1
Massive Transfusion Guideline
Version
3
Name of responsible (ratifying) committee
Hospital Transfusion Committee
Date ratified
25/04/2014
Document Manager (job title)
Peter McQuillan
Date issued
13th May 2014
Review date
1st May 2016
Electronic location
Intranet Clinical Policies and Guidelines
Related Procedural Documents
Blood Transfusion Policy
Key Words (to aid with searching)
Massive transfusion, massive haemorrhage, bleeding,
hypovolaemia, shock, blood
Version Tracking
Version
Date Ratified
Brief Summary of Changes
Author
3
25/04/2014
Section 5 – Flowchart process
P McQuillan
Massive Transfusion Guideline : Version 3 2014
Review date: 2016 (unless requirements change)
2
CONTENTS
QUICK REFERENCE GUIDE…………………………………………………………………………PAGE 3
1. INTRODUCTION…………………………………………………………………………………….PAGE 4
2. PURPOSE………………………………………… …………………………………………………PAGE 4
3. SCOPE………………………………………………………………………………………………..PAGE 4
4. DEFINITIONS……………………………………………………………………………………… PAGE 4
5. DUTIES AND RESPONSIBILITIES……………………………………………………………….PAGE 5
6. PROCESS (ALGORHYTHM)………………………………………………………………………PAGE 6
7. COMMUNICATION AND LOGISTICS…………………………………………………………….PAGE 7
8. NOTES AND CAVEATS…………………………………………………………………………….PAGE 8
9. TIMELINE OF EVENT RECORD…………………………………………………………………PAGE 12
10. REFERENCES……………………………………………………………………………………PAGE 13
Massive Transfusion Guideline : Version 3 2014
Review date: 2016 (unless requirements change)
3
QUICK REFERENCE GUIDE
This policy must be followed in full when developing or reviewing and amending Trust procedural
documents.
For quick reference the guide below is a summary of actions required. This does not negate the need
for the document author and others involved in the process to be aware of and follow the detail of this
policy.
1.
Recognise bleeding is severe and potentially uncontrolled
2. Stop the bleeding if possible
3. Reverse any drugs or processes preventing normal clotting
4. Activate the Massive Transfusion Guideline by
a. Stating that you want to activate the guideline to the attendant staff
b. Phone the lab and say “I want to activate the Massive Transfusion guideline”
5. Send blood samples to the lab
a. Label samples using the patients wristband for identification
b. Send samples to the lab rapidly via a nominated “runner”
6.
Ensure there is a clinician looking after the patient – the clinical arm of the guideline
7.
Ensure there is a coordinator nominated to undertake the organization of the process and
use the audit form as both a process guide and an audit trail of the timings involved
8.
Restore the circulating volume of the patient and clotting factors
GIVE EMERGENCY O NEGATIVE UNITS UNTIL PACK A IS READY
a. Bear in mind that it might be reasonable to tolerate a degree of hypotension
(permissive hypotension) to prevent further bleeding – e.g. in a ruptured aortic
aneurysm scenario
b. Current best evidence suggests that concurrent administration of platelets, FFP and
blood maximizes effectiveness of massive transfusion therapy.
9. Keep the patient warm, calcium levels up. Monitor the patient.
10. Maintain clear and concise communication channels between clinicians, coordinators, lab
staff and transport team members. Remain calm and professional to maximize efficiency.
Massive Transfusion Guideline : Version 3 2014
Review date: 2016 (unless requirements change)
4
INTRODUCTION
Massive bleeding may occur in a variety of circumstances including trauma, gastro-intestinal bleeding
or during surgery. Rapid, decisive action is required when potentially uncontrollable bleeding occurs.
The guideline provides a framework and organisational structure to enable efficient management of
this life-threatening problem.
1. PURPOSE
The purpose of the document is to:
o
o
Provide a structure and organisational process to deal with massive bleeding
Point out the roles involved which include
 The activities of the hands-on clinicians finding the cause, stopping the bleeding,
reversing any anticoagulation or correcting bleeding diatheses, resuscitating and
transfusing fluids and blood products
 The importance of the co-ordinator, ensuring the basic processes are
accomplished in a slick and timely manner, communication occurs and samples
and blood products are delivered appropriately
It has been developed to simplify clinical practice and as part of a NPSA requirement.
2. SCOPE
The document applies to any patient presenting with severe, potentially uncontrollable
bleeding, from whatever cause.
Staff should be aware that patients may have personal or religious reasons to decline
transfusion of blood products. Staff should make reasonable attempts, under the
circumstances, to establish the wishes of the patient. This may not always be feasible and the
guideline may be enacted in best interests of the patient where there is no clear patient refusal
or availability of advance directives
‘In the event of an infection outbreak, flu pandemic or major incident, the Trust recognises
that it may not be possible to adhere to all aspects of this document. In such circumstances,
staff should take advice from their manager and all possible action must be taken to
maintain ongoing patient and staff safety’
3. DEFINITIONS
Massive Haemorrhage: clinically significant bleeding which seems uncontrollable. This is
deliberately simple to ensure there are no delays in enacting the processes within this
document; too many activations are better than undue delay, which may pose a greater risk to
the patient.
