Traditional Poster Round
Background: : Major Haemorrhage carries a high mortality of 32% (1) and requires a co-ordinated response from blood bank, clinical areas and porters. In situ simulation can reveal latent threats in this multidisciplinary emergency situation which are not shown by Patient Safety Incident reporting(2). Repeated simulations allow iterative Quality Improvement (QI) to mitigate these latent threats. In this tertiary hospital specialising in adult and paediatric cardiac surgery we experience on average 17 Major Haemorrhage cases a year. We report our experiences of SPRinT (Simulated interPRofessional Team Training) courses focusing on in situ simulations of Major Haemorrhage between 2012 and 2018. We discuss the latent threats identified through them and the QI they have enabled.
Research Question: : Is it possible to use simulation to achieve significant QI in our response to Major Haemorrhage?
Methodology: : Repeated SPRinT courses were planned cross-departmentally on the ward and in the blood transfusion laboratory to deliver simulated major haemorrhage events. The 'Plan-Do-Study-Act’ tool was applied to the Massive Blood Loss (MBL) guideline to identify latent threats and deliver QI. Observer checklists measured compliance with any new changes. Systems errors responsible for poor outcomes were identified and staff trained to implement subsequent QI measures. This process was repeated in multiple PDSA cycles with the aim to reduce latent threats to zero. Time taken to start transfusion of both the first unit of blood, and subsequent cross matched blood, were monitored. Participants’ confidence was monitored with questionnaires and observer checklists were analysed in cross-departmental meetings looking for solutions. QI aims were categorised into efficiency, patient safety and reducing wastage.
Results: : A total of 9 SPRinT courses and 8 PDSA cycles were completed between 2012 and 2018 with a total of 74 participants. Feedback forms suggest realism of the scenario’s environment and stress level were 82% (IQR 70-90%) and 80% (IQR 65-90%) respectively. Latent threats were identified, of which the major threats resulting in 8 significant QI projects are described in figure (1). Time for emergency blood administration improved from 6.15mins to 2.0mins (a reduction of 2/3rds).
Discussion/Conclusions: : Over 6 years of simulation based PDSA we have overhauled our Major Haemorrhage Protocol, resulting in increased participant confidence and reduced time to initial blood transfusion. Our QI projects have included tackling systems issues such as a lack of overnight access to an outlying site, introducing redundancy into our systems to allow for two sources of emergency blood, and providing improved resources eg a cordless phone to the Blood Transfusion Laboratory. The iterative simulation process was used to improve our Major Haemorrhage Protocol by combating latent threats, and to train staff prior to its rollout. The time to resolve major QI issues was greatest for estates issues (4 years) followed by additional resources (1 year) and training (6 months). We have shown that with targeted in situ simulations, and determination, major improvements are possible in cross departmental protocols.