1.0 QUALITY IMPROVEMENT ANCC Contact Hours 11/23/2020 on 53s0QsWYOnF7r0gOgKxttwWUl05ogzRZsSVjE1+xDug/QiRuHwucAcDdWFN3zl7DXQ+pDjAPxIsGDj7boF+X3TGRNWD5o5VwVzZLuNqA5MOvyFe0/+LaKK0LsG7cwSF7yyaNcewrxzsqvk2cP7OUiAMEZMNh/dbyWUxJAwE6cJ+qQx6/B5443g== by https://journals.lww.com/journaloftraumanursing from Downloaded Downloaded Minimizing Time to Plasma Administration from and Fresh Frozen Plasma Waste: A Multimodal https://journals.lww.com/journaloftraumanursing Approach to Improve Massive Transfusion at a Level 1 Trauma Center ■ ■ Wendy Hyatt , BSN, RN, CEN, TCRN James R. Yon , MD Stephanie Haley-Andrews , BSN, RN by 53s0QsWYOnF7r0gOgKxttwWUl05ogzRZsSVjE1+xDug/QiRuHwucAcDdWFN3zl7DXQ+pDjAPxIsGDj7boF+X3TGRNWD5o5VwVzZLuNqA5MOvyFe0/+LaKK0LsG7cwSF7yyaNcewrxzsqvk2cP7OUiAMEZMNh/dbyWUxJAwE6cJ+qQx6/B5443g== permissive hypotension, and balanced resuscitation ABSTRACT with early plasma, platelets, and red blood cells (RBCs) Massive transfusion protocols are part of damage control (Holcomb et al., 2015). resuscitation for hemorrhaging trauma patients with the The American College of Surgeons (ACS) and the goal of returning the patient to hemodynamic stability. It is Eastern Association for the Surgery of Trauma (EAST) essential that patients receive blood products immediately have established best practice guidelines to direct DCR and in the proper ratios. At our metropolitan Level 1 trauma and MTP for trauma patients experiencing uncontrolled center, we identified several challenges to deploying massive hemorrhage. These guidelines include early and rapid transfusion rapidly and within the recommended ratio deployment of blood products in a ratio of 1:1:1, plas- guidelines. In 2016, we implemented a quality improvement ma to RBCs to platelets ( ACS, 2013 ; Cannon et al., 2017 ). project addressing 4 opportunities: fresh frozen plasma Trauma centers should review the ACS guidelines and (FFP) bag breakage, plasma options, blood bank equipment, compare their current practice with the guidelines, iden- and multidisciplinary policy revision. Implementing tifying areas that need modifications to align with current packaging and shipping improvements, utilization of new recommendations. products, and updating protocols have resulted in a 50% Massive transfusion is a high-risk, low-frequency event decrease in FFP bag breakage rates, a dramatic decrease for most hospitals. Our facility admits more than 2,600 in time for patients receiving massive transfusion to receive trauma patients per year. On average, 25 patients per year plasma products (mean time 3.5 min), and patients being receive MTP. Consistent monitoring of MTP in compari- administered the recommended ratio of blood products. son with MTP guidelines can identify opportunities for improvement. Key Words Hemorrhage , Liquid plasma , Massive transfusion protocol (MTP) , Trauma METHODS One recommendation from the ACS Trauma Quality Im- reventable death after injury is defined as those provement Program (TQIP) massive transfusion guideline casualties whose lives could have been saved by states that universally compatible RBCs and thawed plas- appropriate and timely medical care, irrespective of ma should be immediately available (ACS, 2013). Our fa- tactical, logistical, or environmental issues (Berwick, cility had identified an opportunity for improvement with PDowney, & Cornett, 2016). When evaluating deaths the frequency of bag breakage (and waste) when thawing from traumatic injury, hemorrhagic shock continues fresh frozen plasma (FFP). Our facility was experiencing to be the leading cause of preventable death ( Spinella, bag breakage rates between 10.7% and 14.5%. All bags of 2017 ). Damage control resuscitation (DCR) strategies FFP are visually inspected before being thawed, but there were developed to address uncontrolled hemorrhage. can be tiny holes or tears in the bags that are not visible. These strategies include minimizing crystalloid infusion, The holes occur during the manufacturing, shipping, and processing of the FFP bags before thawing in the facility’s Author Affiliations: UCHealth Highlands Ranch Hospital, Highlands blood bank. These holes are only identified after thawing. Ranch, Colorado; and HealthONE Swedish Medical Center, Englewood, on Two common methods for thawing FFP are the use of a 11/23/2020 Colorado . The authors declare no conflict of interest. water bath thawer and a microwave. Water bath thawers Correspondence: Wendy Hyatt, BSN, RN, CEN, TCRN, UCHealth and microwaves typically take 20 and 10 min, respec- Highlands Ranch Hospital, 1500 Park Central Dr, Highlands Ranch, CO tively, to thaw a bag of FFP. After identifying a bag with a 80129 ( [email protected] ). hole in it, the bag of FFP is unusable and the process of DOI: 10.1097/JTN.0000000000000460 