A massive blood transfusion has been defined as one that requires either a full replacement of the patient’s blood volume or 10 or more units of packed red blood cells (PRBCs) in a 24-hour period.1 While this definition is adequate in describing transfusion volume over time, rate of transfusion is also a critical metric in evaluation of both the patient’s medical need and the demand on blood bank staff.2 At our institution, Massive Transfusion Protocol (MTP) is a term which is used to activate delivery of compatible blood products at a rapid rate (less than five minutes) in emergency situations. This high-pressure situation requires blood bank staff to follow a complex procedure with speed and precision. Complicating the matter further is the relative rarity of MTP activations at the community affiliates within our network (approximately one every three to four weeks, see Table 1) and the difficulty of observing staff execution of the protocol in a controlled setting. In a lab where many cross-trained laboratorians cover the blood bank (nights and weekends), competency assessment for this procedure includes an exam and drills or practice sessions.
Massive Transfusion Protocol
Providing blood products rapidly and effectively requires planning and an understanding of blood banking. The MTP relies on well-developed procedures and some recent improvements in blood product usage in trauma, such as pre-thawed or never-frozen liquid plasma (LQP). Universally compatible blood products are given initially while the patient’s blood type is being determined and screening for antibodies that cause blood transfusion incompatibility is performed. Predetermined universally compatible PRBCs and plasma are immediately available in the blood bank refrigerator. Because of the blood bank’s proximity to the ED and the OR, our community affiliate blood bank does not use blood coolers. Instead, it uses plastic containers (referred to as buckets) that contain two packed cells and two liquid plasma.
This planning allows staff to “grab and go” for delivery to the ED or trauma bay. The first bucket (labeled #1) includes an MTP workflow job aid with critical bullet points. It also contains an MTP worksheet where the laboratorian writes patient information and blood products as they are issued, allowing the blood bank laboratorian to see at a glance what the patient has received and what product they are due to send next. Our blood bank keeps a plasma-to-PRBC ratio of 1:1 during the MTP.3 A member of the blood bank staff delivers the first bucket so he or she can communicate with the trauma team regarding the timing of the next round of products. (Table 2)
Never-frozen or pre-thawed liquid plasma
Recent studies have found plasma which has never been frozen and is kept as a liquid (LQP) to be medically equivalent to rapidly thawed fresh frozen plasma (FFP) in the trauma setting.4-6 This finding is surprising because clotting factors decline in plasma which is not flash frozen.4-6 The reason for this equivalence may be due to the effectiveness of never-frozen LQP in both maintaining intravascular volume and having more clotting factors than isotonic saline.
Although LQP has been shown to be equally effective as FFP in the trauma setting, the scientific basis for this equivalence is not clear. The use of LQP in the first two buckets of the MTP allows frozen plasma to be thawed in time for use in the third bucket. After the third bucket of units has been transfused, a unit of single donor apheresis platelets is transfused and the cycle repeats until the emergency physician or trauma surgeon ends the protocol. The protocol allows for an acceptable ratio of transfused products and facilitates rapid blood product delivery with minimal waste.
Competency assessment strategies
Evaluation of competency in the clinical lab can be roughly divided into direct observation, assessment of problem-solving skills, assessment of test performance (PT and intermediate results review), and supervisory reviews.7-9 Review of blood bank testing and results associated with an MTP is performed within the lab by the supervisor in the days following each MTP activation. However, competent performance of the MTP includes transporting blood products and working with the physicians and nurses involved in the MTP. Traditional peer group-based proficiency testing is not a complete representation of these “outside of the laboratory” skills. Because of the erratic timing of MTPs, direct observation is not realistic. Additionally, problem solving in a situation of clinical urgency needs to be rapid. This combination of needs lends to a competency assessment which includes drills and exams.
The drills to evaluate competency involve three phases which we describe as “Talk, Walk,” and Run.”
Talk: The verbal practice sessions include review of location, equipment, blood products, and technology involved in the MTP as well as an opportunity to work through the checklist. This begins the drill portion of competency assessment.
Walk: The next step of the competency is to walk through the steps discussed verbally. This gives staff the opportunity to see the spaces (Emergency Department, trauma bay) and practice blood product transport in a controlled manner prior to clinical need.
Run: Finally, the drill is timed. Drills are run on the same shift that the laboratorian works; this is done to detect problems, such as a locked door or a security badge not working to open a door, which would prevent delivery of blood products.10,11 A total of two verbal drills, two walkthrough drills, and two timed drills are done by each laboratorian each year.
