1. Trauma Blood Product Preparation and Delivery Improvement
Pam Bilyeu, MN RN and Lynn Eastes, RN MSN ACNP
Oregon Health & Science University
Background: Blood product delivery time to the bedside of hemorrhaging patients at OHSU is one of the slowest in the nation. There is confusion on the part of nursing and other providers about how to order a massive transfusion and how it differs from the box of emergency uncrossmatched blood (formerly known as the Box of Blood). Ordering is usually verbal, with no written order. The blood product delivery process is variable, resulting in blood not getting to the patient fast enough. Because of the delays, there is difficulty maintaining a hemostatic resuscitation with ratios of 1:1:1 (Plasma, red blood cell and platelet ratios). Additionally, the Blood Bank personnel have no way of knowing when the massive transfusion is completed, leading to over-production of blood products and waste. Products are not systematically returned to the Blood Bank, resulting in further wastage of an expensive resource.
Process: The goal of this project was to improve blood arrival times to within ten minutes of patient arrival., have a product waste of less than 5%, and accomplish a 1:1:1 resuscitation rate of at least 90%. The process improvement tea m held a two-day kaizen. The team included the Trauma Chief of Staff and Program Manager, the Clinical Pathology Vice Chairman and Manager , Transportation Services manager, a critical response nurse, trauma response nurse, and blood bank technologist. During the kaizen the team observed the many manual, tedious steps to prepare the blood and a lack of standard work around blood preparation. As a result of this Kaizen event, the group developed a standard work process for urgent, uncrossmatched blood and subsequent massive transfusion protocol activation and de-activation. Nursing and provider education was determined to be key to the success of this new process which will get blood to the patient in less than 10 minutes, maintain a hemostatic resuscitation 90% of the time, and decrease wastage of FFP to < 5%. The Box of Blood was retired and the new 4 x 4 was created, which includes four units of uncrossmatched packed red blood cells and four units of fresh frozen plasma. After one 4x4 is ordered, if the patient has ongoing hemorrhage, a massive transfusion is ordered in EPIC. Each massive transfusion batch of blood will contain 6 units of PRBC, 6 units FFP, and 1 unit of platelets. To prevent the waste of blood products, once the massive transfusion is completed, a stop order is placed in Epic.
Conclusions/Implications: Since the new 4 x 4 blood delivery process began in August, the ratio of plasma to red blood cells has improved from 0.73 units FFP to unit of PRBC to .86 units FFP /PRBC at 4 hours and from .75 units FFP/PRBC to .89 units FFP/PRBC at 24 hours. The turn around time as decreased from 7.22 minutes to 6.70 minutes and continues to improve. The percentage of patients who received a massive transfusion and at least 1:1:2 resuscitation improved from 69% too 100% at 24 hours. This process has improved the hemostatic resuscitation in the trauma patient, decreased product delivery times and reduced the amount of wasted product.