thawing would begin again, creating significant delays in 234 WWW.JOURNALOFTRAUMANURSING.COM Volume 26 | Number 5 | September-October 2019 Copyright © 2019 Society of Trauma Nurses. Unauthorized reproduction of this article is prohibited. delivering plasma to hemorrhaging patients. After identi- mately 30% across all samples. Factor VII and Factor VIII fying a high rate of bag breakage, the blood bank coordi- also decreased significantly ranging from 5% to 22% be- nator contacted two major national blood product suppli- tween all samples. Factor II, Factor X, and Factor XIII ers, Bonfils Blood Center (now Vitalant after acquisition showed minimal changes during storage. Although there and name change) and American Red Cross, to assess is a demonstrated decrease in coagulation factors of liquid and track broken FFP bag rates related to the manufac- plasma over time, it maintains at least 50% of factor activ- turing, packing, and shipping processes. Both organiza- ity and thrombin-generating capacity ( Backholer et al., tions agreed to investigate the issue further. Bonfils Blood 2017 ). Additional research has compared liquid plasma Center identified a trend in the broken FFP bag rates with with thawed plasma to compare two immediately availa- one specific bag type used to hold the FFP. It agreed to ble products. Backholer et al. (2017) found liquid plasma discontinue using the bag with the high failure rate. The to be comparable with thawed plasma in hemostatic vari- American Red Cross identified an increased rate of broken ables. Matijevic et al. (2012) found the hemostatic profile plasma bags when using a specific shipping company. It of liquid plasma to be better and sustained five times formed a nationwide working group to evaluate the ship- longer than thawed plasma. Their research demonstrated ping process for blood products. Through the working that in liquid plasma, most coagulation factors were sta- group, it identified an issue with the packaging materials ble at 26 days of storage and retained at least 88% of used by the shipping company. The American Red Cross the initial activities, which was better in comparison with then changed the packaging materials used to ship its thawed plasma stored at 5 days. They also found liquid product in an attempt to decrease defective products. plasma to have a significant number of residual plate- Plasma is essential for controlling hemorrhage during lets, which contribute to clot strength. The platelets are massive transfusion because it contains proteins for blood destroyed in the freeze–thaw cycle of thawed plasma. In clotting. In the United States, there are seven plasma prod- summary, liquid plasma provides superior shelf life than ucts available, four frozen plasma products and three liq- thawed plasma or FFP ( Van, Holcomb, & Schreiber, 2017 ). uid state products ( American Association of Blood Banks, There are some limitations to utilizing liquid plasma. Cur- 2017 ). Two of the liquid state products are derived from rently, the only indication for liquid plasma is the initial FFP in the form of thawed plasma. The third liquid prod- treatment of patients receiving massive transfusion ( Amer- uct is liquid plasma. Liquid plasma is unique in that it ican Association of Blood Banks, 2017 ). Liquid plasma has is never frozen. It is separated from whole blood and a shelf life of 26 days, which is longer than thawed plasma stored at 1–6 ° C. Liquid plasma provides several benefits with a shelf life of 5 days, but significantly shorter than during massive transfusion. The immediate availability of that of FFP with a shelf life of 365 days when it remains the product eliminates delays in plasma support during frozen. Liquid plasma has been used in Europe since the MTP. Snyder et al. (2009) found in their study regarding 1980s but only recently has become utilized regularly in the delivery of blood products during MTP the medium the United States ( Backholer et al., 2017 ; Gosselin et al., time to the first unit of RBCs was 18 min whereas the 2013 ). Although liquid plasma usage has become more medium time to the first unit of plasma was 93 min. With frequent, it is still not widely used across the country. After the use of liquid plasma, blood products can then be is- reviewing the research and evaluating the risks and ben- sued in correct ratios instead of trying to “catch up” with efits of liquid plasma in our protocol, our multidisciplinary plasma products during the MTP. When utilizing liquid process improvement team chose to implement the use of plasma in the initial phases of MTP, it provides sufficient liquid plasma for the initial phases of massive transfusion. time to thaw additional FFP for continued massive trans- Hospitals can choose to use microwaves