di

massive transfusion protocolexpanding

massive transfusion protocolinto the prehospital system of care

Andre Tra ersAndrew TraversMD MSc FRCPC

Provincial Medical DirectorProfessor Emergency MedicineProfessor Emergency Medicine

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ConflictConflict of Interest

•• AcademicAcademicNoneNone–– NoneNone

•• FinancialFinancialFinancialFinancial–– Contract with DHWContract with DHW–– ED PhysicianED Physician

Outcome

System

P

System

Process

Structure

Outcome

System

P

System

Process

Structure

154

Outcome

System

P

System

Process

Structure

Medical OversightMedical OversightKnowledge TranslationResearch

Knowledge TranslationResearch

Medical First Responder

Medical

Medical First Responder

Medical

ResearchResearch

SimulationLifeflight

SimulationLifeflightMedical

CommunicationsGround Ambulance

Medical Communications

Ground Ambulance

LifeflightTrauma Program

LifeflightTrauma Program

Outcome

System

P

System

Process

Structure

Injury 911 ED DC

CommunitySOC

Out-of-HospitalSOC

HospitalSOC

P ti tPatient Patient

Patient Sprint RelayPatient Sprint Relay

4 Definitive Care

3 EDIndividual superstars cannotIndividual superstars cannot

win without teamwork

Hand offs and smooth

Finish

transitions are critical

Not a turf battle

2 TransportStartEach expected to move fast

1 PatientIvan C. Rokos, MD, FACEP

P fPerformance measures:structure, process & outcomestructure, process & outcome

OptimalSystemsyIntegratedRealtimeFeedback

System of Care: Ideal StateSystem of Care: Ideal State

System of Care: TraumaSystem of Care: Trauma

RegistryPrehospitalActivationActivation

System of Care: Cardiac ArrestSystem of Care: Cardiac Arrest

EHS CPG

TNTNK

TNK

TNK

TNTNK

KK

TNK

TNK

TNK

TNK

KK

TNK

TNK

TNK

TNK

PCI vs TNK

TNK

TNK

TNTN

TNK

TNK

TNK

TNK

PCIK

TNKTN

KTNK

TNK

TNK

TNK

TNK

TNTNTNK

TNK

KKKK

Advanced ‘Time’ Recording

CurrentCurrent Door FlowOnsetOnsetf MIf MI

Drug Data DecisionPatient

Advanced Time Recording

CurrentCurrent ooRestoredof MIof MI Started

PCICathPrimary

Fibrinolysisresponse

Primary PCI

Decision

Onset

Response

First Med

Data

Decision

Drug

Door

Sheath

Balloon

ED

Waite d C

ontact

to Delta

Basic ‘Time’ Recording

CurrentCurrent Door FlowOnsetOnsetf MIf MI

Drug Data DecisionPatient

Basic Time Recording

CurrentCurrent ooRestoredof MIof MI Started

PCICathPrimary

Fibrinolysisresponse

Primary PCI

Onset 1st

ContactReperfusion

Sharing DataSharing DataOptimizing STEMI Care

Time Symptom

Onset

Time1st Medical

TimeReperfusion

PatientOutcome

Onset Contact Started

Prehospital Datap

ED Data

CardiologyData

ED Data

STEMI Performance Scorecard

System of Care: STEMISystem of Care: STEMI

RESTOREPrimary PCI

Low Overtriage Target

System of Care: STROKESystem of Care: STROKE

EHS PARAMEDIC contacts ED CHARGE PHYSICIAN providing ETA

EHS PARAMEDIC identifies MTP ELIGIBLE PATIENT

EHS PARAMEDIC contacts ED CHARGE PHYSICIAN providing ETA

ED CHARGE PHYSICIAN designates ED NURSE to initiate MTP

ED CHARGE NURSE or ED NURSE□ Initiate UNIDENTIFIED PATIENT POLICY if required - patient may be transferred from another

facility ‘identified’. □ Call LOCATING at 473-2220

1. This is a PRE-HOSPITAL MASSIVE TRANSFUSION ACTIVATION 2 Estimated Time of Arrival (ETA) is (Confirm the patient has not arrived)2. Estimated Time of Arrival (ETA) is … (Confirm the patient has not arrived)3. Physician requesting the MTP is … & the phone number is XXX-XXXX

□ Prepare patient chart, if possible

Call BTS 473-4257 to activate MTP Page DPC to initiate registration process

LOCATING

BLOOD TRANSFUSION SERVICE (BTS) □ Call DPC for patient identifying information – 473-4998 or 473-4961

Initiate Porter Services 473-2557 Notify Pathologist-on-Call for BTS

PORTER SERVICES □ Deliver blood

LOCATING

BLOOD COMPONENT STORAGE Blood components (RBC/Plasma/Platelets/Cryoprecipitate) MUST

□ Prepare RBC - O NEG 6 units & AB plasma 1500 mLs □ Platelets supplied as requested

□ Deliver blood components to ED

Compile data for remain in the BTS transport container until administered to patient.quality review

PATIENT ARRIVAL to QEII ED

CHARGE EHS ED NURSE

PATIENT ARRIVAL to QEII ED

PORTER PHYSICIAN

□ Receive EHS report

□ Provide resuscitation

PARAMEDIC □ Transfer of

care □ Document time

of medical

□ Prepare administration supplies for patient arrival. Blood components remain in transport container until infusion.

□ Obtain STAT blood specimens

SERVICES □ Transport

specimens to lab □ Deliver blood

components to care based on MTP Guideline

contact and time of MTP request

PRIOR to blood component administration, if possible

□ Document blood administration times

ED

Changing a patient’s status from ‘unidentified’ to ‘identified’ will require a new blood sample for crossmatch for BTS. The patient’s identification status should only be upgraded to ‘identified’ when the patient is

hemodynamically stable as determined by the physician providing the care. Once the identification status can be upgraded, any staff member can notify Health Information Services.

System of Care: MTPSystem of Care: MTP

Outcome

System

P

System

Process

Structure

H i lEHS

Hospital

Advantages to Prehospital IdentificationAdvantages to Prehospital IdentificationAdvantages to Prehospital IdentificationAdvantages to Prehospital Identification•• TraumaTrauma

–– Rx: Massive transfusion protocolRx: Massive transfusion protocol• Stroke

– Rx: reduced D2N–– DxDx: reduced time to CT: reduced time to CT

•• STEMISTEMI

– Dx: reduced time to CT

• SepsisSTEMISTEMI–– Rx: reduced E2N and E2B timesRx: reduced E2N and E2B times–– DxDx: access old ECGs: access old ECGs

Sepsis– Rx: reduced time to antibiotics– Dx: reduced time to CBC

•• Oncologic EmergenciesOncologic Emergencies–– Rx: reduced time to antibioticsRx: reduced time to antibiotics

DD d d ti t CBCd d ti t CBC

• Cardiac Arrest– Rx: PCI– Dx: NOK notification, DNR, etc–– DxDx: reduced time to CBC: reduced time to CBC , ,