood products Outpatient clinic closed early Someone ordered pizza! The nite shift came in early 3rd supv did a 180

The DATA… 5 Critically Injured Patients (ie 5 CLS!) Between 1810 – 2050 16 Blood Coolers Issued 73 RBC Crossmatched (34 Uncrossmatched) 58 Plasma Thawed 80 Cryo Thawed and Pooled 7 Platelets Issued

MTP Beyond the ED….. Labor and Delivery MTP

What’s going on….. Hemorrhage is the most common cause of maternal death in NY State, and accounts for >50% of deaths in NYC In preliminary analyses, 1/3 of California maternal mortalities from 2002-2004 are related to hemorrhage—

California Maternal Quality Care Collaborative The CMQCC OB Hemorrhage Task Force was formed Comprised of State Agencies, Professional Organizations, Public Groups and California Hospitals The Mission of the CMQCC is to transform maternity care in California to end preventable death and injury Ronald Reagan UCLA Group is compromised of OB Anesthesiologists, RN, and Risk Management

Where in Lies the Problem Per Joint Commission Communication is the most common problem in bad maternal outcomes!

Labor & Delivery MTP Adapted the Trauma Tier System currently in use Commonality Clinical Criteria were developed to categorize patients into the Tier System “Trauma Line” utilized “Non Standard Blood Release” utilized

Labor & Delivery Tier Designations Only Tier II and III used L&D patients have Type and Screen ordered when admitted (ie no need for Tier I designation)

Staff Training Mock Drills with the L&D Staff Lectures to the RN’s and MD’s by the Blood Bank Blood Bank attendance at RN morning meetings Follow up after each MTP Activation

And Beyond…… Operating Room MTP Hospital MTP Policy Training starting at our sister hospital – Santa Monica UCLA Orthopaedic Hospital Hospital MTP Policy

Last Words Hemorrhage is a leading cause of death in trauma patients Hemorrhage remains a major cause of obstetric morbidity and mortality MTP’s provide a system approach to provide appropriate products in a timely manner

Keys to Success Education Follow up On going Evaluation COMMUNICATION Between departments Within the department

The Team