The metropolitan Seattle area employs a centralized transfusion service composed of four laboratories supplying blood products to 20 hospitals and clinics. The Puget Sound Blood Center was established in 1944 and has been in place to this day. While this model has many merits, the constraints of a system relying on preparation and transport of blood products to locations up to 11 miles away, sometimes in heavy traffic conditions, can be problematic in a major hemorrhage situation. For this reason, our institution, the VA Puget Sound, recently implemented a massive transfusion protocol.
Massive transfusion protocols (MTP) with standardized fixed ratios of blood products have been shown to improve morbidity and mortality in traumatic and nontraumatic hemorrhage. Critically bleeding patients require coordinated and efficient decision making within a streamlined system to get blood products quickly to the patient. Most MTPs involve predefined transfusion “packs” that are continually prepared and delivered until deactivated. Given the complexity and number of stake holders involved, achieving MTP goals requires multidisciplinary input from surgery, anesthesia, hematology, laboratory, blood bank, critical care, nursing, pharmacy, transportation and administration. Some of the many components of MTP needing to be addressed include: activation and deactivation criteria; contents of transfusion “packs” and ideal ratio of components; clinical and laboratory goals of resuscitation; use of pharmacologic adjuncts such as recombinant factor VII, antifibrolytics and fibrinogen concentrates; set time goals for each part of the process; whether to include a blood bank physician in the resuscitation; use of point of care testing such as thromboelastography; and acceptable lab turn over times. A hospital relying on a centralized blood center may be dependent on road conditions and time of day to for timely delivery of blood products. The supply of pre-thawed versus frozen FFP will impact finances and is often a limiting time factor.
Beyond medical issues communication challenges abound. Ideally a dedicated blood bank phone or one click activation of the protocol will avoid distraction and redundant communication during a resuscitation. Protocolized communication can streamline the process. Initiatives to reduce phone calls to activate and stop the MTP may involve significant work redesign. Set goals and defined roles are required but should not be so rigid as to hamper flexibility in low staffing conditions or mass causality. Minimizing provider preference must be balanced against clinical judgment. A senior staff ideally would be available to call at all times.
To help in MTP development, a work flow process map can show the flow of work tasks and how critical decision points are reached. The map highlights how environment and task interact to help or hinder the goal. A paper representation of the entire process is a useful tool for analyzing systems. Understanding current practice and inviting input to draft proposals should extend from the surgeon all the way to the designated runner. Real time observation will determine if there is a difference between assumed and actual practice.
To implement change, organizational theory divides complex interventions into behavioral, technologic and organizational components. Human factors influencing work process are divided into human, machine and task related. A business model would attempt to eliminate non-value added activities and reduce waste. Defining and measuring the quality of the many tasks necessary and the process outputs helps identify and remove causes of error in order to achieve more stable and predictable results and bring the process to defect free level.
All MTP activation must be reviewed by a process improvement team for a thorough dissection and direct focused interventions along with provider education. Identification and documentation of exact logistic and communication problems can be used for ongoing revision. Feedback to the provider and input from the provider of all MTP protocol violations are needed. Continuous monitoring of important data points include, predefined time goals from activation to completion of blood products at the blood bank, time to delivery to the clinical area and time to actual transfusion in the patient. Amount and volume of products transfused, actual ratios delivered and wasted blood products are major metrics. Mortality can be adjusted for confounding injury severity score and baseline laboratory parameters. A performance improvement data base will allow statistical evaluation of the impact of compliance with the MTP on outcomes. A financial evaluation of protocol can add insight.
Evaluation of the protocol requires time series analysis. Pre and post intervention data collection can be difficult to compare when there is poor baseline pre intervention information. Protocol under and overutilization factors should be collected. Hard data points can be supplemented with subjective evaluation such as staff satisfaction. Institutional differences can also be used to highlight regional issues of blood protocol compliance and procurement. Evaluation will be hampered by low protocol volume and retrospective comparisons. It is easier to measure process compliance while outcomes of the process are more difficult. Although 30 day mortality and hospital stay are common in trauma outcomes studies these are crude indicators missing many more subtle complications such a transfusion related lung injury or infection.
