Once bleeding is under control, terminate MHP.

• Termination process and criteria must be clear to all team members
  • Terminate protocol when hemostasis is achieved and patient is stabilized or when patient dies
  • Call transfusion medicine laboratory to terminate protocol
• Transfer care to the most appropriate team
  • Complete charting and reconcile transfused components
  • Update patient’s family
  • Consider transporting patient to a higher acuity hospital if more intensive care is needed and/or definitive interventions are needed
• Return all blood components and blood containers/coolers remaining at bedside to transfusion medicine laboratory
  • Blood components can be transfused up to 4 hours post-issue
  • Blood components issued and outside of a validated temperature controlled environment (i.e., blood cooler or fridge) for more than 1 hour (not cumulative) cannot return to inventory and will be discarded by the transfusion medicine lab; to ensure no wastage, portering should be contacted as soon as MHP stands down
• Team debriefing
  • What went well and what can be done better next time
  • Improves compassion fatigue and promotes resiliency, enables quality improvement
• Multidisciplinary review for quality assurance
  • Mortality and morbidity rounds – focusing on facts rather than “blame”
  • Others: trauma care committee, transfusion committee

Quality metrics should be tracked over all activations of the MHP.

• Based on audits of blood component utilization:
  • Common errors made:
    • Starting right away with RBCs, FP, platelets in bleeding patients on the ward (for example, most GI bleeds can start with 2-4 RBCs and do not require other components)
    • Ordering 4 doses of platelets when clinicians are thinking of 4 units of platelets; correct terminology is “1 adult dose” = 4 units of whole blood–derived platelets = 1 unit of apheresis platelets
    • Not moving towards goal-directed therapy and sticking to ratio-based therapy, or focusing only on giving large amounts of RBCs
    • Not checking and/or replacing fibrinogen
    • Not getting a group and screen and overusing group O RBCs and AB plasma
      • Getting a group and screen post-transfusion of group O RBCs is still useful for determining the patient’s blood group

Regular simulations increases team building and non-technical skills in trauma

• Can range from a table-top exercise to high fidelity in situ simulations
• Consider having video recordings of lab and clinical areas to raise awareness of roles within the MHP

References:

1. Barleycorn D, Lee GA. How Effective Is Trauma Simulation as an Educational Process for Healthcare Providers Within the Trauma Networks? A Systematic Review. Int Emerg Nurse. 2018;40:37-45.
2. Callum JL, Yeh CH, Petrosoniak A, et al. A Regional Massive Hemorrhage Protocol Developed Through a Modified Delphi Technique. CMAJ Open. 2019;7(3):e546-561.
3. Rao S, Martin F. Guideline for Management of Massive Blood Loss in Trauma. Update in Anaesthesia. 2012;28(1):125-129.
4. Schmidt M, Haglund K. Debrief in Emergency Departments to Improve Compassion Fatigue and Promote Resiliency. J Trauma Nurse. 2017;24(5):317-322.
5. Spahn DR, Bouillon B, Cerny V, et al. The European Guideline on Management of Major Bleeding and Coagulopathy Following Trauma: Fifth Edition. Crit Care. 2019;23(1):98.
6. Yazer MH, Spinella PC, Doyle L, et al. Transfusion of Uncrossmatched Group O Erythrocyte-containing Products Does Not Interfere With Most ABO Typings. Anesthesiology. 2020;132(3):525-534.