1. Update on Blood Product Administration and Massive Transfusion Next Slide In the Operative Setting

2. Next Slide Previous Slide Objectives In this presentation you will: Define Mass Transfusion Protocol (MTP) Identify your role and responsibilities in the blood administration process Verbalize blood storage & return requirements to reduce blood wastage

3. Next Slide Previous Slide Rationale The activation of a standardized massive transfusion protocol (MTP) for large surgical bleeds and trauma exsanguinations will provide standardized component therapy to avoid coagulopathy associated with massive blood loss Charge nurse will no longer routinely order “Trauma Blood” Outline team responsibilities associated with transfusions Reduce blood product waste

4. Next Slide Previous Slide Initiation of MTPAdditional MTP CoolersEnding MTP Who: Attending Anesthesiologist/ Surgeon Direct Communication to Blood Bank: Initiation of MTP: Physician Name Patient Name Patient gender MR# Location: OR# Who: Attending Anesthesiologist/ Surgeon Direct Communication to Blood Bank: Continue MTP: Physician Name Patient Name MR# Location: OR# Who: Attending Anesthesiologist/ Surgeon Direct Communication to Blood Bank: Stop MTP for: Physician Patient Name MR# Location: OR # Blood Bank: Confirms Patient Location on E-OR Board Prepares MTP Cooler 6 units pRBC 4 units Plasma 1 Platelet MTP Cooler Packed Contacts OR Command Center of Ready for Pick up BB call OR Room for Decision of Continue or Cease: Continue MTP Cycle: BB Prepares: 6:4:1 Ratio MTP Cooler Packed Contacts OR Command Center of Ready for Pick up BB to Receive Order by Attending Surgeon or designee No additional MTP cooler picked up Discontinue MTP cycle: BB Anticipates Arrival of MTP Cooler

5. Next Slide Previous Slide Initiation of MTPAdditional MTP CoolersEnding MTP OR Charge Nurse: Receives Call From BB for cross check of: Patient Patient Gender OR Location Communication of MTP Protocol initiated CN Communicates MTP activation to OR Team: Circulator; Anesthesia CN deploys runner for MPT cooler pick up: To OR to obtain Blue Card or Chart prior to going to Blood Bank Straight to BB for Level 1 trauma if blue card or chart cannot be obtained OR Charge Nurse: Prepares for Continuation of MTP Deploys runner for MPT cooler pick up: To OR to obtain Blue Card or Chart prior to going to Blood Bank Straight to BB for Level 1 trauma if blue card or chart cannot be obtained Anesthesia Tech Prepares: Cooler for Return to BB Anesthesia Tech transports Cooler to Command Center: CN deploys runner to return cooler to Blood Bank Nurse/Anesthesia: Anticipates Arrival of MTP Cooler Nurse/Anesthesia: Follows Blood Administration Check Points Receives call for continuation by BB Nurse /Anesthesia Verifies: No Blood Products Remain in OR

6. Next Slide Previous Slide Initiation of MTPAdditional MTP CoolersEnding MTP OR Runner Deployed for MPT cooler pick up: To OR to obtain Blue Card or Chart prior to going to Blood Bank Straight to BB for Level 1 trauma if blue card or chart cannot be obtained Returns : To OR with cooler if Blue Card or Chart was obtained from OR prior to going to Blood Bank To Command Center if blue card or chart was not obtained for patient location from charge nurse Delivers cooler to designated OR Deployed for MPT cooler pick up: To OR to obtain Blue Card or Chart prior to going to Blood Bank Straight to BB for Level 1 trauma if blue card or chart cannot be obtained Returns : To OR with cooler if Blue Card or Chart was obtained from OR prior to going to Blood Bank To Command Center if blue card or chart was not obtained for patient location from charge nurse Delivers cooler to designated OR Returns cooler to Blood Bank

7. Next Slide Previous Slide The Circulating Nurse Prior to setting up for a case the circulator will ensure that No blue cards, patient labels or blood boxes from previous cases remain in the room. On the In-room white board verify: Patient’s name Procedure, the surgeon, Operative site (specifically L or R) Number of blood products available.

