Developing and implementing a protocol for major haemorrhage Jessica Hargreaves
Key words: Major haemorrhage ■ Clinical protocol ■ Transfusion ■ Blood components
T
he depiction of blood as a ‘life force’ is a well recognised representation found in most societies, cultures and religions (Starr, 2012). The biological explanation of blood as a complex tissue essential for homeostasis is no less significant (Moore et al, 2010). Despite the variation in the descriptions of blood, ranging from the symbolic to the medical, common to each is the integral link this particular body fluid has with the maintenance of life. For nurses (and medical staff) to have a cultural or more notably a physiological understanding of blood is important, as they may be required to care for people in the most extreme circumstance of excessive blood loss. It is therefore essential that nurses are well skilled in the management of patients who are either at risk of or experiencing a major haemorrhage. The author’s experience of being involved in the management of major haemorrhages was while working as a transfusion practitioner (TP). Each acute NHS trust is required to employ a TP who fulfills the remit of ensuring
Jessica Hargreaves, Senior Lecturer, Acute Clinical Practice, University of Brighton Accepted for publication: October 2014
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Background Major haemorrhage is usually defined as the loss of 1 circulating blood volume within a 24-hour period (Contreras, 2009). However, definitions can vary according to medical discipline, for example in obstetrics, blood loss at or greater than 2500 ml is used to determine a major obstetric haemorrhage (Royal College of Obstetricians and Gynaecologists, 2008). This volume is not based on a person’s weight or a percentage of total blood volume, rather it is a defined amount not subject to individual parameters. Recommendations from other clinical working groups suggest that a patient-based assessment should alert the clinician to excessive blood loss rather than reliance on a numerical value (Anaesthetic Association of Great Britain and Ireland (AAGBI), 2010). This approach takes into consideration the occasions when the person’s blood loss is not quantifiable or when a major haemorrhage is one of a number of conditions to be considered in the management
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Abstract
This article presents the author’s experience, in the role of a transfusion practitioner (TP), of developing and implementing a major haemorrhage protocol. A definition is given for the term ‘major haemorrhage’ in conjunction with the incidence of and outcomes for people experiencing excessive blood loss. The advantages and disadvantages of clinical protocols are discussed. Rather than reject the use of protocols because of issues of compliance and resourcing, these should be acknowledged in order to better inform the development and implementation of a protocol. With reference to the specific design of a major haemorrhage protocol for use in an acute NHS trust, a detailed explanation of the stages involved in developing a protocol is given. This is followed by a summary of the standard recommendations specified for protocol implementation. The findings from an audit showed on average that the time to the first transfusion was 26 minutes less for patients in the post-protocol group compared to the pre-protocol group.
blood components are given safely and appropriately both in routine and emergency settings, such as a major haemorrhage (Royal College of Nursing, 2005). The particular acute NHS trust in which the author worked has over 800 beds extending across three sites providing acute services including maternity, accident and emergency, general surgery and critical care. At the time of taking up the TP position in the trust only a major obstetric haemorrhage protocol existed to direct the care of obstetric patients experiencing an ante- or post-partum haemorrhage. No provision was made in this or any other transfusion-related document for the care of non-obstetric patients who may also experience a major haemorrhage. This article is intended to assist those nurses who are directly engaged in the development and implementation of protocols with a discussion of their advantages and disadvantages. The author’s experience of developing a major haemorrhage protocol is used to demonstrate the stages required in the design and implementation of a protocol and to present the latest supporting literature specific to the management of a major haemorrhage. Findings are presented of an audit comparing the speed of delivery of blood components in the patient group before the introduction of the protocol and the patient group following implementation of the protocol. Finally, it is anticipated that all nurses will gain an appreciation of the complexity and the challenges involved in the formation of a protocol and to be encouraged to reflect on the reasons for either their own compliance or non-compliance with clinical protocols.
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CRITICAL CARE of acute illness. Furthermore, a loss of any volume of blood, if it remains uncontrolled, will rapidly exceed (often in a matter of minutes) the volume deemed to indicate a major haemorrhage. Therefore, the risk is that if the trigger volume for determining a major haemorrhage is set too high, further unnecessary blood loss will result before life-saving treatment is commenced (Davenport and Khan, 2011). Consequently, if uncontrolled bleeding occurs it is the effect of this blood loss that should determine the initiation of treatment rather than just a defined volume. Despite the lack of consensus on the specific volume of blood loss that could be used to determine a major haemorrhage there is agreement in the importance of establishing the early recognition of excessive blood loss (Stainsby et al, 2000;AAGBI, 2010; Roberts, 2014). Currently, there are valid concerns regarding the capability of UK hospitals to both recognise and manage major haemorrhage.The UK steering group dedicated to transfusion safety, Serious Hazards of Transfusion (SHOT), compiles an annual summary of all reported transfusionrelated incidents. Data from the 2013 annual report identified that delays in transfusing patients who experienced major haemorrhage contributed to the death of two patients and the increased morbidity of seven other patients (SHOT, 2014).The investigations into these serious untoward incidents identified that the reasons for the delay were failings in the detection of the haemorrhage and the poor communication between the clinical area and the transfusion laboratory. The incidence of major haemorrhage is not isolated to a specific patient group. A range of patients in clinical settings as diverse as acute medicine, surgery, trauma and obstetrics are all at risk of experiencing major haemorrhage either through pathological, traumatic or iatrogenic reasons (National Patient Safety Agency (NPSA), 2010). Kauvar and Wade (2005) identified that uncontrolled bleeding in trauma patients, accounts for between 30% and 40% of all trauma-related deaths. Local data from the acute NHS trust within which the author previously worked showed that on average there are 20 major haemorrhages each year; this equates to between one and two a month with a 5% morbidity. The frequency combined with the risk of poor outcomes has established the management of major haemorrhage as a priority on the NHS’ clinical governance agenda (SHOT, 2014). As a consequence, the hospital transfusion committee (within the author’s acute NHS trust) committed to establishing the measures to be put in place in the event of a major haemorrhage occurring in any patient group. These measures were collectively presented in the form of a major haemorrhage protocol.
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Advantages and disadvantages of clinical protocols There is considerable debate regarding the need for protocols in health care (Rycroft-Malone et al, 2010). The initial barrier to using protocols is found within the term itself, which is often mistakenly used interchangeably with the terms ‘guideline’ or ‘policy’. This has led to confusion, among clinicians intending to follow a protocol regarding its legal status and its required level of compliance (Shearer et al, 2012). As a result of this uncertainty an understandable antipathy has developed towards the use of protocols.
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However, unambiguous definitions do exist. The Working in Partnership Programme (WIPP) (2006), for example, defines a protocol as an agreed framework outlining the care that will be provided in a designated area of practice. Protocols are not prescriptive, they do not describe how a procedure is performed, but rather why, where, when and by whom the care is given. Helpfully the same document also provides clear definitions for the terms ‘standard’, ‘guideline’ and ‘policy’. As the above definition suggests, a protocol provides health professionals with a framework for achieving a complex sequence of activities, such as those required in the management of a major haemorrhage. One of the difficulties inherent in this level of complexity is coordinating the involvement of numerous agencies in providing the care to the patient. In this instance, the agencies involved include doctors, nurses, midwives, biomedical scientists (BMS), portering staff and telecommunications staff. Therefore, a protocol must also facilitate the coordination of these different groups. Establishing roles and responsibilities of each staff group, plus making the means of communication between the different staff groups explicit, can help to achieve this. This level of transparency counters the often-recurring complaint of poor communication (as observed in the management of major haemorrhages) that can exist between health professionals (WIPP, 2006). By establishing the expected roles and responsibilities of each staff group, the development of a protocol has the indirect advantage of prompting a review of the roles and responsibilities currently being undertaken (Engvall et al, 2014). In order to identify the why, where, when and by whom of the protocol, a thorough evaluation of the existing practices is required. As a consequence, any system failings or assumptions about roles and responsibilities will be highlighted, making the opportunity available for more effective or efficient practices to be adopted (Brody et al, 2012). The advantage of using protocols lies not only in formalising agreed practices, but also in supporting practice development and quality assurance. Beyond the immediate application of the protocol for improving patient care there are also strategic benefits for using protocols. For example, the practices outlined in a protocol can be audited and by auditing practice it is possible to identify educational needs and use the findings to assist in changing practice (Davenport and Khan, 2011). However, the use of protocols is also subject to criticism. This is invariably linked to the suggestion that protocols stifle individual care management and restrict clinical autonomy. Clinicians who are not convinced of the evidence base for the protocol often make this censure. There may be concern that the protocol runs counter to the perceived or accepted practice norms (WIPP, 2006). With regard to the major haemorrhage protocol, there is ongoing debate about the optimal transfusion ratio of packed red blood cells to fresh-frozen plasma. The emerging evidence of a 1:1 ratio is derived from patients being treated in a combative military environment rather than an acute NHS trust hence the difficulty in extrapolating the data to other patient groups (Roberts, 2014). Yet this lack of certainty should promote further research to support best practice regardless of whether its use is protocol-driven or clinician-led.
