Using Simulation-Based Education to Improve Team Communication During a Massive Transfusion Protocol in the OR

Hemorrhaging during operative and other invasive procedures can result in devastating outcomes for surgical patients. An effective plan of action in the form of a massive transfusion protocol (MTP), along with teamwork and clear communication among OR personnel, is critical during a hemorrhagic crisis to improve patient outcomes. However, perioperative personnel may be unprepared to manage a hemorrhagic crisis because they lack experiential knowledge of these uncommon, high-risk scenarios. Perioperative leaders at a 500-bed acute-care hospital in the Midwest developed an educational activity involving a video-recorded simulated MTP scenario, learning modules, and debriefing sessions to educate more than 150 employees. Perioperative personnel received pre-education and watched the video-recorded MTP simulation together, and then participated in team debriefings after watching the video. Based on team debriefings and evaluation feedback, most staff members believed that the activity improved team communication.

Haemolytic uraemic syndrome

Although haemolytic uraemic syndrome is rare, it is not uncommon. Here is an overview of the syndrome, with advice on signs and symptoms and how to care for children and young people.

Tranexamic Acid in Anesthetic Management of Surgical Procedures

Blood loss during surgical procedures poses a grave risk to the patient, but transfusion is costly and associated with adverse outcomes. Antifibrinolytics, however, offer an economical and effective means of decreasing blood loss associated with surgical procedures. Tranexamic acid (TXA) is an antifibrinolytic that blocks lysine-binding sites of fibrinogen and fibrin, preventing the breakdown of existing clots. This journal course reviews extensive research demonstrating that antifibrinolytics such as TXA decrease blood loss and in some studies reduce allogeneic transfusion requirements. In addition, this journal course addresses concerns that use of antifibrinolytics increases embolic events, reviews research that demonstrates TXA does not increase the incidence of vascular occlusive events, and describes methods of TXA use in cardiac and orthopedic surgical procedures, neurosurgery, and obstetrics. The Certified Registered Nurse Anesthetist should consider the possibility, on a case-by-case basis, of using TXA in surgical procedures to reduce blood loss with minimal adverse effects.

The Jehovah's Witness Population: Considerations for Preoperative Optimization of Hemoglobin

Most members of the Jehovah's Witness community refuse blood transfusions, and there are variations in what alternatives they will accept depending on their personal decisions. To provide culturally competent care, healthcare providers need to be knowledgeable about substitutions for blood administration as well as the risks and benefits of available alternatives so that they can inform their patients. It has been recognized in the literature that preoperative optimization of hemoglobin levels with alternative treatment modalities through a multidisciplinary approach can improve clinical outcomes in patients who refuse blood products. The purpose of this article is to illuminate the current beliefs of Jehovah's Witnesses regarding receiving blood products, discuss ethical and legal considerations for the nurse anesthetist, discuss the risks of blood transfusions, and examine transfusion alternatives. Finally, this article considers a multidisciplinary approach to the optimization of preoperative hemoglobin levels.

Blood products and their use in traumatic major haemorrhage

Blood loss due to trauma is a leading cause of death in young people and is the result of the 'lethal triad' of hypothermia, acidosis and coagulopathy, which collectively reduce haemostasis. Emergency department nurses can help to reverse the triad through the timely and efficient use of blood products and fluids. This article briefly examines different blood groups, describes the elements of the lethal triad, and discusses the blood products used to transfuse patients with major haemorrhage.

Another first for nursing

Traditionally, doctors have ordered blood transfusions, but nurses are learning to take on this role. Since his training last year, nurse practitioner and prescriber Steve Wright has been authorising blood transfusions on a surgical ward in a London hospital and seeing the benefits for patients.