Promoting knowledge, skill and staff attitudes is essential for implementation. Leaders from different specialties are required to educate and be persistent change agents for wide spread acceptance. Education should be through multiple platforms and mock runs. Boundaries between disciplines may be a source of error and segmentation of care.
Successful development of a MTP will require the highest level management commitment to deal with the myriad of logistic and communication challenges present that delay blood product arrival. Layers of potential problems are too numerous to address here. Lack of high quality data to inform optimum design should not limit sustained improvement in MTP therapy. Well-designed protocols have been shown to improve patient outcome and resource utilization
Room for (Performance) Improvement: Provider-Related Factors Associated with Poor Outcomes in Massive Transfusion: Cotton et al Journal of Trauma Vol 67 number 5
A Review of Decision Support for Massive Transfusion: Understanding Human Factors to Support Implementation of Complex Interventions in Trauma Enticott et al Transfusion Vol 52 December 2012
Update on Massive Transfusion Pham et al British Journal of Anesthesia 111(51) 2013
By Lisa M. Judge, MD and Gary Yurina, CRNA
As we welcomed a fresh batch of second year anesthesia residents, I began to think of the moments that I dreaded the most during my first couple of months in the operating room. I recalled the usual clinical scenarios such as not being able to secure the airway and every cardiac patient. Yet, there is one scenario that is still a frequent challenge: intraoperative communication with the surgical attending. Communication in the operating room, from the perspective of an anesthesia resident, can be challenging as we often have to make decisions with the surgery attending in the absence of our own attending. In most instances, our conversations are exchanges with mutual respect and different medical specialties combining their knowledge to make the best decision for the patient. At times, however, these exchanges can be challenging and it may seem easier to simply yield to the request of the surgery attending.
An analysis of the Joint Commission’s Sentinel Event data, from 1995 to 2005, revealed poor communication as the cause of 66% of the reported events during that time period. Communication in healthcare is just as important now, as it was 10 years ago and increasingly communication in the operating room is being identified as a unique challenge. In an observational study in the operating room, Halverson et al., observed 66 incidents of failed communication over a period of 150 hours. The majority of the communication failures were associated with equipment and failure to communicate about the progress of the surgery. Communication can be difficult in even the most basic healthcare environments and in the high stakes operating room environment extremely challenging. This challenge can be confounded by the professional status of the person you are communicating with.
As an anesthesia resident, I try to take advantage of these opportunities and view them as an opportunity to practice my communication skills. First, I anticipate potential challenges and clear my plan with my attending before and during the surgery. When unanticipated challenges arise, I resist the temptation to simply give more drugs or change my anesthetic plan without evaluating surgical and physiologic changes, and the availability of equipment and additional personnel. Generally with effective communication, i.e. understanding the dynamics of the surgery, the surgeon and I can agree; however, in the few instances when I could not honor the surgeon’s wishes, patient safety came first. Finally, the entire operating room team is evaluating the communication between the surgeon and I and consistent professional communication sets the tone for the entire team.
Andersson, J., Casey, J., & Halverson, A. (2010). Communication failure in the operating room. Surgery, 49, 305-310. http://dx.doi.org/10.1016/j.surg.2010.07.051
Communication. (2015, June 1). Agency for Healthcare Research and Quality. Retrieved July 11, 2015.