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Developing a major haemorrhage protocol It is important to appreciate that successful implementation of a protocol is dependent on its development. The stages of development involve: identifying the need for a protocol, establishing the aims of a protocol, designing the format of a protocol and evaluating the effectiveness of a protocol. The following are reflections on the author’s experience of developing a protocol, which have been further informed by guidance from Broughton and Rathbone (2001), the McDonnell Norms Group (2006) and Grol et al (2013).
Identifying the need for a protocol A risk assessment carried out on the transfusion practices within the trust highlighted that there was only a major haemorrhage protocol for use with obstetric patients.Yet, the data on blood component usage identified that many more than just obstetric patients had experienced excessive blood loss. As a result, there was a high likelihood that in the event of a major haemorrhage some patients would be managed outside of an agreed standard of care. According to the NHS Litigation Authority (2014) Risk Management Standards 201314, all acute care services are required to have documented processes for the administration of blood components and this must include transfusion in a major haemorrhage. The NPSA (2010) and the UK Blood Transfusion and Tissue Transplantation Services (UKBTS) (2010) in response to the national review of incidences of major haemorrhage, also stipulate the need for acute NHS trusts to have such a protocol in place for all patient groups. The need for a protocol also reflects the importance of standardising the process of selecting which of the latest developments in the management of a major haemorrhage to adopt. These include the experience from the military in haemodynamic resuscitation, the increased use of near-patient Box 1. Agreed aims of the major haemorrhage protocol ■ A
single protocol i.e. to be used for all patients in all clinical areas visible protocol i.e. easily accessible for all staff to refer to ■ An evaluated protocol i.e. subject to regular review and audit ■ A
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testing techniques such as thromboelastography, and the use of additional therapies such as tranexamic acid, prothrombin complex concentrate and fibrinogen concentrate (UKBTS, 2010;Young et al, 2011; Sinha et al, 2013; Baumann Kreuziger et al, 2014).Without an approved system for determining which of these investigations and therapies, if any, should be used, there will be an ongoing disparity in the care received by patients and an over-reliance on each individual clinician to be informed of and discriminate between the most suitable treatment advances (Wall and Coubrie, 2011;Young et al, 2011; Khan et al, 2013).
Establishing the aims of a protocol The established aims of the major haemorrhage protocol were a product of a 2-month consultation period with all the stakeholder staff groups (clinicians, BMS and ancillary staff) involved to a varying extent in the management of a major haemorrhage. According to Broughton and Rathbone (2001) collaboration is an essential element of successful protocol design. In her role as a TP, it was necessary for the author to engage each of the staff groups in establishing their individual aims and to present these to the hospital transfusion committee who had overall responsibility for the review and approval of the protocol. The aims derived from this approach sought to unify the procedure, to aid communication between the staff groups and to ensure the protocol remained up-to-date (Pottle et al, 2012; McDaniel et al, 2014). Box 1 lists the aims derived from the consultation and agreed by the hospital transfusion committee.
Designing the format of a protocol To ensure the aims were met, the protocol contained the following key elements: ■■ An agreed definition of major haemorrhage for all patient groups i.e. estimated blood loss > 1.5 litres or 50% total blood volume loss within 3 hours (a volumebased definition of major haemorrhage was adopted as it was agreed by the working party that staff preferred an objective measure rather than reliance on prompts for clinical judgement) ■■ A list of the various roles and responsibilities of all staff groups involved in a major haemorrhage ■■ An explanation of the different blood components and products available to use in a major haemorrhage (Borgman et al, 2007) ■■ An explanation of the different medications and treatments, in addition to blood components and products, available to use in a major haemorrhage (McDaniel et al, 2014) ■■ A detailed account of the process of managing a major haemorrhage including potential complications (Westerman et al, 2008; Wall and Coubrie, 2011). Fundamental to the writing of the protocol was to use staff who had knowledge of the local structures and systems in the trust. This insight was invaluable as the trust has three sites that all require major haemorrhage cover but the provision of clinical support and even the availability of blood components varies between sites. Therefore, how these differences were accommodated in the protocol had to be made explicit for each site. In addition, four new initiatives were devised specifically
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A further disadvantage of the use of protocols is that even if there is consensus in its development, compliance with the implementation of the protocol can still prove problematic. The higher the number of different staff groups involved and the greater the complexity of care practices, the harder it is to achieve conformity or standardisation, a hallmark of protocol use (Shearer et al, 2012). Linked to the difficulties of implementation, once a protocol is instituted it will also require regular review, which brings with it further implications for resourcing (Grol et al, 2013). It is clear that there are recognised advantages to using protocols in order to provide systematic and consistent care delivered by health professionals and ancillary staff. In addition, the disadvantages of protocols, such as resourcing and compliance, should not be seen as preclusions to the use of protocols. Instead, by acknowledging the associated difficulties it is possible to better understand how to factor in these issues when developing and implementing a protocol.
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CRITICAL CARE for the protocol focusing on improving or reinforcing communication. The first initiative encouraged any staff member who recognised that a patient met the defined criteria of a major haemorrhage to initiate the protocol. The aim was to prevent unnecessary delays by waiting for senior staff to confirm a major haemorrhage. The potential for ‘false alarms’ were accepted as the risk of actioning the protocol unnecessarily was outweighed by the risk of not delivering blood components in a timely and coordinated approach to a person suffering major haemorrhage. All calls are subject to regular review in the annual audit. Previously, informing all the appropriate staff of a major haemorrhage would have required each person to be told on an individual basis. This lengthy procedure could cause significant delays and was considered too unreliable; therefore a new strategy was devised. This was the second initiative, whereby one call is made to the switchboard staff who are then responsible for contacting a pre-specified group of staff to alert them to the occurrence and the location of the major haemorrhage. The third initiative involved allocating a specific role to a clinical staff member. In the early stages of a major haemorrhage a clinical liaison is assigned from the clinical staff present at the time. This is a new role with a threefold purpose, requiring the clinician to communicate with other departments in the hospital, such as the laboratory, theatre and critical care, to coordinate delivery and receipt of blood components and to document the events of the major haemorrhage. Invariably, the TP, a senior nurse or junior doctor will undertake this role, as they will have experience of leading teams. The final initiative involves a quick guide, which was designed to supplement the formal protocol. It distils the key actions, to be completed in the event of a major haemorrhage, onto one page (Figure 1). There are a number of unique features of this quick guide including setting out the actions of both the clinical area and the transfusion laboratory. This was in response to the uncertainty expressed by both clinical and laboratory staff of ‘working blind’ i.e. not knowing the actions being undertaken or to be anticipated. It also simplifies the information that needs to be communicated between the clinical area and the transfusion laboratory and it divides the management of a major haemorrhage into precise stages. The quick guide is printed on yellow paper to make it more prominent and to make it easier to read. This is particularly important for people with dyslexia who may have difficulty distinguishing dark text on a white background (Dale and Aitken, 2007). It is laminated for infection prevention and control purposes and always positioned next to a telephone. The chosen locations of the quick guide include the transfusion laboratory and known at-risk clinical areas i.e. each theatre room, the critical care unit, the resuscitation room in the emergency department and the acute medical and surgical units. The comprehensive design of the protocol required a consideration of the local requirements of the trust and the development of initiatives to support effective communication. The information contained within the protocol was based on the latest available evidence and subject to peer review prior to implementation.