Red box: a red-coloured box, located in strategic places where massive haemorrhage may
occur, containing a copy of the guideline and the necessary forms and blood bottles to begin
the process. It already exists in most of these locations and the guideline simply formalises the
process
Massive Transfusion Guideline : Version 3 2014
Review date: 2016 (unless requirements change)
5
4. DUTIES AND RESPONSIBILITIES
Hospital Transfusion Practitioner will ensure massive transfusion / haemorrhage is added to
the educational programme for staff.
Transfusion Department Managers will ensure that sufficient resources, including manpower,
are available including: laboratory staff; portering; transportation; training and education, to
maintain a credible service as sanctioned by regulatory authorities.
Trust Clinicians must follow the policy appropriately and fill in the audit form to facilitate
analysis of events and hence improve structure, process and organisation within the Trust
Hospital Transfusion Team will function as the facilitators of the processes involved in this
policy
Hospital Transfusion Committee will:


Oversee the audit of massive haemorrhage events and facilitate appropriate action where
necessary
Review this document by the required review date, or sooner if pertinent advice or
evidence arises
Massive Transfusion Guideline : Version 3 2014
Review date: 2016 (unless requirements change)
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5. PROCESS
Massive Transfusion Guideline (NB Give emergency O negs until Pack A ready)
Secure Vascular Access
* 2 large peripheral IV lines
* Large bore central venous access
* Intra-osseous needles
Xmatch, Coags, FBC, U&E
Patient ID =
(1) Surname (2) 1st name
(3) DoB
(4) Hosp #
Recognise Massive Bleeding
Call Blood Bank x6539, 6492 state ...
“Activating Massive Transfusion Guideline”
(1) Patient ID (2) Location
Reverse
* Warfarin
* LMWH (Enoxaparin)
* Heparin
* Anti-platelet agents
Enlist more help
Organise
* Lead clinician, Co-ordinator, Runner
* Use MTG timing/audit form
Restore Circulating Volume
with Blood & Coag Factors
Stop the Bleeding
Treat the cause
* Direct pressure
(bimanual to uterus)
* Balloon tamponade
* Splint? Elevate?
* Surgery? Endoscopy?
* Invasive Radiology?
Clinically significant massive
bleeding, which seems uncontrollable
RBC:FFP:plats in ratio 6:6:1
Cryo every 10-12 units RBC
* Minimise Cryst/Colloid
* Avoid vasopressors
Give Tranexamic acid in
trauma
Normalise Environment
Use Level One Infusor
Use Cell Saver
Check Blood/Patient ID
Pack A
Keep Patient Warm
* Forced Air Warmers
* Warming Mattress
* Warm fluids – use Level 1
Pack B
Later blood products
Don't wait for coag results to treat
Seek haematology advice - after Pack B (12 RBCs)
Obstetric Bleeds: use FFP in 2nd phase (Pack B) only
Normalise Ionised Calcium
Ca2+ Gluconate 10% (20ml) or
Ca2+ Chloride 10% (10ml)
Beware hyperkalaemia
Monitoring & Targets
* Clinical Haemodynamics & Temperature
* [Hb] – Haemacue (near pt)
* Blood gases: art or ven
* FBC, coags, fibrinogen hourly
Consider permissive hypotension
(syst 90 mmHg, max 1 hr from start of bleeding)
Not in head injury
* Stop MTG episode if bleeding controlled
Reassess & Stand-down
* Ionised calcium > 1
* Normal pH
- Hb > 8, Plats > 100, INR & APTR < 1.5
- Fibrinogen > 1
* Stand-down/thank lab @ end
* Restock kit, debrief staff
Queen Alexandra Hospital, Portsmouth
Transfusion Committee: 2013
Massive Transfusion Guideline : Version 3 2014
Review date: 2016 (unless requirements change)
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Communication & Logistics
Runner:
HCSW, nurse, ODP
Co-ordinator
Continuous liaison with
Clinical team Leader
Phase 1
1 Enlist runner
2 Start Maj Transf Alert timings form
3 Ensure labelled samples (1) for lab
4 Phone lab (x 6539, 6492)
* Agree dispatch Red Box Pack A
= 6 RBCs, 6 FFP
* Obst bleeds – FFP with Pack B only
* Ensure lab orders more plats
5 Send runner for Pack B when ready
= 6 RBCs, 6 FFP, 2 Plats, 1 Cryo
Xmatch, Hb, U&E (1)
1 Deliver samples (1) to lab
2 Wait for blood products
3 Return with Red Box Pack A
1 Run for Red Box Pack B
when it is available
1 Ensure monitoring of patient & [Hb]
* Cell Saver, Rapid infusor, Warming
2 Document blood results
Phase 2
If continuing
bleeding
Coags, Hb, ABG samples (2)
Maintain
immediate
