Development and Implementation of a Neonatal Massive Transfusion Protocol: A Quality Improvement Project

Authors

Hellen Ko, Division of Neonatology, Department of Pediatrics, University of New Mexico
Joseph Griggs, Division of Transfusion Medicine, Department of Pathology, University of New Mexico
Tara Zamora, Division of Neonatology, Department of Pediatrics, Children’s Minnesota Hospital

Document Type

Poster

Publication Date

4-14-2021

Abstract

Background: A Massive Transfusion Protocol (MTP) is an institutional plan created to expedite the allocation and delivery of blood products to patients with active bleeding. When run as designed, the MTP facilitates communication, ensures timely lab monitoring, and reduces delays/errors when ordering and administering blood products. Adult and pediatric MTPs have been developed, and their utility has been well-established for patients involved in trauma, major surgery, or extracorporeal membrane oxygenation (ECMO). However, these same MTPs are ill-suited for use in the neonatal population. Evidence-based guidelines for neonatal MTPs (N-MTP) are lacking for infants, including those born preterm. Given the unique nature of neonates, this population could benefit from an N-MTP. In this single center quality improvement initiative, we aimed to create a standardized process for ordering and transfusing multiple blood products to infants and neonates at the University of New Mexico Hospital (UNMH) with active bleeding or hypovolemic shock.

Plan: Work with a multi-disciplinary team to develop an N-MTP including clinical staff in the NICU, Transfusion Medicine, UNMH transfusion committee, and another large children’s hospital.

Do: Literature search, background information on N-MTPs, creation of an N-MTP.

Study: Pre-implementation survey sent out to clinical staff in the NICU.

Act: Approval for use and creation of order set in the hospital’s electronic medical record system.

Summary: Our multi-disciplinary group collectively developed an N-MTP to allow for a safer, timelier, and standardized approach to administering multiple blood products. Massive transfusions are rare but high-risk events in the NICU setting thus this study will hopefully improve patient outcomes related to transfusions. In future PDSA cycles, we plan to complete mock codes within the NICU as well as offer educational videos.

Recommended Citation

Ko, Hellen; Joseph Griggs; and Tara Zamora. "Development and Implementation of a Neonatal Massive Transfusion Protocol: A Quality Improvement Project." (2021). https://digitalrepository.unm.edu/hsc_2021_pediatric_research/10