The exam is centered on understanding the role of the blood bank in the clinical context of the patient care emergency. It includes such questions as “The physician initiates an MTP. What is the very first thing done—even before grabbing the bucket?” The correct answer to this question demonstrates that the blood banker knows to notify other lab staff. This allows staff to rotate into the blood bank from other areas of the lab to accommodate the high level of need in the MTP.
Performing drills can stand in for direct observation of duties, while the exam and verbal discussions with senior staff and the blood bank supervisor demonstrate problem-solving skills. Results of drills and exams are included in performance evaluations.
Staff response
These procedures were developed due to the intense demand of the MTP and the large numbers of staff members who rotate through our blood bank. While we have two dedicated laboratorians who work most of their shifts in the blood bank, 18 other staff members rotate through to cover second shift, third shift, and the weekend. This competency, which is performed in addition to the standard blood bank competency, was developed to document readiness of staff to perform this procedure. Junior staff and recent hires were most appreciative of the opportunity to drill. Senior and experienced staff, after performing the drills, also recognized the value of this competency assessment.
Challenges and future direction
Although at our institution this protocol is used primarily in the trauma setting, it can be used in any setting where a patient has rapid, heavy blood loss. The same type of protocols can be applied to surgical and obstetric patients.10,11 In future drills, the blood bank is expected to integrate more closely with emergency and trauma services to help nursing and physician colleagues understand and appreciate blood bank services. This closer integration will help lab staff ask questions and interact with the patient’s care team; for example, “We haven’t used the last unit delivered, should we consider slowing or stopping the MTP?” Finally, both the drills and the execution of the MTP reinforce in staff, through experience, the critical value that the blood bank provides in emergency and critical patient care.
REFERENCES
- Como JJ, Dutton RP, Scalea TM, Edelman BB, Hess JR. Blood transfusion rates in the care of acute trauma. Transfusion. 2004;44(6):809-813.
- Savage SA, Sumaslawski JJ, Zarzaur BL, Dutton WP, Croce MA, Fabian TC. The new metric to define large-volume hemorrhage: results of a prospective study of the critical administration threshold. J Trauma Acute Care Surg. 2015;78(2):224-230.
- Holcomb JB, Tilley BC, Baraniuk S, et al. Transfusion of plasma, platelets, and red blood cells in a 1:1:1 vs a 1:1:2 ratio and mortality in patients with severe trauma: the PROPPR randomized Controlled Trial. JAMA. 2015;313(5):471-482.
- Mehr CR, Gupta R, von Recklinghausen FM, Szczepiorkowski ZM, Dunbar NM. Balancing risk and benefit: maintenance of a thawed Group A plasma inventory for trauma patients requiring massive transfusion. J Trauma Acute Care Surg. 2013;74(6):1425-1431.
- Dudaryk R, Hess AS, Varon AJ, Hess JR. What is new in the blood bank for trauma resuscitation. Curr Opin Anaesthesiol. 2015;28(2):206-209.
- Gosselin RC, Marshall C, Dwyre DM, et al. Coagulation profile of liquid-state plasma. Transfusion. 2013;53(3):579-590.
- Gerbasi S. Competency assessment in a team-based laboratory. MLO. 2000;32(9):46-52, 54.
- Nemenqani DM, Tekian A, Park YS. Competency assessment in laboratory medicine: Standardization and utility for technical staff assessment and recertification in Saudi Arabia. Med Teach. 2017;39 (Sup1):S63-S74.
- Tiehen A. Competency assessment in the transfusion service. MLO. 1993;25(10):35-38, 40, 42.
- O’Reilly K. Massive transfusion: a question of timing, detail, a golden ratio. CAP TODAY. 2014 December.
- Langston A, Downing D, Packard J, et al. Massive transfusion protocol simulation: an innovative approach to team training. Crit Care Nurs Clin North Am. 2017;29(2):259-269.
- Zielinski MD, Johnson PM, Jenkins D, Goussous N, Stubbs JR. Emergency use of prethawed Group A plasma in trauma patients. J Trauma Acute Care Surg. 2013;74(1):69-75.
Samuel P. Barasch, MD, serves as Medical Director of Transfusion Services at MidHudson Regional Hospital and Staff Pathologist at WMCHealth.
Patricia V. Adem, MD, serves as Medical Director of Clinical Laboratories Westchester Medical Center and WMCHealth.
Rita Curtis, MT, BB(ASCP), serves as Blood Bank Supervisor at MidHudson Regional Hospital of WMCHealth.
