Let’s continue with my series on the massive transfusion protocol (MTP). I’ll continue today with information on deactivating and analyzing your MTP.

Deactivation. There are two components to this: recognizing that high volume blood products are no longer needed, and communicating this with the blood bank. As bleeding comes under surgical control, and CBC and clotting parameters (and maybe TEG/ROTEM) normalize, the pace of transfusion slows, and ultimately stops. Until this happens, the MTP must stay active. Even a low level of product need should be met with coolers stocked with the appropriate ratios of products.

There are two ways to stop the MTP: the surgeon or their surrogate calls the blood bank (when no more blood products are to be used), or the blood bank calls the surgeon after the next cooler has been waiting for pickup for a finite period of time. This is typically about 30 minutes. It is extremely helpful if the exact deactivation time is recorded in the electronic medical record. However, this information can be obtained from the blood bank.

Analysis. It’s all over, and now the real fun begins. For most trauma centers, the blood bank maintains extensive data about every aspect of each MTP event. They record what units were released and when, when they were returned, which ones were used, were they at a safe temperature on return or were they wasted, and much, much more! Typically, one of the blood bank supervisors or a pathologist then compiles and reviews this data. What happens next varies by hospital.

Ideally, the information from every MTP activation gets passed on to the trauma program. Presentation at your transfusion committee is fine, but this data is most suitable for presentation at the trauma operations committee. And if significant variances are present (e.g. product ratios are way off) then it should also be discussed at your multidisciplinary trauma PI committee as well.

There are relatively few standard tools out there that allow the display of MTP data in an easily digestible form. Here are some of the key points that must be reviewed by the trauma PI program:

• Demographics
• Components used (for ratio analysis)
• Lab values (INR, TEG, Hgb, etc)
• Logistics
• Waste

I am aware of two tools, the Broxton form and an MTP audit tool from the Australian National Blood Authority. The Broxton tool covers all the basics and includes some additional data points that cover activation criteria, TXA administration, and administration of uncrossmatched blood. Click here to check it out. The Australian tool is much more robust with more data points that make a lot of sense. You can download a copy by clicking here.

In the next post, I’ll continue with activation criteria for the MTP.

My series on the massive transfusion protocol (MTP) continues! Today, I’ll provide some tips on the logistics of your MTP.

MTP logistics include details such as who will be delivering the blood, what actually goes in each cooler, what ratios should be used, limitations imposed by the use of frozen plasma, and documentation. I’ll discuss details about ratios and FFP in the next Trauma MedEd newsletter.

The runners who travel between the blood bank and the patient need to be selected carefully. Blood bank tech? Not ideal because they’ve got more important work to do. ED or OR tech? Maybe, as long as you’ve got a reliable pool. Student or resident? Probably not, because they may not know their way to the blood bank, which is typically placed in the farthest corner of the basement as possible. One of the most creative solutions I’ve seen is the use of a hospital security officer. Think about it. They know the hospital layout cold, including that obscure corner where the blood bank is located. And there are plenty around all the time!

Documentation is critically important, both in the trauma bay and the blood bank. Trauma activations, especially ones requiring MTP, are very fast-moving and complex. Two sets of documentation are crucial: accurate records of blood product administration (on the trauma flow sheet), and documentation of just about everything else (in the blood bank). A specific timestamp on the trauma flow sheet that records the exact time of activation of MTP is a big plus.

What about coolers? I’ve seen everything used from uninsulated plastic buckets, picnic coolers, and pneumatic tube containers to large, self-contained rolling refrigeration units. The choice of container really boils down to cost vs waste. The cheaper the container is, the less insulated it is, the more likely that blood products will be discarded due to high temperature if not transfused promptly. The best blend of cost vs utility seems to be the good, old-fashioned picnic cooler. It’s very portable, reasonably cheap, and can be tested for temperature maintenance. Just be sure to secure a pouch to the outside to keep platelets at room temperature to maintain full functionality.

Here’s a sample MTP cooler that’s ready for use. The platelets are in the pouch on the left. Note the reminder to prompt the team to give TXA if not contraindicated. This is often forgotten in the heat of the trauma activation.

Who actually runs your MTP? In some ways, it should run itself. Coolers get delivered, products get transfused. However, some decision making is needed to decide how long to continue and whether any tweaking of product ratios needs to happen. In the emergency department, the surgeon or emergency physician can do this. But once a trauma patient arrives in the OR, that is no longer the case. The emergency physician was left behind in the ED and the surgeon is up to her elbows in trouble. What about the anesthesiologist? Nope, they are busy keeping the patient safely asleep, regulating rapid infusions, and actually administering the blood.

Most of the time, however, these two physicians actually end up running the MTP while multi-tasking at their other job. Unfortunately, this can lead to errors and delays. One best practice to consider: a highly trained trauma resuscitation nurse or advanced practice provider (APP) can run the MTP from the sidelines. They travel with the patient from ED to OR, managing the MTP the entire time. This offloads responsibility from busier people.

In the next post, I’ll continue with MTP deactivation and analysis.

Every trauma center needs a massive transfusion protocol (MTP). It automates the preparation and delivery of critical blood products in seriously injured patients. Unfortunately, there are many moving parts, so numerous things can go wrong.

This series of posts will break down the entire MTP process, step by step. Although it is designed for centers developing their first MTP, it also provides valuable information for established centers that want to tweak and optimize theirs. I’ll start today with tips on how to build a solid MTP at your center.

Your massive transfusion protocol is a complex set of processes that touch many, many areas within your hospital. There are five basic components (and a few sub-components) to any MTP, so let’s dig into them one by one. They are:

• Universality
• Activation
• Logistics
  • Components
  • Runners
  • Documentation
  • Coolers
• Deactivation
• Analysis

Let’s scrutinize each one, starting with the first two today.

Universality. This means that there should be one, and only one MTP in your hospital. I’ve seen some hospitals that have one MTP for trauma, one for cardiothoracic surgery, one for OB, one for GI, and on and on. Yes, each of those services deals with patients who are suffering from blood loss. But it’s the same blood that your trauma patients lose! There’s no need to create a protocol for each, with different ratios, extra drugs, etc. This can and will create confusion in the blood bank which may lead to serious errors.

Activation. This consists of two parts: how do we decide to activate, and then how does everyone involved find out that the MTP is actually being activated? I’ll discuss activation criteria later in the series. But what about the notification process? Phone call? Order in the electronic medical record (EMR)? Smoke signals?

The most reliable method is a good, old-fashioned phone call. Do not use your EMR except for documentation purposes. Unless there is a very reliable system in the blood bank that translates an EMR order into an annoying alarm or flashing lights, don’t rely on this at all.

Then decide upon the minimum amount of information that the blood bank needs to begin preparing blood products. This usually consists of a name or temporary patient identifier, sex, and location of activation. Ensure that an ID or transfusion band is affixed to the patient so that wrong blood products are not given in multiple patient events.

In my next post, I’ll continue with the logistics of the MTP.