Hemorrhage
Chapter 1: Introduction
Introduction
Hemorrhage is a paramount issue that can precipitate a fatal patient outcome. Massive
transfusion is a vital, high-risk treatment for extreme blood loss. The replacement of a
patient’s blood volume by rapidly transfusing blood products is particularly unpredictable.
There can be various precipitating events causing massive bleeding, all of which require quick
recognition, expeditious response, and concise treatment. Blood management and resuscitation
during hemorrhage requires a team of knowledgeable participants, with assigned roles, the
proper equipment for rapid administration and an atmosphere with structure and order (Milligan,
Higginson, & Smith, 2011).
Each massive transfusion is different, which creates a certain level of stress and
uncertainty among responding staff. When staff is inexperienced with massive transfusion
protocols or unfamiliar with the requirements, their performance can fluctuate. Performance
could be stronger under a moderate amount of stress, or they could shut down and question their
abilities. Massive transfusions require team participation, protocols, and an algorithm to follow,
in addition to hands-on training, which can ease the fight-or-flight response, support confidence
and improve patient outcomes (Stout, 2013).
Background
The use of evidence-based protocols implemented by an experienced team reduces
variability, enhances correct blood administration, and improves outcomes. The initial
demonstration of these benefits was clearly showcased by the armed services in the early 1900s
(Roberts, Chandler, & Mayles, n.d.). Their precise management of hemorrhage using a massive
bleeding protocol led to improved survivability of severe trauma in the field (Roberts, Chandler,
& Mayles, n.d.). Hemorrhage and death are familiar outcomes on the battlefield. However,
proactive care and early blood administration have prevented some deaths that were previously
seen as inevitable. Today, hospitals around the world have adopted massive transfusion protocols
based on previous, documented evidence and tracking of the military protocols and outcomes
(Roberts et al., n.d.).
Having protocols for patients undergoing massive bleeding can reduce mortality,
increase teamwork and facilitate proper product usage (Engelbrecht et al., 2013). Massive
transfusion protocols continue to evolve. Research shows the composition of protocols, massive
transfusion delivery methods, and product ratios differ by the institution (Etchill, Sperry,
Zuckerbraun, Alrcon, Brown, Schuster, Kaplan, Piper, Peitzman & Neal, 2016). In addition, the
authors noted variability in products dispensed. In some protocols, there are no plasma or
platelets dispensed during the first response, no crystalloid administration guidelines, and
calcium is not part of the protocol. Although institutions have a massive bleeding protocol, it
may need to be updated to include recent developments (Etchill et al., 2016).
The four goals during hemorrhage are; early hemostasis, restoration of oxygen-carrying
capacity, prevention of coagulopathy, and identification and treatment of the injury. With
various causes of hemorrhage, we can use massive hemorrhage clinical guidelines to determine
proper indication, correct dosing and precise timing for this high-risk procedure. The four goals
of hemorrhage, cannot be reached without collaboration and involvement of a designated rapid
response team, trained specifically in massive blood replacement. The influence of a designated,
trained team could be an advantage for early interventions and the resuscitation of the patient
(Treml, Gorlin, Dutton, & Scavone, 2017).
This Capstone project will evaluate a group of registered nurses and their response
during a simulated massive transfusion. The group will use the WellSpan York Hospital
Massive Transfusion Protocol (MTP) Algorithm (Appendix A). This protocol was developed by
Dr. Michelle Erickson in 2010 and updated in 2016 after newly published data. Dr. Erickson
updated the component algorithm and order in which products were transfused. In addition, a
Transfusion Safety Officer position was added to improve staff education with blood
transfusions. However, with each massive transfusion activation, errors continue to occur.
Some of the inaccuracy is due to a lack of communication, knowledge deficits, improper
equipment, nursing shortages and lack of bedside assistance for medication administration,
laboratory monitoring, and recording. The need to educate and train a team solely responsible for the massive response team is imperative.
During a crisis, such as massive hemorrhage, mistakes happen. Miscommunication, lack
of knowledge and uncertainty of how to properly institute a massive transfusion are areas for
improvement, and a partnership with clinicians is essential. Research proves the Crew Resource
Management (CRM) training model improves team dynamics and decreases errors (Hughes,
Benenson, Krichten, Clancy, Ryan & Hammond, 2014). This training model was originally used
in the field of aviation to improve safety. However, hospitals have tailored this model to be
used in critical situations and areas of high stress. CRM is currently taught to the trauma
and code response teams at WellSpan York Hospital. Following training, there is evidence of
better communication, knowledge of role assignment and improved relations between team
members (Hughes et al., 2014). CRM training has proven to provide safer patient care and
favorable patient outcomes (Hughes et al., 2014).
Statement of the Problem
Protocols are created to help guide the massive transfusion; however, providers do not
always follow the guidelines (Bawazeer, Ahmed, Izadi, McFarlan, Nathens, & Pavenski, 2015).
A deficiency of available resources, type of injury, delayed response of medical personnel and
understanding of proper protocol usage can have a detrimental effect on patient outcomes.
During a massive transfusion, the crisis can cause chaos and confusion. A checklist of directions
can be effective and serve as reminders of the next steps (Hilton, Daniels, Goldhaber-Fiebert,
Lipman, Carvalho, & Butwick, 2016). A massive transfusion requires close monitoring and
active management. One must monitor laboratory values, vital signs, medical intervention,
intake amounts, and blood product ratios (Pham, & Shaz, 2013).
