Dr. David Slater, medical director at a level I trauma center in Central California (University Medical Center in Fresno; attribution used with permission) reports that they are considering a better tracking system to assess adequacy of transfusion support for emergent and massive transfusion events in their facility. He acknowledges that many of the time points recorded in their Laboratory Information System, their Hospital Information System and their paper medical records are somewhat inaccurate for massive transfusion events. Data entry/documentation is often deferred, since delivering emergency care is the first priority. The inquiring physician assumes that his local situation is similar to what happens in many other places, yet the adequacy of blood support of trauma services is a vital metric in all trauma centers. He is hopeful that an improved data collection process will not need to be too complex. His question is, what audit/tracking systems do trauma centers use to assess the adequacy of transfusion support for emergent and massive transfusion events in their facility?

The following comments have been received.

ADDENDA Dec. 16, 2006

1. A colleague in Southern California reports that her facility monitors the adequacy of transfusion support for emergent and massive transfusion events by analyzing physician complaints and trauma fatalities. Based upon these events, with input from their trauma team, they made improvements to the accessibility of uncrossmatched blood and to their massive transfusion protocols. A major improvement was achieved by the placement of refrigerators in the ER and Trauma OR which contain group O uncrossmatched RBC units. Following these refrigerator placements they have seen a significant drop in the number of physician complaints. Most recently they placed an additional refrigerator containing uncrossmatched blood in a new, remote intensive care area. One positive outcome of having improved access to uncrossmatched blood is a reduction in disruption of the Transfusion Service, as over 80% of their uncrossmatched blood is now dispensed from these remote areas.

2. Editor's note: The approach described by the above colleague is similar to that used at LAC+USC Medical Center, as described in posting #4 in the discussion "Policies for Ensuring An Adequate Supply of O Rh Negative Blood in Emergencies".

ADDENDA Dec. 19, 2006

3. A transfusion medicine physician in Southern California reports that for about ten years at her institution, when it had a Level I trauma center, the transfusion service collected data on turn-around-time for uncrossmatched blood requests.

• The first data element was the time of patient arrival in the ER or trauma center.
• The second was the time the blood bank specimen was collected (on the label).
• The third was the time the blood bank specimen and request arrived in the blood bank (clocked in).
• The fourth was the time of uncrossmatched blood issue (both type-specific and group O Rh negative RBCs).
• The fifth was the time of transfusion.

Over the ten-year period, the average time from the patient's arrival to specimen draw was 20 minutes. The average time from specimen draw to its arrival in the blood bank was 20 minutes. The average time from specimen arrival in the blood bank to the issuance of type-specific uncrossmatched RBC was four to five minutes. Only two to three minutes were needed for issuance of uncrossmatched group O Rh negative RBCs (without an accompanying specimen). Provision of those data on a monthly basis to the trauma service decreased compliants of the blood bank not providing blood in a timely manner. The solution most affecting the turn-around-time was the provision of runners to ferry specimens and blood products.

ADDENDA June 27, 2007

4. A colleague in Louisiana reports that her hospital is a trauma center and utilizes a massive transfusion protocol. She wants to know what response times are achieved at other institutions for massive transfusion. This question has come up due to a recent software "upgrade" which contributed to an incident in which an unacceptably long time was required to dispense red cells, FFP, and platelets. The software prohibits two different technologists from working simultaneously to issue different components to the same patient. Also, in order to dispense a group A Rh positive RBC unit to a group A Rh negative patient, four overrides are required. She asks if other blood banks have experienced similar problems, and if so, are there any safe and compliant workarounds?

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