D’Onior Felton, PGY3
Mobile technology in the health care industry has evolved rapidly with many new ways to communicate emerging every day. Maintaining the privacy of patient’s health care information with these new technologies is a serious concern. The Health Insurance Portability and Accountability Act (HIPAA), the federal law that addresses health information privacy and data security, was originally introduced in 1996. The protected health information under HIPAA includes: information maintained in medical records, conversations health care providers have concerning patients such as diagnoses and treatment plans, and medical information stored in the health insurer’s computer system. Violations of HIPAA privacy rules carry significant penalties including civil monetary penalties, criminal fines, and criminal prosecution. 1,2
In January 2013, the Department of Health and Human Services published the Final Rule. The Final Rule clarified the breach notification’s mechanism, made business associates of covered entities liable for HIPAA compliance, established tiered structure civil penalties, and modified certain procedures to safeguard the integrity and confidentiality of electronic private health information. For example, the monetary penalties increased according to the violation infringement. The four categories are: did not know, reasonable cause, willful neglect-corrected and willful neglect-not corrected. The penalties per violation range from $100 to $ 50,000. 3
Last year, McKnight and Franko published an article exploring HIPAA compliance with mobile devices among ACGME programs. They sent a survey to 678 academic institutions over a one-month period, and analyzed the results. Their study found that 58% of all residents self-reported violating HIPAA by sharing protected health information via text messaging. Although, 53% of attendings and 41% of residents used encrypted e-mail routinely, the rest did not. The survey results are a call to action to protect patient health information and limit institutions’ exposure to liability due to HIPAA non-compliance. 4
Text messages are usually not encrypted, and can be intercepted during transit. Also, the sender has no control over the end user’s phone. The next time that you send or receive a patient’s chest film image or video using your mobile, ask yourself if the communication is through a secured platform. If it is not secured, you are breaching HIPAA compliance, and your organization needs to develop strategies to protect and secure health information while using mobile devices. 5
There are several products in the market that address the security issue and provide a HIPAA compliant platform for effective communication. Cureatr provides a HIPAA-secure solution to send messages and share photos and files. 6 MD Chat is an online communications platform designed to improve communications, workflow, and productivity. 7 Zinc is a HIPAA compliant secure messaging app for healthcare teams. Zinc allows the users to create individual or group conversations, and send secure messages, files, photos, videos. Coworkers are automatically added to your contact list and you may connect to Box, Dropbox, Google Drive and Microsoft One Drive to send and view files. 8 Tiger Text is a HIPAA compliant app launched in 2010 that began offering $1 million security guarantee against HIPAA fines for compliance violations. It allows the user to recall messages if sent to the wrong person with the capability of choosing a maximum lifespan before the message auto-destructs. 9 Spok offers secure messaging, allows physicians to specify which device they may be contacted on, provides clinical alerts via text messages, and simultaneously updates electronic medical records (EMR). 10 Everbridge provides HIPAA-compliant texting and telemedicine with one colleague or a group. 11
Some institutions have created their own secure platforms to share protected health information among providers. The US government posted recommendations to safeguard health information while using mobile devices at Health IT.gov/mobile devices. 12 Recently, the Joint Commission changed its position in favor of allowing orders via text messaging as long as the following requirements are meet: secure platform, secure sign-on process, encrypted messaging, delivery and read receipts, date and time stamp, message retention time setting, and a contact list for personnel authorized to receive and record orders. 13
In summary, independent of the organization’s choice to communicate among providers, mobile technology is a part of our daily life and responsible administrators should prevent HIPAA breaches where possible. Education and acquisition of HIPAA secured mobile technology are paramount to achieve this important goal.
1. US Department of Health and Human Services. Summary of the HIPAA Privacy Rule. Available at: http://www.hhs.gov.ocr/privacy/hipaa/understading/summary/index/html. Accessed July 24, 2016
2. Hoyt RE, Yoshihashi AK. Health Informatics Practical Guide for Healthcare and Information Technology Professionals 6th Edition 2014 Informatics Education
3. US Department of Health and Human Services. Final Rule. Federal Register Vol 78 No.17 January 25, 2013
4. McKnight R, Franko O. HIPAA compliance with mobile devices among ACGME programs. J Med Syst (2016) 40:129
5. Karasz H, Eiden A, Bogan S. Text messaging to communicate with public health audiences: How the HIPAA security rule affects practice Am J Public Health 2013; 103(4) 617-622
6. https://cureatr.com Accessed July 24, 2016
7. https://www.mdchat.com Accessed July 24, 2016
8. https://www.zinc.it/ Accessed July 24, 2016
9. https://www.tigertext.com Accessed July 24, 2016
10. http:// www.spok.com Accessed July 24, 2016
11. http://www.everbridge.com Accessed July 24, 2016
12. https://www.healthit.gov/providers-professionals/faqs/can-you-use-texting-to-communicate-health-information Accessed July 21, 2016
13. Joint Commission Update: Texting Orders. Joint Commission Perspectives, May 2016, Volume 36, Issue 5
Lilibeth Fermin, MD, MBA and Laura Varela, MBA