[Closed-loop blood transfusion management system based on PDA]

A closed-loop transfusion management system is constructed that covers blood preservation, transportation, transfer, distribution of blood, distribution, clinical blood specimen collection and blood transfusion process, which can monitor the implementation of doctor's advice, view the transport process of blood and blood samples, and record blood transfusion and adverse reaction information. These measurements can play a good effect in reduction of manual records and handover links in blood transfusion management, enhance the blood bank management, guarantee safely using blood, and realize the goal of real-time monitoring and closed-loop management.

[Blood transfusions, a closely monitored procedure]

A blood transfusion is a medical procedure which, in most cases, is delegated to a nurse. Strictly regulated, it requires vigilance at every stage. In the transfusion safety chain, the nurse plays a central role, notably in terms of information, identification, control, traceability, monitoring and reporting.

[The nurse, a key player in transfusion safety]

In the chain of transfusion safety, the nurse is the last line of defence in the battery of controls to avoid transfusion errors. The final pre-transfusion test carried out at the patient's bedside is a meticulous procedure. It involves cross-referencing documents, checking the identity of the patient and determining the ABO blood group through an agglutination test.

Caring for patients with kidney failure

Patients with end-stage renal disease can present to unscheduled care settings for different reasons, but are managed in the same way. This article aims to increase emergency nurses' knowledge of the main areas of concern and management associated with this condition, including fluid management, blood transfusion, pain control and hyperkalaemia. The article also includes a case study to illustrate how nurses can put this knowledge into practice.

Perioperative blood transfusion: the role of allogenous and autologous transfusions, and pharmacological agents

The decision to transfuse patients perioperatively is made on an individual basis and should consider factors such as duration and severity of anaemia, symptoms, physiological parameters and comorbidities. Autologous blood transfusion has the benefit of avoiding some of the immunological and infective complications associated with allogenic blood transfusion. Pharmacological agents as well as anaesthetic and surgical techniques have a role in avoiding the need for blood transfusion.

Understanding blood groups and transfusion in nursing practice

A donation of whole blood can be processed into red cells, platelets, fresh frozen plasma and cryoprecipitate. This processing permits individual blood components to be given to several different patients and transfusion of appropriate blood components according to the specific needs of the individual. Although blood transfusion may be perceived as a common practice, it is not without risk and all staff should be aware of their roles and responsibilities within this process. To help reduce the risks associated with transfusion, staff must be aware of local policies and procedures, receive the relevant transfusion training, and be assessed as competent.

An evaluation of a domiciliary blood transfusion service for palliative care patients in Northern Ireland

Marie Curie Cancer Care is a national charitable organisation that provides specialist palliative care services to patients with cancer and other life-limiting illnesses. Marie Curie Nursing Service (MCNS) provides nursing services to patients in their own homes. The administration of blood transfusions to palliative care patients is required to improve symptom management and quality of life; however, this procedure often results in unnecessary hospital admissions. Recognising that the majority of patients wish to be cared for and die in their own home, and with national guidance recommending that specialist palliative care services should be provided to patients in their preferred place of care, a recent service initiative by MCNS was domiciliary blood transfusions. While this is not a new service within domiciliary care, this pilot project aimed to capture patient views to evaluate this service initiative. Telephone interviews were conducted, using a questionnaire, with 11 patients who had received the service. Findings indicated positive evaluation of the service. Domiciliary blood transfusions helped to avoid unnecessary hospital admissions, the quality of life of patients and their families was improved in the palliative phase of illness and they received the service in their preferred place of care.

Blood transfusions. 2: Signs and symptoms of acute reactions

This two-part unit focuses on monitoring patients who have blood transfusions. The first part emphasised the importance of visual observations and monitoring patients' vital signs to ensure rapid action should there be any adverse effects. This second part describes the physiology behind the signs and symptoms of a blood transfusion reaction.

