‘Blood, sweat and tears’

Reducing delays in transfusion with a new major hemorrhage protocol, algorithm and virtual reality simulation.

Introduction

On average, there are three major haemorrhage (MH) calls a week at the Royal United Hospital (RUH), Bath, UK. As junior doctors working in different departments, we observed varied practice and confusion about how to utilise the MH call. After several serious incidents at the RUH which involved significant delays in transfusion following a major haemorrhage call, we formed a multidisciplinary team (MDT) to address this issue.

Aims

Primary Aim: To reduce the time between MH protocol activation and the start of transfusion by 25% by December 2022. Secondary aims include improving confidence of staff in managing an MH call and improving staff knowledge of the MH protocol. Our study excluded obstetric MH calls as they had already developed a separate process.

Measuring Current Practice

Several steps were undertaken to understand the current system and measure current practice:

1)An MDT process map identified several areas of potential delay to transfusion (Fig 1).

2)Baseline measures of time from MH call activation to transfusion showed a mean of 38 minutes from March 2021-Oct 2021 (Fig 2).

3)A staff survey showed 85% had no training in MH calls and none could correctly identify the exact personnel on the MH team.

4)‘Point of care' (POC) simulation of MH was performed to evaluate human factors and latent safety threats and test the wholesystem. We identified that correct personnel did not attend call and no-one is routinely sent to collect blood products (Fig 3).

5) Key stakeholders (transfusion committee, patient safety committee and risk register) supported the initial interventions of development of a new MH algorithm and immediate amendment of personnel alerted by an MH call.

Interventions

Difficult to maintain 1:1 teaching. Approached groups to deliver larger group teaching on algorithm on departmental study days

VR SIM and algorithm

1:1 virtual reality simulation combined with ‘tea trolley training’ in 3 ‘high MH frequency’ areas; MAU, SAU and ICU

Quantitative and qualitative data collected from participants.

Results and Discussion

Developed e-prescribing ‘care plan’ and mandatory elearning video

Wider departmental teaching

Large group teaching combined with trauma debriefing in partnership with our Trauma Risk Management team to recognise the emotional aspect of learning from MH. Quantitative and qualitative data collected from participants.

Collected quantitative and qualitative feedback

Initial VR simulation did not produce any significant change in our outcome measure (time taken to initiate transfusion). We were limited to how many people we could train due to our own work pressures. It was clear that to establish real change we needed to target larger groups of staff without disrupting normal working. However our secondary measures (below) improved substantially and qualitative feedback was positive. Staff survey quantitative data from VR training

Trust wide teaching with e-learning and e-prescribing package

Sustainability of our project required us to develop a trust wide mandatory elearning and e-prescribing package. This cycle is still in development.

Large groups taught in multiple departments such

Target whole hospital with e-learning and e-

Staff survey quantitative data from large group training

Whilst this intervention is still ongoing, we will continue to monitor transfusion audit data using SPC chart analysis. Current SPC chart analysis shows a decrease in variation around the mean although no definite shift in practice (fig 4).

Future plans include implementing a trust wide mandatory e-learning package to allow this training to be delivered to every staff member. We are also creating an e-prescribing package to reduce time taken to prescribe blood and reduce variation in practice. These strategies will ensure sustainability of the project. Audit data analysis will be taken on by the transfusion team and will be reported to the transfusion committee a nd patient safety committee.