8. Next Slide Previous Slide Prior to the beginning of the case The circulator and anesthesia provider individually verify patient identify Ask patient to state his/her name when appropriate. Before patient is moved to the OR table, together the caregivers compare: Stated name to wrist band Blue addressograph card, whiteboard and face sheet on the chart. Names should be identical. Medical record number and physician name should also be compared on the ID Band, blue card, whiteboard and medical record. (See Patient Identification Policy # 100-32)

9. Next Slide Previous Slide Anesthesia Provider In the OR, transfusion is the responsibility of: Attending Physician Resident Physician Certified Registered Nurse Anesthetist (CRNA) Student Registered Nurse Anesthetist (SRNA) Perfusionist When blood/blood products are needed: Circulator is notified Circulator orders blood/blood products via Wiz Ordering application

10. Next Slide Previous Slide Notification by Blood Bank The Blood Bank calls appropriate location when blood cooler is ready to be picked up or blood products have been tubed. The Command Center for the VOR - 22090 MCE board- 66777 4 South/GYN surgery board- 32736 Hybrid - 22090 L & D - 22255 If cooler is needed, charge nurse will dispatch a runner to the designated OR and obtain the blue card or patient chart for the patient needing blood as soon as the call is received or patient arrives to the OR. The runner presents the blue card or patient chart to the Blood Bank.

11. Next Slide Previous Slide Blood Bank Technologist Requests patient ID from runner Confirms transfusion order ID presented (current type and screen available) All MTP cycles will be type-specific, cross-matched blood products. ID is presented (current type & screen unavailable) Trauma blood will be issued. ID cannot be obtained Trauma blood will be issued.

12. Next Slide Previous Slide Responsibilities of Runner Runner has patient chart or blue card Returns to the designated OR : Requested blood Patient’s blue card or patient chart OR runner gives blood product to licensed practitioner Runner does not have patient chart or blue card Returns to Command Center for patient location from charge nurse Delivers cooler to designated OR

13. Blood Verification Two (2) licensed personnel together verify the following information, (only one may be an LPN). Patients name and medical record number from the wristband/blue card/whiteboard Blood product expiration date Blood product donor numbers and type Verify all information with the Transfusion Record Donor number and type Expiration Next Slide Previous Slide

14. Next Slide Previous Slide Blood Product Transfusion Form Two licensed personnel sign and date Acts as the receipt for the blood product Circulator places on the chart Becomes part of the permanent record

15. Next Slide Previous Slide Multiple units- Cooler. Cooler stays with Anesthesia team May take units out to check off ( with transfusion record, patients name and medical record number from the wristband/blue card/whiteboard Must return all units back in the cooler under ice after verification process All units must remain under ice until used and lid closed at all times except when removing units Blood bags kept on top of the ice do not remain at proper temperatures Do not removed ice from bag Keep ice bag closed

16. Next Slide Previous Slide NOTE Coolers are returned to Blood Bank as soon as the need is over. Blood Bank checks the temperature at that time to determine if the blood is still the proper temperature. Do Not place platelets or cryoprecipitate in the cooler. Cooler

17. Next Slide Previous Slide Ice RBC’s must be transfused within 30 minutes unless in a blood box. Plasma must be infused within 4 hours of leaving the Blood Bank Platelets –use immediately Cryoprecipitate – must be used within 4 hour of pooling No Ice Blood Product Reminders

18. Next Slide Previous Slide One or Two Units of Blood Tubed to OR The Blood Bank calls appropriate location when blood products have been tubed. The Command Center for the VOR - 22090 MCE board- 66777 4 South/GYN surgery board- 32736 Hybrid - 22090 L & D - 22255 Charge Nurse/Runner Responsibilities Sends runner to tube station Runner returns to Charge Nurse for patient location Charge Nurse validates patient name on blood product Charge Nurse sends runner & patient blood product to OR where patient is located.

19. Next Slide Previous Slide Preventing Blood Wastage RBCs & Plasma: If tubed, & not needed, return immediately to Blood Bank by runner In cooler, leave under ice, keep lid closed Return cooler as soon as possible Platelets: Never in a cooler! Pooled platelets expire in 4 hrs. Cryoprecipitate: Never in a cooler! Expires in 4 hours! Never tube any blood products back to blood bank!

20. Next Slide Previous Slide Unused Products Unused products are returned to Blood Bank: As soon as the MTP is discontinued If blood products are tubed & not needed Patient is transferred to another location (Out of OR) Return process: Anesthesia Tech transports cooler to command center Charge nurse deploys runner to return: Cooler to blood bank Any unused tubed blood products to blood bank

21. Next Slide Previous Slide MTP Review Each MTP activation will be reviewed within 24 hours and feedback provided to the attending as well as Transfusion Committee leadership team

22. Next Slide Previous Slide Summary MTP provides standardized component therapy to avoid coagulopathy associated with massive blood loss MTP continues until: Attending anesthesiologist or attending surgeon discontinues No more coolers are picked up from the Blood Bank All unused products are returned to the Blood Bank As soon as the MTP is discontinued If tubed blood products are no longer needed If patient transfers to another location (out of OR)