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Figure 1. A quick reference guide was designed for staff in clinical areas and the transfusion laboratory
Major haemorrhage confirmed Estimated blood loss >1.5L OR 50% total blood volume loss within 3 hours Dial 2222 state “major haemorrhage, + location” Automatic call to Transfusion, on-call anaesthetist/ODP, surgeon, haematologist, porters and clinical matron Identify and treat cause of bleed / establish venous access / arrest bleeding Administer IVI crystalloid/colloid, consider use of prothrombin complex concentrate (Beriplex) Team leader to assign clinical liaison (CL) CL communicates with transfusion, theatre, X-ray, HDU etc, Coordinates delivery/receipt of blood components and maintains documentation Consider use of cell salvage and complications such as DIC, hypoxia and hypothermia Stage 1, Clinical bleep lab (273) with patient details, extent of bleeding and contact number ■■ Transfuse Stage 1 blood components: red cells (x4) and FFP (x4) ■■ Transfuse O neg red cells (x2) if required ■■ Send urgent FBC, clotting and chemistry ■■ Send urgent G&S if requested by lab ■■ CL
Stage 2, Clinical second stage G&S if requested by lab ■■ CL request Stage 2 blood components: red cells (x4) and FFP (x4) ■■ CL request pro-coagulation products: platelets (x1) and cryoprecipitate (x2) ■■ Repeat FBC and clotting after Stage 2 blood components transfused ■■ Send
Stage 3, Clinical ■■ Review and repeat Stage 2 or specify type and amount of blood components ■■ Repeat FBC and clotting after blood components transfused
Stage 4, Clinical protocol rescinded CL to inform lab ■■ Document each transfusion and return tags ■■ Once
ODP = operating department practitioner IVI = intravenous infusion HDU = high dependency unit DIC= disseminated intravascular coagulation (clotting disorder)
Stage 1, Transfusion patient details, CL contact number and request G&S if required ■■ Issue Stage 1 blood components: red cells (x4) and FFP (x4) ■■ Order platelets ■■ Automatic fibrinogen check ■■ Confirm
Stage 2, Transfusion ■■ Request second G&S if required ■■ On request issue Stage 2 blood
components: red cells (x4) and FFP (x4) ■■ On request issue products: platelets (x1) and cryoprecipitate (x2) ■■ Order more platelets as required
Stage 3, Transfusion and repeat Stage 2 or provide type and amount specified by CL ■■ If continued bleeding consider use of: Factor VIIa and tranexamic acid ■■ Review
Stage 4, Transfusion ■■ Await CL to rescind protocol ■■ Lab to confirm traceability
FFP = fresh frozen plasma O neg = blood group O negative FBC = full blood count G&S = ‘group and save’ (pre-transfusion blood test)
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Recognise barriers to sustained application The barriers were broadly grouped into of the protocol cognitive i.e. lack of staff education and socio-cultural i.e. ongoing reliance on current practices. These were dealt with by training, the support of transfusion advocates* and audit
packed red blood cells). The audit collated data on the timings for each major haemorrhage that had occurred in the 6 months since the start of the protocol and 6 months before its implementation. A major haemorrhage was confirmed by using the protocol definition and/or by the rapid transfusion of multiple blood components within 4 hours. Timing in the management of major haemorrhage is critical, yet delays in transfusing patients have been repeatedly identified by SHOT and current studies as the contributory cause of poor outcomes (Pottle et al, 2012; SHOT, 2014). The results of the audit showed a significant reduction in the time required from alerting the transfusion laboratory to transfusing the first unit within the 6-month period post-protocol. The total time on average was reduced from 42 minutes to 16 minutes, an improvement of 26 minutes. Interestingly, the total amout of O negative red blood cells (universal donor blood) used did not increase in the postprotocol period. This may be accounted for by the rapid alerting system of the transfusion laboratory, which allowed the issue of cross-matched blood components within an acceptable timeframe. The findings from the audit maintain the need for a protocol to manage a patient experiencing a major haemorrhage and support the measures taken to develop and implement the protocol. Further areas for audit include examining the effectiveness of the clinical liaison role, calculating wastage of blood components and reviewing the documentation of a major haemorrhage in both the clinical area and the transfusion laboratory.
Use champion(s) to engage users of the protocol
The TP enlisted the support of transfusion advocates to be early adopters and provide feedback on (exemplary/poor) adherence to the protocol
Conclusion
Establish standardisation to minimise variance to the protocol
The written protocol was available on the trust intranet and the quick guide was made available in all ‘at-risk’ areas as well as the transfusion laboratory
Identify financial incentives to aid compliance with the protocol
The protocol complies with NHS Litigation Authority requirements for reduced insurance premiums
Conduct training to ensure adherence to the protocol
The TP and transfusion advocates undertook initial training on a departmental basis. This included use of skills drills and small group teaching. Ongoing education is included in trust induction and mandatory training sessions for all staff groups
Conduct regular audits and reviews to evaluate the protocol
The review of the protocol includes updating the content in line with the latest research Conduct an annual audit of the protocol and present the findings to the hospital transfusion committee
Successful implementation of a protocol requires a multi-factorial approach. Table 1 identifies the standard recommendations for implementing a protocol and the specific actions taken by the author’s acute NHS trust at the time in response to these recommendations. These recommendations are based on work by Shearer et al (2012) and Grol et al (2013).
Evaluating a major haemorrhage protocol Six months after the introduction of the major haemorrhage protocol an audit was carried out within the author’s acute NHS trust. The audit was designed to compare pre- and post-protocol the time taken from alerting the transfusion laboratory to issuing and transfusing the first blood component (the initial unit transfused in a major haemorrhage is always Table 1. The standard recommendations for protocol implementation and the trust response to these Standard recommendations
Trust response
Identify legislation to support requirement for the protocol
NHS Litigation Authority Risk Management Standards
*A transfusion advocate is a nurse, junior doctor or biomedical scientist who has an interest in transfusion medicine. Transfusion advocates represent their clinical area on a voluntary basis i.e. it is not included as part of a formal job description. In her capacity as a TP, the author created this new role in order to strengthen clinical and laboratory working, to support dissemination of transfusion-related information and to improve transfusion safety. Sources: Shearer et al, 2012; Grol et al, 2013
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The lack of an agreed definition of ‘major haemorrhage’, coupled with the incidence and poor outcomes associated with major haemorrhage, highlighted the need for improvements to be made in local practices. A clinical protocol is one method available to support the management of a person experiencing excessive blood loss. The advantages of clinical protocols include: providing an agreed framework, identifying communication strategies, reviewing systems, roles and responsibilities and providing the facility for conducting audits. In relation to the major haemorrhage protocol, the rapid provision of blood components and effective communication are fundamental aspects of safe transfusion practice. The initial audit comparing pre- and post-protocol timings showed a marked improvement in clinical and laboratory response time to a patient with a major haemorrhage. However, the use of clinical protocols can be criticised on the basis of concerns about compliance and resourcing. Rather than undermine the use of protocols, having knowledge of these issues can be used to inform successful development and implementation of a protocol. As illustrated here with the example of the author’s experience, the development process requires collaboration with key stakeholders, recognition of local need and use of national guidance in order to produce a protocol that is fit for purpose; one that is evidence-based and individualised to the users. BJN Conflict of interest: none