Using a team approach to massive transfusion is essential for patient outcomes. However,
there are limited studies on a team approach to massive transfusion. Having a response team,
and a leader who is trained in transfusion medicine, treatments, coagulopathy, and interpretation
of laboratory values are necessary to improve patient outcomes (Quintana-Diaz, & Garcia Erce,
2016). Training a designated massive transfusion rapid response team, including nurses,
physicians, and other areas, such as trauma teams, anesthesia providers, and residents can
increase optimal patient care, bedside support, and expert input during the critical initiation of a
massive transfusion (Nunez, Young, Holcomb & Cotton, 2010).
Purpose
The purpose of this project is to assess the proficiency of nurses during a massive
transfusion simulation. This Capstone Project will provide essential knowledge and skills to
nurses who respond to hemorrhaging patients. Nurses require vital information such as the
WellSpan York Hospital MTP Algorithm (Appendix A), and the MTP Nursing Checklist
(Appendix B). In addition, having a list of MTP Important Phone Numbers (Appendix C) play a
key role in assembling extra resources to assist in monitoring the patient, administering blood
products, managing medications and reporting laboratory values. Having confidence in your
practice, increasing your knowledge through simulation, and working together as a team to
provide optimal care for patients can produce a feeling of empowerment. A team approach is
necessary during massive bleeding, and with the right guidance, nurses can become a
collaborative force, adding value or additional insight that may help stop the bleeding patient.
Theoretical Framework
Conceptual frameworks are theories where we assimilate, digest, and incorporate
information after being given the details. Through nursing educating, we strive to reach learning
objectives and apply that information at the bedside. Although our surroundings, beliefs, and
experience play a role in our knowledge, there are theories that support other ideas of learning.
There are six main theories of learning: behaviorism, cognitivism, social learning, social
constructivism, multiple intelligences, and brain-based learning (Rubio, n.d.).
Cognitive Learning Theory favors discovery learning. Theorist, Jerome Bruner
believed anyone could learn if it is taught to them in ways they understand. The brain-based
learning theory suggested by the theorist, John Dewey, allows learners the opportunity for batch
learning, memory recall, and intellect from repetition. In addition to these theories, humanists
believe learning is motivated by one’s inner desire to learn and should be reinforced over time
(Rubio, n.d.).
A newer instructor strategy is educating through High Fidelity Simulation (HFS), which
allows an extensive variety of experimental learning. HFS helps the learner use their mind, be
hands-on with the activity, and interact with other team members to find solutions. Each case
scenario uses the foundation of learning framework while providing educational components to
the learner (Paige & Daley, 2009).
Nature of the Project
The nature of this project is to identify knowledge deficits among nursing staff related to
the MTP. A volunteer group of registered nurses from WellSpan York Hospital will be assessed.
The project will consist of group training. The curriculum contains a short MTP Education
Module PowerPoint presentation on MTP framework (Appendix D), evidence-based practices,
blood administration order, and medications and when they are given. Additionally, nurses will
be taught the WellSpan York Hospital MTP Algorithm (Appendix A) and review Additional
Resources (Appendix E) available to them. The group will be evaluated on their understanding
of the MTP process through pre-testing, simulation, debriefing, and education.
Significance of the Project
The project can have a significant impact on patient safety, early hemostasis, and errors.
Blood transfusions are high-risk events. Having a knowledgeable, dedicated, massive
transfusion response team can decrease mistakes, increase communication, and ensure the safest
practice for every patient. The Joint Commissions (2017) established four National Safety
Goals. These goals are correct patient identification using two identifiers and improving staff
communication. Also, medication safety, and preventing mistakes, which are similar to the four
goals during hemorrhage and can be accomplished by education, training, simulation, and having
a devoted massive transfusion response team.
Definitions
Algorithm: A self-contained sequence of actions to be performed (eMedicineHealth, 2017).
Coagulopathy: A condition in which the blood’s ability to form clots is impaired (eMedicineHealth, 2017).
Crew Resource Management: A set of training procedures for use in environments where human error can have devastating effects (The Free Dictionary, 2017).
Exsanguination: Blood loss to a degree sufficient to cause death (eMedicineHealth, 2017).
Hemorrhage: To bleed profusely • Bleeding or the abnormal flow of blood (eMedicineHealth, 2017).
Hemostasis: A process which causes bleeding to stop (eMedicineHealth, 2017).
Hemovigilance: A set of surveillance procedures covering blood techniques and protocols (eMedicineHealth, 2017).
High Fidelity Simulation : An imitation of the operation of a real-world process (The Free Dictionary, 2017).
Intuitional Review Board : A committee used to approve research (eMedicineHealth, 2017).
Massive Transfusion: The replacement of >50% of total blood volume (The Free Dictionary, 2017).
Protocol: Guidelines for medical treatment (eMedicineHealth, 2017).
Summary
Hemorrhage can cause death if not treated quickly. When an MTP is initiated, everyone
involved with the care of the patient must be prepared to act fast. Approximately 50 percent of
deaths occur within the first 24 hours’ after injury because of exsanguination and coagulopathy
(Pham & Shaz, 2013). This project is based on the belief that a committed, exclusive, massive
transfusion response team, trained and educated on the proper way to deliver blood products,
medications, and other treatments to a bleeding patient will result in positive patient outcomes
and increase patient safety. Educating a team in acceptable practice during hemorrhage must
be seriously considered. In addition, it is important to understand team dynamics, collaboration,
and communication necessary to run a massive transfusion successfully. Applying a team
approach, with assigned roles and a leader can provide the patient with optimal care during their
crisis and lead to an overall better outcome.