Evaluation of a teaching pack designed for nursing students to acquire the essential knowledge for competent practice in blood transfusion administration

This article describes the evaluation of a teaching pack designed for nursing students to acquire the knowledge required for safe administration of blood transfusions. The Serious Hazards of Transfusion (SHOT) Committee is a confidential reporting body, which gathers data from the United Kingdom and reports the serious sequelae of blood transfusion. The SHOT reports have repeatedly identified that errors in blood transfusions are wholly avoidable. Nurses, as the health care professionals ultimately responsible for the bedside check, have the final opportunity to prevent a mis-transfusion [Nursing and Midwifery Council, 2004a. The NMC code of professional conduct: standards for conduct, performance and ethics. NMC, London; Serious Hazards of Transfusion, 2002. SHOT Annual Report 2001-2002. SHOT Scheme, Manchester]. The educational strategies implemented will be explained and evidence that applying structured learning programmes in the undergraduate nursing curriculum can improve students' knowledge presented. A structured questionnaire was employed to assess students' knowledge of the process for transfusing blood components pre- and post-teaching and evaluate the effectiveness of the teaching pack. The results will be presented and discussed.

Promoting safer blood transfusion practice in hospital

Results from a national comparative audit of bedside transfusion practice show that patients in the UK are at risk of misidentification and poor monitoring when undergoing a blood transfusion. A commonly identified reason for poor compliance with guidelines from the British Committee for Standards in Haematology (BCSH et al 1999) is a lack of awareness of good transfusion practice (National Blood Service (NBS) 2005). This article discusses the implications of the audit findings for the administration of blood at the bedside and examines initiatives to support hospital staff in their efforts to improve blood transfusion safety.

Should nurses prescribe blood components?

AIM

To explore the feasibility of nurses prescribing blood components.

METHOD

Using a convenience snowball sample, a UK-wide questionnaire survey was undertaken to identify transfusion practices and canvass the opinions of nurses and doctors.

RESULTS

A total of 179 (59%) of 302 respondents were supportive of nurses prescribing blood components, saying it would have a positive effect on the quality of patient care, result in fewer treatment delays and help doctors and nurses to use their time more effectively. The remaining 123 (41%) respondents had reservations about time and resource constraints and worries about undermining medical care and responsibility.

CONCLUSION

Development of non-medical prescribing to allow nurses to prescribe blood components has the potential to deliver a more patient-centred quality service.

A case study of an older adult with severe anemia refusing blood transfusion

PURPOSE

To discuss the diagnosis and treatment of severe anemia in an older adult who presents the challenge of declining blood transfusion in a real-world scenario where critical thinking, evidence-based care, and collaboration with other providers must come together to serve this patient's unique needs.

DATA SOURCES

Extensive review of the scientific literature on anemia and the situation in which a patient refuses blood transfusion presented in a case study format.

CONCLUSIONS

A thorough physical assessment, complete health history, and appropriate diagnostic workup should be used to distinguish the normal effects of senescence from the signs and symptoms of anemia. Common conditions that cause anemia in the elderly include chronic disease, iron deficiency, and gastrointestinal bleeding. These conditions may result in profound anemia. The challenge can be compounded when, because of religious tenets, a patient does not accept a blood transfusion. This case study challenges nurse practitioners to apply knowledge, seek guidance, and make appropriate referrals to care for a patient in order to render care within the parameters of the patient's belief system.

IMPLICATIONS FOR PRACTICE

The astute primary care provider recognizes that anemia is not an expected physiological change associated with aging but a manifestation of an underlying disease process. Fatigue, weakness, and dyspnea are all symptoms of anemia that may be overlooked and attributed to the aging process. Further, in keeping with the principles of autonomy and self-determination, it is the clinician's duty to work with all patients to restore them to a state of optimal health while respecting deeply held spiritual beliefs.

Blood simple

New recommendations are aimed at making blood transfusions safer for patients and less complicated for nurses to administer.

