1. 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.  

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

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

4. Flow Chart, cont.
Question 3
YES or NO?

5. 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 ????

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

8. 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?

9. 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?

10. 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.

11. 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 Feb;62(2):
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

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

13. “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 Oct;63(4):
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….

14. MTP Improvement in Patient Outcomes
All patients
Blunt Trauma
Penetrating Trauma
J Trauma 2009:66:
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.

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

16. 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

17. 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

18. 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

19. No Wasted Motion

20. Massive Transfusion Protocol
The Ronald Reagan UCLA Trauma MTP

21. 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

22. 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.

24. 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

25. 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

26. 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

27. 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.

28. 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

29. 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

31. 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?

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

33. 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

34. 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

35. 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

36. 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

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

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

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

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

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

42. 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%)

43. 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?

44. 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”

45. 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)

46. 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

47. 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

48. MTP Beyond the ED…..
Labor and Delivery MTP

49. 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 are related to hemorrhage—

50. 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

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

52. 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

53. 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)

54. 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

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

56. 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

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

58. The Team