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Implementing a major haemorrhage protocol
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CRITICAL CARE Anaesthetic Association of Great Britain and Ireland (2010) Blood Transfusion and the Anaesthetist: Management of Massive Haemorrhage. AAGBI, London Baumann Kreuziger L, Morton C, Subramanian A, Anderson C, Dries D (2014) Not only in trauma patients: hospital-wide implementation of a massive transfusion protocol. Transfus Med 24(3):162-8. doi: 10.1111/ tme.12096. Epub 2013 Borgman M, Spinella P, Perkins J et al (2007) The ratio of blood products transfused affects mortality in patients receiving massive transfusions at a combat support hospital. J Trauma 63(4): 805-13 Brody A, Barnes K, Ruble C, Sakowski J (2012) Evidence-based practice councils: Potential path to staff nurse empowerment and leadership growth. J Nurs Adm 42(1):28-33. doi: 10.1097/NNA.0b013e31823c17f5 Broughton R, Rathbone B (2001) What makes a good clinical guideline? http://tinyurl.com/onfmdur (accessed 5 November 2014) Contreras M, ed (2009) ABC of Transfusion. 4th edn. BMJ Books/John Wiley and Sons, Chichester Dale C, Aitken F for RCN Practice Education Forum (2007) A Review of the Literature into Dyslexia in Nursing Practice: Final Report. Royal College of Nursing, London Davenport R, Khan S (2011) Management of major trauma: treatment priorities and controversies. Br J Haematol 155(5): 537-48. doi: 10.1111/j.1365-2141.2011.08885.x. Engvall J, Padula C, Krajewski A et al (2014) Empowering the development of a nurse-driven protocol. MedSurg Nurs 23(3): 149-54 Grol R, Wensing M, Eccles M, Davies D (2013) Improving Patient Care: the implementation of change in clinical practice. 2nd edn.Wiley-Blackwell, Oxford Kauvar D, Wade C (2005) The epidemiology and modern management of traumatic haemorrhage: US and international perspectives. Crit Care 9(Suppl 5): S1-S9 Khan S, Allard S, Weaver A, Barber C, Davenport R, Brohi K (2013) A major haemorrhage protocol improves the delivery of blood component therapy and reduces waste in trauma massive transfusion. Injury 44(5): 587-92 McDaniel L, Etchill E, Raval J, Neal M (2014) State of the art: massive transfusion. Transfus Med 24(3): 138-44. doi: 10.1111/tme.12125 McDonnell Norms Group (2006) Enhancing the use of clinical guidelines: a social norms perspective. J Am Coll Surg 202(5): 826-56 Moore G, Knight G, Blann A (2010) Haematology. [Fundamentals of Biomedical Science series]. Oxford University Press, Oxford NHS Litigation Authority (2014) Risk Management Standards 2013-2014. http://tinyurl.com/oy72ref (accessed 5 November 2014) National Patient Safety Agency (2010) Rapid Response Report 017: The transfusion of blood and blood components in an emergency. http://tinyurl.com/ px5ucuk (accessed 5 November 2014) Pottle J, Staves J, Curry N (2012) Transfusion delays: an audit of transfusion practice for major blood loss in a UK teaching hospital. Transfus Med 22(1): 71-2. doi: 10.1111/j.1365-3148.2011.01112.x. Epub 2011 Royal College of Nursing (2005) Right blood, right patient, right time: RCN guidance for improving transfusion practice. http://tinyurl.com/8kc3xt (accessed 5 November 2014) Royal College of Obstetricians and Gynaecologists (2008) Blood Transfusion in Obstetrics. Green-top Guideline No. 47. http://tinyurl.com/ohha4c6 (accessed 5 November 2014) Roberts D (2014) Transfusion in military and civilian trauma and major haemorrhage. Transfus Med 24(3): 133-4. doi: 10.1111/tme.12128 Rycroft-Malone J, Fontenia M, Bick D, Seers K (2010) A realistic evaluation: the case of protocol-based care. Implement Sci 5:38. doi: 10.1186/17485908-5-38 Serious Hazards of Transfusion (2014) 2013 Annual report and summary. http://tinyurl.com/ope4uf2 (accessed 5 November 2014) Shearer B, Marshall S, Buist M et al (2012) What stops hospital clinical staff
KEY POINTS n Identification
of and appropriate response to major haemorrhage has been identified as a priority for clinical governance—this article discusses the introduction of a clinical protocol to improve practice
n Advantages
of clinical protocols include: providing an agreed framework, identifying communication strategies, reviewing systems, roles and responsibilities and providing the facility for conducting audits.
n The
stages of development of a protocol are: identifying the need, establishing the aims and designing the format
n Development
of a protocol requires collaboration with key stakeholders, recognition of local need and use of national guidance to produce a protocol that is fit for purpose, evidence-based and appropriate for the users
n In
the example here, key aspects included ensuring rapid provision of blood components and effective communication—initial audit showed a marked improvement in clinical and laboratory response time
from following protocols? An analysis of the incidence and factors behind the failure of bedside clinical staff to activate the rapid response system in a multi-campus Australian metropolitan healthcare service. BMJ Qual Safe 21(7): 569-75. doi: 10.1136/bmjqs-2011-000692 Sinha R, Roxby D, Bersten A (2013) Experience with a massive transfusion protocol in the management of major haemorrhage. Transfus Med 23(2): 108-13. doi: 10.1111/tme.12022 Stainsby D, MacLennan S, Hamilton P (2000) Management of massive blood loss: a template guideline. Br J Anaesth 85(3):487-91 Starr D (2012) Blood: An Epic History of Medicine and Commerce. 4th edn. Knopf Doubleday, New York UK Blood Transfusion and Tissue Transplantation Services (2010) Massive Haemorrhage Toolkit. http://tinyurl.com/korkd8a (accessed 5 November 2014) Wall J, Coubrie D (2011) Haemostatic resuscitation in the emergency department: how does the introduction of a major haemorrhage protocol influence transfusion practice for haemorrhagic shock. [In: Abstracts from the 2011 Meeting of the British Trauma Society, 4th – 6th May 2011] Injury Extra 42(9): 141. doi: 10.1016/j.injury.2011.06.329 Westerman R, Davey K, Porter K (2008) Assessing the potential for major trauma transfusion guidelines in the UK. Emerg Med J 25(3):134-5. doi: 10.1136/emj.2007.055756 Working in Partnership Programme (2006) Using protocols, standards, policies and guidelines to enhance confidence and career development. http://tinyurl. com/oddo9rc (accessed 5 November 2014) Young P, Cotton B, Goodnough L (2011) Massive transfusion protocols for patients with substantial haemorrhage. Transfus Med Rev 25(4):293-303. doi: 10.1016/j.tmrv.2011.04.002
About the book
n
Illustrates how reflective practice can fulfil a need for all health care professionals to make sense of their clinical experience Discusses the clinical implications of the principles and processes associated with reflective practice
n n
Represents a variety of models and classifies and critiques them
The book is designed to assist health care professionals to develop the art of learning from reflective practice. Journal writing and analysis of critical incidents are two ways to facilitate reflection. Specifically they relate to the art of reflection-on-action . The book is divided into three broad sections to do with ‘context’, ‘learning processes’ and ‘outcomes’. In Part 1: Context, the genesis, goals and interests of reflective practice are set out. Part 2: Process describes and justifies journal writing and critical incident analysis as two ways to learn from reflection-on-action. Finally, in Part 3: Outcomes the implications for clinical practice that arise from reflecting-on-action through journal writing and critical incident analysis are examined.
Includes practical suggestions along with discussion of their advantages and limitations This book is intended to support health care professionals in becoming more personally and publicly accountable by helping them to reflect upon what may well be perceived as competent and skilful clinical action. Through the more generic process of reflective practice and the more specific and related approaches of journal writing and critical incident analysis, we hope that health care professionals may be able to make even more sense of their clinical worlds by additionally inquiring into, and understanding more richly, that which is often implicit in everyday practice.
Tony Ghaye is C.E.O. of the Institute of Reflective Practice-UK, Professor in Educare, Visiting Professor at the Universities of Lulea, Sweden, Wales-NEWI and Senior International Consultant at Beijing-Geely University, China.