Care of patients with haemoglobin abnormalities: nursing management

This second of two articles on sickle cell disease (SCD) aims to provide advice on nursing care for patients. All health professionals should be aware of the various manifestations of the disease, the life-threatening complications and their optimal management. Prophylactic strategy is of paramount importance as it may avert many possible adverse outcomes. Recurrent episodes of acute, severe pain require frequent hospital admissions. The care of individuals with SCD must extend into the community and take account of domestic, employment and educational issues. Affected pregnant women should be looked after by units experienced in the care of women with this condition. The diagnosis of haemoglobin type is simple and inexpensive and a comprehensive national screening programme to detect SCD in pregnant women and newborn babies was started in April 2002 as part of the Government's broader aims to tackle inequalities in health and community.

Transfusing safely: a 2006 guide for nurses

Transfusion is a 'vein-to-vein' process. The blood supply in Australia is extremely safe in terms of viral risk, although a 'zero risk' blood transfusion is never possible. Safe transfusion practice continues to rely on highly-trained and experienced staff undertaking procedures correctly, in robust hospital systems within a safety and quality framework that includes an adverse event reporting system. Such a reporting system should work to enhance any hospital system where weaknesses or deficiencies are found. Further information on national guidelines and other aspects of transfusion in Australia can be found at: www.anzsbt.org.au/publications and www.transfusion.com.au. A transfusion administration checklist for nurses can be downloaded from: http://www.transfusion.com.au/Resourc eLibrary/resource_safety_2 .asp

Chronic blood transfusion therapy practices to treat strokes in children with sickle cell disease

PURPOSE

To identify variations in practices used by nurses for pediatric patients with sickle cell disease (SCD) receiving chronic blood transfusion therapy for strokes.

DATA SOURCES

Descriptive study of a convenience sample of 11 nurses who care for children with SCD from nine institutions completed a closed-ended questionnaire consisting of 37 items. Responses reflected practice experience with a total of 189 transfused patients with SCD.

CONCLUSIONS

A wide range of nursing practices exists for blood transfusion therapy for children with SCD and strokes. Manual partial exchange transfusion (66%) was the most commonly used method for blood transfusion in children with strokes reported among the nurses surveyed. Simple transfusions and erythrocytapheresis account for 21% and 13% of the practices reported. Opportunities exist to establish evidence-based nursing care guidelines to improve the care of children with strokes receiving blood transfusion therapy.

IMPLICATIONS FOR PRACTICE

A wide range of local standard care guidelines for blood transfusion therapy exists. The results of this survey indicate that partial manual exchange transfusion is the most commonly used method of chronic blood transfusion therapy in children with SCD and stroke despite the fact that the magnitude of benefit in comparison with simple transfusion has not been established. Factors such as peripheral venous access, compliance with current chelation regimen, and the presence of antibodies are important considerations in the choice of method.

Blood transfusion and Jehovah's Witnesses: the legal and ethical issues

A critical incident is any event that had an effect, or could have had an effect, on the welfare of a patient. Patients must be treated with respect by staff who demonstrate that they are sensitive to individual needs, values, beliefs and cultural background. This article will examine the legal and ethical issues relevant to the right of an unconscious Jehovah's Witness in an intensive care unit (ICU) to refuse a blood transfusion. The concepts of consent, capacity to consent, necessity to act, advance directives, decision making, consequences of failing to obtain consent, ethical principles, human rights and the best interests of the patient will be explored, in the light of relevant statute and case law, in order to demonstrate some of the legal and ethical complexities within acute healthcare delivery.

When Your Patient Is From the Obstetric Department: Postpartum Hemorrhage and Massive Transfusion

When caring for patients receiving massive transfusion, the nurse will be required to perform ongoing assessments and apply critical thinking to provide optimum care and avoid further complications. The perianesthesia nurse must be aware of the hemodynamic and coagulation changes of pregnancy when caring for an obstetric patient in the PACU to optimize patient outcomes. Understanding the causes of obstetric hemorrhage, which may result in the need for massive transfusion, will enable the nurse to anticipate and prevent potentially deadly complications.