Is there any regulation that requires Transfusion Services to have a massive transfusion protocol?

My hospital system has two facilities- one is a trauma center with a very active MTP that works great. The other hospital is much smaller and in theory does not accept any trauma patients. I found a mini MTP policy at the smaller facility today- it basically states exactly the same thing as the normal Uncrossmatched policy does. The only reason I can think of why this mini policy exists is because some regulating agency says so.

 

I believe critical access hospitals are required to have a massive transfusion protocol.  I'm not sure of other regulatory requirements.  Even if a smaller hospital doesn't accept Trauma patients, there is always the chance that they will experience a bad GI bleed, OB hemorrhage, or "routine " surgery gone awry.  Working with the larger facility to develop a plan to stabilize and transfer could be included in the protocol.  My hospital works with referring facilities to develop plans to improve outcomes.  These will include pharmaceuticals like TXA, Kcentra, and vitamin K.  With more blood suppliers providing liquid plasma, a small hospital still has the opportunity to hit a 1:1 prbc/plasma ratio prior to transfer.

If you are inspected by CAP you are required to have a protocol for providing blood in emergency situations. I would suspect that CLIA has a similar requirement and your lab would certainly fall under CLIA requirements.

Your plan should be written according to the resources you have. It should also address what to do when your resources have been depleted or are about to be depleted and what to do if/when the patient is transferred (do you send blood with the patient and how would you do that). Spelling out how you would deal with replacing your depleted blood supply would be a good addition to the other information.

Crazy stuff happens even at small hospitals - if somebody needs blood badly, not being prepared to deal with providing it rapidly could be a matter of life and death for the patient. I think too often we all fall into complacency and think that just because something occurs rarely, the associated policies aren't very important. In actual fact, the things that are seldom done are the things that are most likely to be screwed up. We've just spent several years making sure that our emergency release and mass transfusion protocols are up to date, realistic and (most importantly) making sure that all staff, not just lab, are aware of them. It's paid off in better performance by everyone during those uncommon events.

 

All of our hospitals have an MTP protocol. The beauty of the protocol is it helps eliminate any roadblocks that might slow down product getting to the patient. Also it removes guesswork for the clinical staff. Too many times they freak out and keep ordering RBCs and forget about balancing FFP.

Both CAP and AABB reference having an MTP protocol (AABB is more specific).  Massive transfusions aren't always trauma patients, so it is important to document what you would do in the unlikely event that you needed to massively transfuse a patient.

5.19.5    Massive Transfusion

The BB/TS shall have a policy regarding compatibility testing when, within 24 hours, a patient has received an amount of blood approximating or greater than the total blood volume.

TRM.40770 Life-Threatening Situations Phase II

Adequate policies and procedures have been established for the investigation and handling of life-threatening situations (such as the use of uncrossmatched blood or abbreviation of testing) that include the written authorization of a qualified physician.

NOTE: Written policies and procedures must be available to expedite testing for transfusion in a life-threatening situation. If an institution's procedure allows abbreviated testing in massive transfusion situations, records should indicate that the procedure was followed. Records must include the authorization by a qualified physician. (If approved by the institution and recorded in the laboratory's procedures, the physician responsible for the transfusion service laboratory may accept this responsibility.) If an incompatibility is discovered on completion of an incomplete crossmatch, the responsible physician must be notified in a timely manner and this notification recorded. Red blood cells released before testing has been completed must be conspicuously labeled as uncrossmatched on the tag or label. Records of completion of compatibility testing for units released uncrossmatched must be maintained.

Outside of the BB, there is the College of Trauma Surgeons and the Joint Commission.  Both require a policy.

How do you apply verbal orders for uncrossmatched RBC's?  We have meditech and there is no order set placed in the EMR by a physician just a phone call and it can come from anyone in the ED. 

We have two tests built in Meditech - One is Massive Transfusion Initiated and the other is Massive Transfusion Discontinued.  Anyone can order them either on the Clinical Side or the Lab side, they are for documenting the MTG order.

How are Critical Access Hospitals dealing with the need for plasma in MTPs?  Do you use liquid plasma?  Keep thawed 5 day units on hand or thaw on demand and have to come from behind on keeping a 1:1 ratio?  If you have a specific protocol that covers use of TXA or cryo at these locations to make up for not having platelets & thawed plasma available, I would love to see your procedure.

3 hours ago, Mabel Adams said:

Keep thawed 5 day units on hand

This.  We rarely outdate any.

On 12/15/2017 at 2:33 PM, Mabel Adams said:

How are Critical Access Hospitals dealing with the need for plasma in MTPs?  Do you use liquid plasma?  Keep thawed 5 day units on hand or thaw on demand and have to come from behind on keeping a 1:1 ratio?  If you have a specific protocol that covers use of TXA or cryo at these locations to make up for not having platelets & thawed plasma available, I would love to see your procedure.

Most of the critical access hospitals in our area are quite small and don't stock any plasma - frozen or otherwise. They stock 4-6 units of blood total, transfusing maybe 1 or 2 units every couple of months, if that. Their MTP (if they even have one - though they should) would be to whistle up a helicopter, start running all the type O blood they have (all 2 or 4 units) and get the patient out to someone like us as quickly as possible. I doubt they'd use more than a unit or 2 of liquid plasma over a year or two, if that much. Lots of waste and $$ to stock liquid plasma. The somewhat larger critical access hospitals have maybe a dozen or so units of blood in stock and also stock no plasma. Their plan would be to hang some blood and fly out the patient as quickly as possible.

These facilities are inspected by the state - not CAP, AABB, JC.

Edited December 18, 20177 yr by AMcCord

All of the hospitals in our system follow the same policy as although they may not receive the traumas that the trauma center has they do go on massive with other patients, such as OB.

On ‎12‎/‎18‎/‎2017 at 7:42 AM, slsmith said:

All of the hospitals in our system follow the same policy as although they may not receive the traumas that the trauma center has they do go on massive with other patients, such as OB.

So what do all of your hospitals do for plasma, stock thawed, liquid or only frozen plasma?