Safety & human factors in major haemorrhage clinical case

Top view of emergency medical kit on a dark wood.

[Audio] Standard definitions are not particularly helpful because they are retrospective. However, not all staff are focused on the anaesthetic monitor during a surgical procedure. Still, the suction unit and swabs could be more visible to everybody. The anaesthetist must be informed when blood loss is more than 1500ml and ongoing bleeding in an adult. At this point, the decision should be taken by the senior anaesthetist. Major haemorrhage training is essential for all staff to recognise bleeding and to understand processes for activating major haemorrhage protocol and rapid access to blood components and products. Therefore, staff must revisit this training on an annual basis..

[Audio] The key points are learning from defects and applying a principle of safe design to both technical tasks and adaptive teamwork; also, they reduce risks for future patients by improving work processes and increasing compliance with the major haemorrhage training..

[Audio] We have an online self-directed learning package on the Transfusion intranet page. There are separate ppt.'s for PIND&DDH, PONT and Children. Maternity has a separate process via PROMPT. On completion of the training, we must inform occupational development to update the ESR records. Unfortunately, they don't send reminders, a concern that the Safety and Quality team considers in the action plan. We have the major haemorrhage policy available on intranet Trust policies, and we are introducing more simulation sessions rather than just during the Safety CEPOD. Dr Rob Neal is our simulation lead for anaesthetics and theatre. As team educators, we involved our clinical specialists, Emily Wray and Gareth Barrick, to create an additional learning simulation from the scrub point of view..

[Audio] Good communication is essential to ensure the best clinical outcome. To coordinate communication with the transfusion laboratory and any support services required for the duration of the incident, we must declare major haemorrhages immediately so emergency procedures can be activated promptly. Portering staff should also be informed to arrange a designated runner to transport samples, blood and blood components required during the incident..

[Audio] As many of you may know, we had a major haemorrhage incident last March . Let's have an overview of the case: This case study will highlight the issues of major haemorrhage and outline the steps required to reduce delays to the activation protocol and thus optimise patient outcomes. The patient was listed for laparoscopic radical nephrectomy. Team Brief was performed, and concerns were discussed. During the procedure, the surgeon found very dense adhesions around the kidney; therefore, unable to mobilise the kidney laparoscopically. Considering the patient desired outcome, the surgeon, the anaesthetist, and the team decided in unison to convert to open with the help of a vascular surgeon. We contacted the vascular surgeon, who gave us the estimated time to get to the theatres. During this time, the circulator team prepared all the instruments required by the vascular surgeon whilst the anaesthetist, and the ODP performed various checks, including blood gas analysis. At this point, the patient was stable with no active bleeding. After two hours from conversion, the vascular and urology surgeon struggled to visualise and mobilise the renal vein. During the kidney manipulation, an injury to the anterior part of the IVC happened, and the patient lost around 8L of blood. During this event, the anaesthetist required the available patient's blood, and the ODP followed the blood request procedure. Two additional 14G cannulas were introduced, and more blood gas analyses were performed. On arrival, the blood was checked and administered to the patient. Amid everything, the anaesthetist sent the ODP for more blood gas analysis and soon after collected the 0 negative blood from the bank collection fridge. At this point, the situation precipitated, with the patient dropping in blood pressure. The vascular surgeon temporarily clamped the aorta to give the anaesthetist time to allow fluid resuscitation. While waiting for the ODP to return with the 0 negative blood, the anaesthetist asked for more blood, and communication was an issue. However, more help arrived to assist the anaesthetist and the ODP. We had a clear communication set, and the situation returned under control. At the end of the procedure, the patient was transferred to ICU and recovered fully with minimal complications..

[Audio] Where risks and problems are identified, the Serious Hazards Of Transfusion group produces recommendations to improve patient Safety. In the 2021 annual report, SHOT states, " communication failures were identified in 48% as a continuing problem leading to or compounding delay. Team function failures contributed to some extent in 50.3%, and workload issues are also identified in a third of the reports. Individual patient factors were much less likely to contribute." On top of this, delays in running the major haemorrhage protocols occurred in many cases. Communication issues can occur at several different points, and delays accumulate..

[Audio] We reconstructed the timeline, gathering information from each staff member's perspective using a visual tool framework like this. " All too often in healthcare, when looking to make improvements, we do so using the lens of examining what went wrong rather than also considering what good looks like." Ian Lavery.

[Audio] The aim is to promote good practice and quality assurance by ensuring safe surgery is always performed. The debrief minutes and the learning points are part of CQC audits and are used for educational drills..

[Audio] We considered all contributing factors involved in every defect, including the role-playing of members involved. This process helped us develop a " system perspective" to see the hidden factors and identify whether they harmed or protected the patient. This is the first debrief minutes recorded on our Safety and quality control system following a live major haemorrhage incident. If the patient does require acute vascular surgical assessment/ intervention, ring the on-call Vascular Consultant at the LGI via the LGI switchboard ( 0113 2432799) to discuss and agree on the most appropriate care..

[Audio] Put yourself in the place of those involved, in the middle of the event unfolding, and take time to listen. Dig down to the reasoning and emotions behind actions and seek to understand rather than judge. The impact of ambiguous communication, such as" I need more blood", could lead to assumptions. On the flip side, clearly stating" activate major haemorrhage protocol" is preferable to manage expectations between the clinical area, staff, and laboratory..

[Audio] Looking beyond the surface, we should consider the incidents when things go right. The term " human factors" is associated with human abilities, behaviours, and limitations in the context of a workplace safety system. It should not be mistaken for being only about factors related to the individual. We considered some key points during the debrief. Some factors, such as the on-call vascular surgeon, were outside the individual's or the managers' control. The pathway we used to have for the on-call vascular surgeon stopped in 2014, and we don't have a direct number anymore..

[Audio] Thank you for your attention I also want to thank Clare for helping me edit the script. Thank you to Ali and Dr Raj for contributing to the clinical case overview. Thank you to Safety and quality team for the resources material..

REFERENCES: https://www.shotuk.org/resources/ https://intranet.midyorks.nhs.uk/departments/integratedcare/pathology/transfusion/Pages/,DanaInfo=intranet.midyorks.nhs.uk,SSL+Major-Haemorrhage-Training.aspx https://www.transfusionguidelines.org/transfusion-handbook/7-effective-transfusion-in-surgery-and-critical-care Human factors investigation tool Available online: https://www.hse.gov.uk/humanfactors/topics/investigation.htm Learning from defects Available online: https://www.ahrq.gov/hai/cusp/toolkit/learn-defects.html Major haemorrhage Trust policy: https://intranet.midyorks.nhs.uk/trustpolicies/MY%20Policies%20and%20Procedures%20Published%20Documents/Major%20Haemorrhage%20Policy%20(Adults).pdf https://intranet.midyorks.nhs.uk/trustpolicies/MY%20Policies%20and%20Procedures%20Published%20Documents/Major%20Haemorrhage%20Policy%20(Adults).pdf.