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Key words: Major haemorrhage ■ Clinical protocol ■ Transfusion ■ Blood components
T
he depiction of blood as a ‘life force’ is a well recognised representation found in most societies, cultures and religions (Starr, 2012). The biological explanation of blood as a complex tissue essential for homeostasis is no less significant (Moore et al, 2010). Despite the variation in the descriptions of blood, ranging from the symbolic to the medical, common to each is the integral link this particular body fluid has with the maintenance of life. For nurses (and medical staff) to have a cultural or more notably a physiological understanding of blood is important, as they may be required to care for people in the most extreme circumstance of excessive blood loss. It is therefore essential that nurses are well skilled in the management of patients who are either at risk of or experiencing a major haemorrhage. The author’s experience of being involved in the management of major haemorrhages was while working as a transfusion practitioner (TP). Each acute NHS trust is required to employ a TP who fulfills the remit of ensuring
Jessica Hargreaves, Senior Lecturer, Acute Clinical Practice, University of Brighton Accepted for publication: October 2014
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Background Major haemorrhage is usually defined as the loss of 1 circulating blood volume within a 24-hour period (Contreras, 2009). However, definitions can vary according to medical discipline, for example in obstetrics, blood loss at or greater than 2500 ml is used to determine a major obstetric haemorrhage (Royal College of Obstetricians and Gynaecologists, 2008). This volume is not based on a person’s weight or a percentage of total blood volume, rather it is a defined amount not subject to individual parameters. Recommendations from other clinical working groups suggest that a patient-based assessment should alert the clinician to excessive blood loss rather than reliance on a numerical value (Anaesthetic Association of Great Britain and Ireland (AAGBI), 2010). This approach takes into consideration the occasions when the person’s blood loss is not quantifiable or when a major haemorrhage is one of a number of conditions to be considered in the management
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Abstract
This article presents the author’s experience, in the role of a transfusion practitioner (TP), of developing and implementing a major haemorrhage protocol. A definition is given for the term ‘major haemorrhage’ in conjunction with the incidence of and outcomes for people experiencing excessive blood loss. The advantages and disadvantages of clinical protocols are discussed. Rather than reject the use of protocols because of issues of compliance and resourcing, these should be acknowledged in order to better inform the development and implementation of a protocol. With reference to the specific design of a major haemorrhage protocol for use in an acute NHS trust, a detailed explanation of the stages involved in developing a protocol is given. This is followed by a summary of the standard recommendations specified for protocol implementation. The findings from an audit showed on average that the time to the first transfusion was 26 minutes less for patients in the post-protocol group compared to the pre-protocol group.
blood components are given safely and appropriately both in routine and emergency settings, such as a major haemorrhage (Royal College of Nursing, 2005). The particular acute NHS trust in which the author worked has over 800 beds extending across three sites providing acute services including maternity, accident and emergency, general surgery and critical care. At the time of taking up the TP position in the trust only a major obstetric haemorrhage protocol existed to direct the care of obstetric patients experiencing an ante- or post-partum haemorrhage. No provision was made in this or any other transfusion-related document for the care of non-obstetric patients who may also experience a major haemorrhage. This article is intended to assist those nurses who are directly engaged in the development and implementation of protocols with a discussion of their advantages and disadvantages. The author’s experience of developing a major haemorrhage protocol is used to demonstrate the stages required in the design and implementation of a protocol and to present the latest supporting literature specific to the management of a major haemorrhage. Findings are presented of an audit comparing the speed of delivery of blood components in the patient group before the introduction of the protocol and the patient group following implementation of the protocol. Finally, it is anticipated that all nurses will gain an appreciation of the complexity and the challenges involved in the formation of a protocol and to be encouraged to reflect on the reasons for either their own compliance or non-compliance with clinical protocols.
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CRITICAL CARE of acute illness. Furthermore, a loss of any volume of blood, if it remains uncontrolled, will rapidly exceed (often in a matter of minutes) the volume deemed to indicate a major haemorrhage. Therefore, the risk is that if the trigger volume for determining a major haemorrhage is set too high, further unnecessary blood loss will result before life-saving treatment is commenced (Davenport and Khan, 2011). Consequently, if uncontrolled bleeding occurs it is the effect of this blood loss that should determine the initiation of treatment rather than just a defined volume. Despite the lack of consensus on the specific volume of blood loss that could be used to determine a major haemorrhage there is agreement in the importance of establishing the early recognition of excessive blood loss (Stainsby et al, 2000;AAGBI, 2010; Roberts, 2014). Currently, there are valid concerns regarding the capability of UK hospitals to both recognise and manage major haemorrhage.The UK steering group dedicated to transfusion safety, Serious Hazards of Transfusion (SHOT), compiles an annual summary of all reported transfusionrelated incidents. Data from the 2013 annual report identified that delays in transfusing patients who experienced major haemorrhage contributed to the death of two patients and the increased morbidity of seven other patients (SHOT, 2014).The investigations into these serious untoward incidents identified that the reasons for the delay were failings in the detection of the haemorrhage and the poor communication between the clinical area and the transfusion laboratory. The incidence of major haemorrhage is not isolated to a specific patient group. A range of patients in clinical settings as diverse as acute medicine, surgery, trauma and obstetrics are all at risk of experiencing major haemorrhage either through pathological, traumatic or iatrogenic reasons (National Patient Safety Agency (NPSA), 2010). Kauvar and Wade (2005) identified that uncontrolled bleeding in trauma patients, accounts for between 30% and 40% of all trauma-related deaths. Local data from the acute NHS trust within which the author previously worked showed that on average there are 20 major haemorrhages each year; this equates to between one and two a month with a 5% morbidity. The frequency combined with the risk of poor outcomes has established the management of major haemorrhage as a priority on the NHS’ clinical governance agenda (SHOT, 2014). As a consequence, the hospital transfusion committee (within the author’s acute NHS trust) committed to establishing the measures to be put in place in the event of a major haemorrhage occurring in any patient group. These measures were collectively presented in the form of a major haemorrhage protocol.
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Advantages and disadvantages of clinical protocols There is considerable debate regarding the need for protocols in health care (Rycroft-Malone et al, 2010). The initial barrier to using protocols is found within the term itself, which is often mistakenly used interchangeably with the terms ‘guideline’ or ‘policy’. This has led to confusion, among clinicians intending to follow a protocol regarding its legal status and its required level of compliance (Shearer et al, 2012). As a result of this uncertainty an understandable antipathy has developed towards the use of protocols.
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However, unambiguous definitions do exist. The Working in Partnership Programme (WIPP) (2006), for example, defines a protocol as an agreed framework outlining the care that will be provided in a designated area of practice. Protocols are not prescriptive, they do not describe how a procedure is performed, but rather why, where, when and by whom the care is given. Helpfully the same document also provides clear definitions for the terms ‘standard’, ‘guideline’ and ‘policy’. As the above definition suggests, a protocol provides health professionals with a framework for achieving a complex sequence of activities, such as those required in the management of a major haemorrhage. One of the difficulties inherent in this level of complexity is coordinating the involvement of numerous agencies in providing the care to the patient. In this instance, the agencies involved include doctors, nurses, midwives, biomedical scientists (BMS), portering staff and telecommunications staff. Therefore, a protocol must also facilitate the coordination of these different groups. Establishing roles and responsibilities of each staff group, plus making the means of communication between the different staff groups explicit, can help to achieve this. This level of transparency counters the often-recurring complaint of poor communication (as observed in the management of major haemorrhages) that can exist between health professionals (WIPP, 2006). By establishing the expected roles and responsibilities of each staff group, the development of a protocol has the indirect advantage of prompting a review of the roles and responsibilities currently being undertaken (Engvall et al, 2014). In order to identify the why, where, when and by whom of the protocol, a thorough evaluation of the existing practices is required. As a consequence, any system failings or assumptions about roles and responsibilities will be highlighted, making the opportunity available for more effective or efficient practices to be adopted (Brody et al, 2012). The advantage of using protocols lies not only in formalising agreed practices, but also in supporting practice development and quality assurance. Beyond the immediate application of the protocol for improving patient care there are also strategic benefits for using protocols. For example, the practices outlined in a protocol can be audited and by auditing practice it is possible to identify educational needs and use the findings to assist in changing practice (Davenport and Khan, 2011). However, the use of protocols is also subject to criticism. This is invariably linked to the suggestion that protocols stifle individual care management and restrict clinical autonomy. Clinicians who are not convinced of the evidence base for the protocol often make this censure. There may be concern that the protocol runs counter to the perceived or accepted practice norms (WIPP, 2006). With regard to the major haemorrhage protocol, there is ongoing debate about the optimal transfusion ratio of packed red blood cells to fresh-frozen plasma. The emerging evidence of a 1:1 ratio is derived from patients being treated in a combative military environment rather than an acute NHS trust hence the difficulty in extrapolating the data to other patient groups (Roberts, 2014). Yet this lack of certainty should promote further research to support best practice regardless of whether its use is protocol-driven or clinician-led.
