1. Obstetrical Hemorrhage Management
Authors: Ariana Dye MT, MPH, Ruth Barnes MSN, APN Project Leads: Angela Treml MD, Michael O’Connor MD, Barbara Scavone MD, Kenneth Nunes MD
Background
Changes Made
The Blood Bank relocated to CCD in 2013 but Labor & Delivery (L&D) and Mother-Baby units remained in Mitchell Hospital. Clinical specimens and blood products are transported between the two departments using the pneumatic tube system.
The pneumatic tube system is comprised of several pathways between Mitchell and CCD but one or more pathways was frequently out of service. The Blood Bank did not have a process established for transporting blood products in case of a pneumatic tube system outage.
Walking time between the Blood Bank and Labor & Delivery is 12 or more minutes
Labor & Delivery staff did not receive adequate training for the Massive Transfusion Protocol (MTP).
Held an unannounced simulation in L&D OR to identify process improvement opportunities.
Partnered with Inpatient Pharmacy to establish Blood Runner system for blood delivery when the pneumatic tube system is down.
Secured a mobile refrigerator for L&D Operating Room to ensure blood products are stored appropriately during an MTP
Created an Epic Obstetrical MTP transfusion order automatically pre- set with blood product quantities for MTP pack.
Provided training and education for nurses, medical technologists, pharmacy techs and physicians.
Created a scripted exchange between L&D and Blood Bank to ensure critical information is communicated.
Led a second unannounced simulation to measure the impact of process improvements made
Conducted an FMEA with key stakeholders to evaluate additional improvement opportunities
Aims
Within one year, implement a process to ensure timely delivery of blood products and facilitate the safe and efficient management of hemorrhaging mothers in Labor & Delivery.
Dr. Scavone and Team providing care to a mannequin during a simulation
Project Design/Strategy
Pre Training Simulation
Project Design: Held an unannounced simulation in L&D to identify process deficiencies then collaborated with stakeholders to implement process improvements. Led a second simulation to measure the effects of implemented improvements.
Process Measure: Blood product delivery turn-around-time using a runner
Outcome Measures: The number of MTP activations, maternal morbidity.
Key Stakeholders: Labor & Delivery, Mother-Baby, Blood Bank, Inpatient Pharmacy, Risk Management, Quality Performance Improvement, CBIS, Clinical Laboratory
Quality Improvement Tools Used: Process Mapping, Failure Modes and Effects Analysis (FMEA)
MTP Activation
Patient Transfused
Elapsed Time
MTP Pack #1
8:09 pm
8:40 pm
31 minutes
Post Training Simulation
MTP Activation
Units Transfused or Refrigerated
Elapsed Time
MTP Pack #1
9:18 pm
9:39 pm
21 minutes
MTP Pack #2
9:40 pm
9:55 pm
15 minutes
OBGYN Massive Transfusion Protocol Process Flow
Outcomes & Lessons Learned
Turn-around-time for initial MTP pack with a runner reduced from 31 minutes to 21 minutes. Time to receive an additional pack was 15 minutes.
Pharmacy techs will be the designated runner if the tube system is down.
All staff received appropriate MTP training.
Communication between L&D and Blood Bank improved using scripts and assigned responsibilities
Next Steps
Acknowledgements
Expand the MTP to adult and pediatric Emergency Rooms and Critical Care locations.
Incorporate MTP into clinical staff’s Continuing Education programs
UCM Obstetrics, Blood Bank, Nursing and Nursing Education, UCM Simulation Center, UCM Inpatient Pharmacy, Center for Quality