Massive Transfusion Protocol St. Mary's/St. Francis

Massive Transfusion Protocol (MTP)

Included in MTP:

4 un-crossmatched RBCs (O neg), 4 FFP (AB) in coolers and 1 apheresis platelets.

RBCs, FFP, and platelets are ready for pick up in 5 minutes

Procedure:

  1. 1. Identify RUNNER to retrieve MTP from Blood Bank

  2. 2. Make sure the RUNNER has a patient LABEL

  3. 3. CALL the Blood Bank:

     

     

    Phone number

    Location

    St. Mary’s

    415-750-5753 or x505753 (internal)

    Level A Main Tower (A6)

    Saint Francis

    415-353-6334 or x6334 (internal)

    1st Floor Building 68 (near main lobby)

    Follow script:

    1. 1. “We need to activate the Massive Transfusion Protocol.”

    2. 2. “The patient’s name is                    and medical record number is         .”

    3. 3. “The location is         unit/OR# at St. Mary's or Saint Francis.”

    4. 4. “The unit/OR contact person is:        (name & phone # to take calls from blood bank)

    5. 5. “The ordering provider is                       (full name).”

    6. 6. We will send a runner with a patient label to get the blood.”

  4. 4. SEND runner with patient LABEL to Blood Bank to pick up blood*

    • -Instruct runner to go to front of line at Blood Bank and tell staff “I am here to pick up MTP blood products”

    • -A patient label is required for all subsequent pick-ups from Blood Bank

    • -If more blood is needed, Contact Person CALLS blood bank (ask to speak to Lead Tech) and order additional MTP cycles/packs (4+4+1) or ask for specific type/number of products.

  5. 5. If possible, draw a blood sample for a Type and Screen BEFORE blood products are infused

  6. 6. APeX orders for Massive Transfusion Protocol are entered by the authorizing provider, as soon as patient is stable. Enter orders within 24 hours after event. This is an FDA requirement.

  7. 7. RETURN unused blood products to the Blood Bank ASAP

* Downtime process is activated for exceptional situations- e.g. runner fails to bring a patient label/unable to provide patient name and MRN. To avoid delays, Blood Bank Staff will call the unit, confirm that runner is picking up blood for the correct patient, and release blood products.