Major bleeding can occur in surgical, trauma, obstetric or critically ill patients, but remains difficult to manage, requiring significant hospital resources often urgently and unexpectedly.
Patients may require massive blood transfusion (MT). Recent studies show 30-day mortality at over 20%, related to blood loss, underlying causes, or complications. Studies show that MT requires a time-critical, coordinated effort between front-line clinicians, haematologists, and hospital blood bank staff, working in separate environments to expedite complex transfusion support.
Most hospitals use a locally-adapted MT Protocol (MTP) to determine roles, activities, blood products, quantities, laboratory investigation guidance, success markers for resuscitation, and continuing management specific to cause of bleeding. High quality process completion is associated with better patient outcomes, and reduced blood resource requirements and overall cost.
MT requires critical decisions on timing and blood product selection, often by staff resuscitating the patient, involving significant stress. Clinical decision support systems (CDS) developed to improve complex care, involving computerised evidence-based rules, algorithms and patient information, are shown to reduce blood transfused and complications in non-critical settings. However, before this research no studies had evaluated their efficacy in critical bleeding requiring MT.
Dr Brenton Sanderson, Westmead Hospital and Macquarie University, NSW
Professor Enrico Coiera, Macquarie University, NSW
Professor Erica Wood, Monash Univeristy, Melbourne, Vic
Dr Lise Estcourt, John Radcliffe Hospital, Oxford UK
Dr Jeremy Field, Westmead Hospital, NSW
The project was awarded $A130,244 including scholarship through the ANZCA research grants program in 2020.
This project aimed to: enhance MT decision-making by developing and evaluating a CDS; identify quality indicators and processes for optimised MT decision-making; and to describe barriers and risks in these processes.
The team’s systemic literature review of current MT measures research identified a lack of international consensus on optimal quality care measures. Significant variation in the quality indicators reported limited potential to guide future decision making. Pragmatic indicators that may represent high quality care were also identified for future investigation.
In a binational MT survey, anaesthetists reported that multiple simultaneous tasks and lack of equipment to measure patient’s blood clotting potential limited their subjective performance the most. A majority supported future use of a CDS for MT.
A prototype MT CDS was then developed using best-practice evidence-based software development, involving clinical staff, and several opportunities were identified to improve MT efficiency and efficacy. The prototype, ‘MTP Assistant’, was evaluated in a randomised simulation trial using a simulated bleeding patient compared to current best practice. MTP Assistant improved decision efficiency, with similar efficacy, while reducing clinical team cognitive load.
These outcomes also support the potential to use a decision support approach in other emergency scenarios associated with high cognitive load.
Sanderson, B., Coiera, E., Asrianti, L., Field, J., Estcourt, L. J., & Wood, E. M. How well does your massive transfusion protocol perform? A scoping review of quality indicators. Blood Transfusion 2020;18(6), 423. Doi: 10.2450/2020.0082-20
Sanderson, B. J., Field, J. D., Estcourt, L. J., Wood, E. M., & Coiera, E. W. Massive transfusion experience, current practice and decision support: A survey of Australian and New Zealand anaesthetists. Anaesthesia and Intensive Care 2021. Doi: 0310057X20974035.
Sanderson B, Field JD, Kocaballi AB, et al. Multicenter, multidisciplinary user-centered design of a clinical decision-support and simulation system for massive transfusion. Transfusion. 2023;63(5):993-1004. Doi: 10.1111/trf.17315
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