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Developing a major haemorrhage protocol It is important to appreciate that successful implementation of a protocol is dependent on its development. The stages of development involve: identifying the need for a protocol, establishing the aims of a protocol, designing the format of a protocol and evaluating the effectiveness of a protocol. The following are reflections on the author’s experience of developing a protocol, which have been further informed by guidance from Broughton and Rathbone (2001), the McDonnell Norms Group (2006) and Grol et al (2013).
Identifying the need for a protocol A risk assessment carried out on the transfusion practices within the trust highlighted that there was only a major haemorrhage protocol for use with obstetric patients.Yet, the data on blood component usage identified that many more than just obstetric patients had experienced excessive blood loss. As a result, there was a high likelihood that in the event of a major haemorrhage some patients would be managed outside of an agreed standard of care. According to the NHS Litigation Authority (2014) Risk Management Standards 201314, all acute care services are required to have documented processes for the administration of blood components and this must include transfusion in a major haemorrhage. The NPSA (2010) and the UK Blood Transfusion and Tissue Transplantation Services (UKBTS) (2010) in response to the national review of incidences of major haemorrhage, also stipulate the need for acute NHS trusts to have such a protocol in place for all patient groups. The need for a protocol also reflects the importance of standardising the process of selecting which of the latest developments in the management of a major haemorrhage to adopt. These include the experience from the military in haemodynamic resuscitation, the increased use of near-patient Box 1. Agreed aims of the major haemorrhage protocol ■ A
single protocol i.e. to be used for all patients in all clinical areas visible protocol i.e. easily accessible for all staff to refer to ■ An evaluated protocol i.e. subject to regular review and audit ■ A
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testing techniques such as thromboelastography, and the use of additional therapies such as tranexamic acid, prothrombin complex concentrate and fibrinogen concentrate (UKBTS, 2010;Young et al, 2011; Sinha et al, 2013; Baumann Kreuziger et al, 2014).Without an approved system for determining which of these investigations and therapies, if any, should be used, there will be an ongoing disparity in the care received by patients and an over-reliance on each individual clinician to be informed of and discriminate between the most suitable treatment advances (Wall and Coubrie, 2011;Young et al, 2011; Khan et al, 2013).
Establishing the aims of a protocol The established aims of the major haemorrhage protocol were a product of a 2-month consultation period with all the stakeholder staff groups (clinicians, BMS and ancillary staff) involved to a varying extent in the management of a major haemorrhage. According to Broughton and Rathbone (2001) collaboration is an essential element of successful protocol design. In her role as a TP, it was necessary for the author to engage each of the staff groups in establishing their individual aims and to present these to the hospital transfusion committee who had overall responsibility for the review and approval of the protocol. The aims derived from this approach sought to unify the procedure, to aid communication between the staff groups and to ensure the protocol remained up-to-date (Pottle et al, 2012; McDaniel et al, 2014). Box 1 lists the aims derived from the consultation and agreed by the hospital transfusion committee.
Designing the format of a protocol To ensure the aims were met, the protocol contained the following key elements: ■■ An agreed definition of major haemorrhage for all patient groups i.e. estimated blood loss > 1.5 litres or 50% total blood volume loss within 3 hours (a volumebased definition of major haemorrhage was adopted as it was agreed by the working party that staff preferred an objective measure rather than reliance on prompts for clinical judgement) ■■ A list of the various roles and responsibilities of all staff groups involved in a major haemorrhage ■■ An explanation of the different blood components and products available to use in a major haemorrhage (Borgman et al, 2007) ■■ An explanation of the different medications and treatments, in addition to blood components and products, available to use in a major haemorrhage (McDaniel et al, 2014) ■■ A detailed account of the process of managing a major haemorrhage including potential complications (Westerman et al, 2008; Wall and Coubrie, 2011). Fundamental to the writing of the protocol was to use staff who had knowledge of the local structures and systems in the trust. This insight was invaluable as the trust has three sites that all require major haemorrhage cover but the provision of clinical support and even the availability of blood components varies between sites. Therefore, how these differences were accommodated in the protocol had to be made explicit for each site. In addition, four new initiatives were devised specifically
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A further disadvantage of the use of protocols is that even if there is consensus in its development, compliance with the implementation of the protocol can still prove problematic. The higher the number of different staff groups involved and the greater the complexity of care practices, the harder it is to achieve conformity or standardisation, a hallmark of protocol use (Shearer et al, 2012). Linked to the difficulties of implementation, once a protocol is instituted it will also require regular review, which brings with it further implications for resourcing (Grol et al, 2013). It is clear that there are recognised advantages to using protocols in order to provide systematic and consistent care delivered by health professionals and ancillary staff. In addition, the disadvantages of protocols, such as resourcing and compliance, should not be seen as preclusions to the use of protocols. Instead, by acknowledging the associated difficulties it is possible to better understand how to factor in these issues when developing and implementing a protocol.
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CRITICAL CARE for the protocol focusing on improving or reinforcing communication. The first initiative encouraged any staff member who recognised that a patient met the defined criteria of a major haemorrhage to initiate the protocol. The aim was to prevent unnecessary delays by waiting for senior staff to confirm a major haemorrhage. The potential for ‘false alarms’ were accepted as the risk of actioning the protocol unnecessarily was outweighed by the risk of not delivering blood components in a timely and coordinated approach to a person suffering major haemorrhage. All calls are subject to regular review in the annual audit. Previously, informing all the appropriate staff of a major haemorrhage would have required each person to be told on an individual basis. This lengthy procedure could cause significant delays and was considered too unreliable; therefore a new strategy was devised. This was the second initiative, whereby one call is made to the switchboard staff who are then responsible for contacting a pre-specified group of staff to alert them to the occurrence and the location of the major haemorrhage. The third initiative involved allocating a specific role to a clinical staff member. In the early stages of a major haemorrhage a clinical liaison is assigned from the clinical staff present at the time. This is a new role with a threefold purpose, requiring the clinician to communicate with other departments in the hospital, such as the laboratory, theatre and critical care, to coordinate delivery and receipt of blood components and to document the events of the major haemorrhage. Invariably, the TP, a senior nurse or junior doctor will undertake this role, as they will have experience of leading teams. The final initiative involves a quick guide, which was designed to supplement the formal protocol. It distils the key actions, to be completed in the event of a major haemorrhage, onto one page (Figure 1). There are a number of unique features of this quick guide including setting out the actions of both the clinical area and the transfusion laboratory. This was in response to the uncertainty expressed by both clinical and laboratory staff of ‘working blind’ i.e. not knowing the actions being undertaken or to be anticipated. It also simplifies the information that needs to be communicated between the clinical area and the transfusion laboratory and it divides the management of a major haemorrhage into precise stages. The quick guide is printed on yellow paper to make it more prominent and to make it easier to read. This is particularly important for people with dyslexia who may have difficulty distinguishing dark text on a white background (Dale and Aitken, 2007). It is laminated for infection prevention and control purposes and always positioned next to a telephone. The chosen locations of the quick guide include the transfusion laboratory and known at-risk clinical areas i.e. each theatre room, the critical care unit, the resuscitation room in the emergency department and the acute medical and surgical units. The comprehensive design of the protocol required a consideration of the local requirements of the trust and the development of initiatives to support effective communication. The information contained within the protocol was based on the latest available evidence and subject to peer review prior to implementation.
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Figure 1. A quick reference guide was designed for staff in clinical areas and the transfusion laboratory
Major haemorrhage confirmed Estimated blood loss >1.5L OR 50% total blood volume loss within 3 hours Dial 2222 state “major haemorrhage, + location” Automatic call to Transfusion, on-call anaesthetist/ODP, surgeon, haematologist, porters and clinical matron Identify and treat cause of bleed / establish venous access / arrest bleeding Administer IVI crystalloid/colloid, consider use of prothrombin complex concentrate (Beriplex) Team leader to assign clinical liaison (CL) CL communicates with transfusion, theatre, X-ray, HDU etc, Coordinates delivery/receipt of blood components and maintains documentation Consider use of cell salvage and complications such as DIC, hypoxia and hypothermia Stage 1, Clinical bleep lab (273) with patient details, extent of bleeding and contact number ■■ Transfuse Stage 1 blood components: red cells (x4) and FFP (x4) ■■ Transfuse O neg red cells (x2) if required ■■ Send urgent FBC, clotting and chemistry ■■ Send urgent G&S if requested by lab ■■ CL
Stage 2, Clinical second stage G&S if requested by lab ■■ CL request Stage 2 blood components: red cells (x4) and FFP (x4) ■■ CL request pro-coagulation products: platelets (x1) and cryoprecipitate (x2) ■■ Repeat FBC and clotting after Stage 2 blood components transfused ■■ Send
Stage 3, Clinical ■■ Review and repeat Stage 2 or specify type and amount of blood components ■■ Repeat FBC and clotting after blood components transfused
Stage 4, Clinical protocol rescinded CL to inform lab ■■ Document each transfusion and return tags ■■ Once
ODP = operating department practitioner IVI = intravenous infusion HDU = high dependency unit DIC= disseminated intravascular coagulation (clotting disorder)
Stage 1, Transfusion patient details, CL contact number and request G&S if required ■■ Issue Stage 1 blood components: red cells (x4) and FFP (x4) ■■ Order platelets ■■ Automatic fibrinogen check ■■ Confirm
Stage 2, Transfusion ■■ Request second G&S if required ■■ On request issue Stage 2 blood
components: red cells (x4) and FFP (x4) ■■ On request issue products: platelets (x1) and cryoprecipitate (x2) ■■ Order more platelets as required
Stage 3, Transfusion and repeat Stage 2 or provide type and amount specified by CL ■■ If continued bleeding consider use of: Factor VIIa and tranexamic acid ■■ Review
Stage 4, Transfusion ■■ Await CL to rescind protocol ■■ Lab to confirm traceability
FFP = fresh frozen plasma O neg = blood group O negative FBC = full blood count G&S = ‘group and save’ (pre-transfusion blood test)
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Recognise barriers to sustained application The barriers were broadly grouped into of the protocol cognitive i.e. lack of staff education and socio-cultural i.e. ongoing reliance on current practices. These were dealt with by training, the support of transfusion advocates* and audit
packed red blood cells). The audit collated data on the timings for each major haemorrhage that had occurred in the 6 months since the start of the protocol and 6 months before its implementation. A major haemorrhage was confirmed by using the protocol definition and/or by the rapid transfusion of multiple blood components within 4 hours. Timing in the management of major haemorrhage is critical, yet delays in transfusing patients have been repeatedly identified by SHOT and current studies as the contributory cause of poor outcomes (Pottle et al, 2012; SHOT, 2014). The results of the audit showed a significant reduction in the time required from alerting the transfusion laboratory to transfusing the first unit within the 6-month period post-protocol. The total time on average was reduced from 42 minutes to 16 minutes, an improvement of 26 minutes. Interestingly, the total amout of O negative red blood cells (universal donor blood) used did not increase in the postprotocol period. This may be accounted for by the rapid alerting system of the transfusion laboratory, which allowed the issue of cross-matched blood components within an acceptable timeframe. The findings from the audit maintain the need for a protocol to manage a patient experiencing a major haemorrhage and support the measures taken to develop and implement the protocol. Further areas for audit include examining the effectiveness of the clinical liaison role, calculating wastage of blood components and reviewing the documentation of a major haemorrhage in both the clinical area and the transfusion laboratory.
Use champion(s) to engage users of the protocol
The TP enlisted the support of transfusion advocates to be early adopters and provide feedback on (exemplary/poor) adherence to the protocol
Conclusion
Establish standardisation to minimise variance to the protocol
The written protocol was available on the trust intranet and the quick guide was made available in all ‘at-risk’ areas as well as the transfusion laboratory
Identify financial incentives to aid compliance with the protocol
The protocol complies with NHS Litigation Authority requirements for reduced insurance premiums
Conduct training to ensure adherence to the protocol
The TP and transfusion advocates undertook initial training on a departmental basis. This included use of skills drills and small group teaching. Ongoing education is included in trust induction and mandatory training sessions for all staff groups
Conduct regular audits and reviews to evaluate the protocol
The review of the protocol includes updating the content in line with the latest research Conduct an annual audit of the protocol and present the findings to the hospital transfusion committee
Successful implementation of a protocol requires a multi-factorial approach. Table 1 identifies the standard recommendations for implementing a protocol and the specific actions taken by the author’s acute NHS trust at the time in response to these recommendations. These recommendations are based on work by Shearer et al (2012) and Grol et al (2013).
Evaluating a major haemorrhage protocol Six months after the introduction of the major haemorrhage protocol an audit was carried out within the author’s acute NHS trust. The audit was designed to compare pre- and post-protocol the time taken from alerting the transfusion laboratory to issuing and transfusing the first blood component (the initial unit transfused in a major haemorrhage is always Table 1. The standard recommendations for protocol implementation and the trust response to these Standard recommendations
Trust response
Identify legislation to support requirement for the protocol
NHS Litigation Authority Risk Management Standards
*A transfusion advocate is a nurse, junior doctor or biomedical scientist who has an interest in transfusion medicine. Transfusion advocates represent their clinical area on a voluntary basis i.e. it is not included as part of a formal job description. In her capacity as a TP, the author created this new role in order to strengthen clinical and laboratory working, to support dissemination of transfusion-related information and to improve transfusion safety. Sources: Shearer et al, 2012; Grol et al, 2013
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The lack of an agreed definition of ‘major haemorrhage’, coupled with the incidence and poor outcomes associated with major haemorrhage, highlighted the need for improvements to be made in local practices. A clinical protocol is one method available to support the management of a person experiencing excessive blood loss. The advantages of clinical protocols include: providing an agreed framework, identifying communication strategies, reviewing systems, roles and responsibilities and providing the facility for conducting audits. In relation to the major haemorrhage protocol, the rapid provision of blood components and effective communication are fundamental aspects of safe transfusion practice. The initial audit comparing pre- and post-protocol timings showed a marked improvement in clinical and laboratory response time to a patient with a major haemorrhage. However, the use of clinical protocols can be criticised on the basis of concerns about compliance and resourcing. Rather than undermine the use of protocols, having knowledge of these issues can be used to inform successful development and implementation of a protocol. As illustrated here with the example of the author’s experience, the development process requires collaboration with key stakeholders, recognition of local need and use of national guidance in order to produce a protocol that is fit for purpose; one that is evidence-based and individualised to the users. BJN Conflict of interest: none
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Implementing a major haemorrhage protocol
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CRITICAL CARE Anaesthetic Association of Great Britain and Ireland (2010) Blood Transfusion and the Anaesthetist: Management of Massive Haemorrhage. AAGBI, London Baumann Kreuziger L, Morton C, Subramanian A, Anderson C, Dries D (2014) Not only in trauma patients: hospital-wide implementation of a massive transfusion protocol. Transfus Med 24(3):162-8. doi: 10.1111/ tme.12096. Epub 2013 Borgman M, Spinella P, Perkins J et al (2007) The ratio of blood products transfused affects mortality in patients receiving massive transfusions at a combat support hospital. J Trauma 63(4): 805-13 Brody A, Barnes K, Ruble C, Sakowski J (2012) Evidence-based practice councils: Potential path to staff nurse empowerment and leadership growth. J Nurs Adm 42(1):28-33. doi: 10.1097/NNA.0b013e31823c17f5 Broughton R, Rathbone B (2001) What makes a good clinical guideline? http://tinyurl.com/onfmdur (accessed 5 November 2014) Contreras M, ed (2009) ABC of Transfusion. 4th edn. BMJ Books/John Wiley and Sons, Chichester Dale C, Aitken F for RCN Practice Education Forum (2007) A Review of the Literature into Dyslexia in Nursing Practice: Final Report. Royal College of Nursing, London Davenport R, Khan S (2011) Management of major trauma: treatment priorities and controversies. Br J Haematol 155(5): 537-48. doi: 10.1111/j.1365-2141.2011.08885.x. Engvall J, Padula C, Krajewski A et al (2014) Empowering the development of a nurse-driven protocol. MedSurg Nurs 23(3): 149-54 Grol R, Wensing M, Eccles M, Davies D (2013) Improving Patient Care: the implementation of change in clinical practice. 2nd edn.Wiley-Blackwell, Oxford Kauvar D, Wade C (2005) The epidemiology and modern management of traumatic haemorrhage: US and international perspectives. Crit Care 9(Suppl 5): S1-S9 Khan S, Allard S, Weaver A, Barber C, Davenport R, Brohi K (2013) A major haemorrhage protocol improves the delivery of blood component therapy and reduces waste in trauma massive transfusion. Injury 44(5): 587-92 McDaniel L, Etchill E, Raval J, Neal M (2014) State of the art: massive transfusion. Transfus Med 24(3): 138-44. doi: 10.1111/tme.12125 McDonnell Norms Group (2006) Enhancing the use of clinical guidelines: a social norms perspective. J Am Coll Surg 202(5): 826-56 Moore G, Knight G, Blann A (2010) Haematology. [Fundamentals of Biomedical Science series]. Oxford University Press, Oxford NHS Litigation Authority (2014) Risk Management Standards 2013-2014. http://tinyurl.com/oy72ref (accessed 5 November 2014) National Patient Safety Agency (2010) Rapid Response Report 017: The transfusion of blood and blood components in an emergency. http://tinyurl.com/ px5ucuk (accessed 5 November 2014) Pottle J, Staves J, Curry N (2012) Transfusion delays: an audit of transfusion practice for major blood loss in a UK teaching hospital. Transfus Med 22(1): 71-2. doi: 10.1111/j.1365-3148.2011.01112.x. Epub 2011 Royal College of Nursing (2005) Right blood, right patient, right time: RCN guidance for improving transfusion practice. http://tinyurl.com/8kc3xt (accessed 5 November 2014) Royal College of Obstetricians and Gynaecologists (2008) Blood Transfusion in Obstetrics. Green-top Guideline No. 47. http://tinyurl.com/ohha4c6 (accessed 5 November 2014) Roberts D (2014) Transfusion in military and civilian trauma and major haemorrhage. Transfus Med 24(3): 133-4. doi: 10.1111/tme.12128 Rycroft-Malone J, Fontenia M, Bick D, Seers K (2010) A realistic evaluation: the case of protocol-based care. Implement Sci 5:38. doi: 10.1186/17485908-5-38 Serious Hazards of Transfusion (2014) 2013 Annual report and summary. http://tinyurl.com/ope4uf2 (accessed 5 November 2014) Shearer B, Marshall S, Buist M et al (2012) What stops hospital clinical staff
KEY POINTS n Identification
of and appropriate response to major haemorrhage has been identified as a priority for clinical governance—this article discusses the introduction of a clinical protocol to improve practice
n Advantages
of clinical protocols include: providing an agreed framework, identifying communication strategies, reviewing systems, roles and responsibilities and providing the facility for conducting audits.
n The
stages of development of a protocol are: identifying the need, establishing the aims and designing the format
n Development
of a protocol requires collaboration with key stakeholders, recognition of local need and use of national guidance to produce a protocol that is fit for purpose, evidence-based and appropriate for the users
n In
the example here, key aspects included ensuring rapid provision of blood components and effective communication—initial audit showed a marked improvement in clinical and laboratory response time
from following protocols? An analysis of the incidence and factors behind the failure of bedside clinical staff to activate the rapid response system in a multi-campus Australian metropolitan healthcare service. BMJ Qual Safe 21(7): 569-75. doi: 10.1136/bmjqs-2011-000692 Sinha R, Roxby D, Bersten A (2013) Experience with a massive transfusion protocol in the management of major haemorrhage. Transfus Med 23(2): 108-13. doi: 10.1111/tme.12022 Stainsby D, MacLennan S, Hamilton P (2000) Management of massive blood loss: a template guideline. Br J Anaesth 85(3):487-91 Starr D (2012) Blood: An Epic History of Medicine and Commerce. 4th edn. Knopf Doubleday, New York UK Blood Transfusion and Tissue Transplantation Services (2010) Massive Haemorrhage Toolkit. http://tinyurl.com/korkd8a (accessed 5 November 2014) Wall J, Coubrie D (2011) Haemostatic resuscitation in the emergency department: how does the introduction of a major haemorrhage protocol influence transfusion practice for haemorrhagic shock. [In: Abstracts from the 2011 Meeting of the British Trauma Society, 4th – 6th May 2011] Injury Extra 42(9): 141. doi: 10.1016/j.injury.2011.06.329 Westerman R, Davey K, Porter K (2008) Assessing the potential for major trauma transfusion guidelines in the UK. Emerg Med J 25(3):134-5. doi: 10.1136/emj.2007.055756 Working in Partnership Programme (2006) Using protocols, standards, policies and guidelines to enhance confidence and career development. http://tinyurl. com/oddo9rc (accessed 5 November 2014) Young P, Cotton B, Goodnough L (2011) Massive transfusion protocols for patients with substantial haemorrhage. Transfus Med Rev 25(4):293-303. doi: 10.1016/j.tmrv.2011.04.002
About the book
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Illustrates how reflective practice can fulfil a need for all health care professionals to make sense of their clinical experience Discusses the clinical implications of the principles and processes associated with reflective practice
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Represents a variety of models and classifies and critiques them
The book is designed to assist health care professionals to develop the art of learning from reflective practice. Journal writing and analysis of critical incidents are two ways to facilitate reflection. Specifically they relate to the art of reflection-on-action . The book is divided into three broad sections to do with ‘context’, ‘learning processes’ and ‘outcomes’. In Part 1: Context, the genesis, goals and interests of reflective practice are set out. Part 2: Process describes and justifies journal writing and critical incident analysis as two ways to learn from reflection-on-action. Finally, in Part 3: Outcomes the implications for clinical practice that arise from reflecting-on-action through journal writing and critical incident analysis are examined.
Includes practical suggestions along with discussion of their advantages and limitations This book is intended to support health care professionals in becoming more personally and publicly accountable by helping them to reflect upon what may well be perceived as competent and skilful clinical action. Through the more generic process of reflective practice and the more specific and related approaches of journal writing and critical incident analysis, we hope that health care professionals may be able to make even more sense of their clinical worlds by additionally inquiring into, and understanding more richly, that which is often implicit in everyday practice.
Tony Ghaye is C.E.O. of the Institute of Reflective Practice-UK, Professor in Educare, Visiting Professor at the Universities of Lulea, Sweden, Wales-NEWI and Senior International Consultant at Beijing-Geely University, China.
Order your copies by visiting
www.quaybooks.co.uk British Journal of Nursing, 2014, Vol 23, No 21
Sue Lillyman is a Senior Lecturer at University of Central England and Affiliated consultant at the institute of Reflective Practice-UK.
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Learning Journals and Critical Incidents Reflective Practice for Health Care Professionals
2nd edition
by Tony Ghaye and Sue Lillyman
© 2014 MA Healthcare Ltd
ISBN-13: 978-1-85642-248-2; ISBN-10: 1-85642-248-8; 234 x 156 mm; paperback; 260 pages; publication About the authors 2008; £24.99
Learning Journals and Critical Incidents 2nd edition
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This is the 2nd edition of the best selling book Learning Journals and Critical Incidents which has been widely acknowledged for its contribution to the understanding of reflection and reflective practice. This edition has been thoroughly updated to recognise changes and developments in both theory and practice over recent years.
1145 by Tony Ghaye and
Lillyman www.quaybooks.co.uk British Journal of Nursing. Downloaded from magonlinelibrary.com by 130.237.122.245 on November 15, 2015. For personal use only. No other uses Sue without permission. . All rights reserved.