availability
1 Enlist runner
2 Ensure labelled samples (2) for lab
3 Phone lab (x 6539, 6492)
inform samples en route
4 Phone Haematology Consultant
* Bleep 1972, Mob 07775 800 240 or
via operator at night
* Agree next coag support
5 Phone lab (x 6539, 6492)
* Agree dispatch of blood prods
1 Deliver samples (2) to lab
2 Wait for blood products
3 Return with blood products
1 Ensure monitoring of patient & [Hb]
* Cell Saver, Rapid infusor, Warming
2 Document blood results
Phase 3
If continuing
bleeding
Maintain
immediate
availability
Coags, Hb, ABG samples (3)
1 Enlist runner
2 Ensure labelled samples (3) for lab
3 Phone lab (x 6539, 6492)
inform samples en route
4 Phone Haematology Consultant
* Agree next coag support
5 Phone lab (x 6539, 6492)
* Agree dispatch of blood prods
1 Deliver samples (3) to lab
2 Wait for blood products
3 Return with blood products
Consider other measures with Haematology Cons
Phase 4
1 Reassess need for continuing MTG
2 Stand down lab at end
3 Complete timings/audit form
Massive Transfusion Guideline : Version 3 2014
Coagulation Support Guideline
Plat < 100
1 Plats
Plat < 50
2 Plats
Fibrinogen < 1
1 Cryo
APTR/INR > 1.5
4 FFP
Hospital Transfusion Committee
Queen Alexandra Hospital, Portsmouth, 2013
Review date: 2016 (unless requirements change)
8
Massive Transfusion Guideline: Notes and Caveats
Recognition of Massive Bleeding
 Definition: clinically significant massive haemorrhage, which seems uncontrollable.
o This is a deliberately simple definition, without specific volumes: to prevent delays
measuring volumes or waiting specific lengths of time to trigger a massive
haemorrhage alert. It is better to trigger too many alerts (with the benefit of the
retrospectoscope) than have too many delayed diagnoses of major haemorrhage.
o If it looks like massive bleeding that seems uncontrollable – then it probably is!
 Phone blood bank x6539, 6492: state “I want to activate the Massive Transfusion Guideline”
 Give patient identification details and site of patient (ED, ward) and send blood samples
Cross-Matching & Bloods
 Send cross-match bloods, FBC, U&E, Coagulation profile.
 All the necessary forms should be available in areas likely to experience massive bleeding. An
excellent example is in Maternity, where a “red box” exists, containing the blood bottles and forms
needed for urgent sampling. It also contains a laminated copy of the guideline.
 Blood bank may already have a group & screen sample (e.g. in elective surgical patients) and can
thus issue blood immediately but otherwise it takes 5 mins to obtain a blood group. Important to
use the appropriate group FFP.
Volume & Coagulation Factors
Pack A
Pack B





RBCs
6
6
FFP
6
6
Plats
1
2
Cryo
-----2
Best outcomes occur with concurrent use of RBC, FFP, platelets (in ration 6:6:1), with cryo
(cryoprecipitate) every 6-12 units RBC. Minimise the volumes of crystalloids & colloids.
The lab provides Pack A and Pack B will become available automatically shortly thereafter,
unless a cancellation occurs & is communicated. Platelets may not be onsite, so may be delayed.
In obstetric haemorrhage only use FFP with Pack B (in phase 2), as patients initially
hypercoagulable.
Further blood products will be provided on basis of blood results (timed according to the
algorithm) and liaison with consultant haematologist.
Cell salvaged blood (CSB) contains no clotting factors. Count cell salvaged blood in transfusion
count. CSB has high Hct, so 250 ml CSB = 1 unit. For example: 6 units bank blood + 1500 ml
CSB = 12 units total and requires 12 units FFP.
Give tranexamic acid in major trauma (1g IV over 10 mins, 1 g infusion over 8 hrs)
Organisation
This is the key strategy – to appoint roles to individuals, working to a plan/guideline, as a cohesive
team.
 Seeking help & support
o These situations are very labour intensive and several people are required.
o Calling for help early is imperative. In theatre at least two anaesthetists are required.

Clinical Leader: has overall responsibility and leads (ideally hands off to allow situational
awareness)
Emergency Dept (ED) = consultant or most senior ED clinician
Theatre = consultant or most senior anaesthetist
MAU/SAU/Wards = consultant or most senior clinician
o The Clinical Leader has responsibility for clinical interventions

The coordinator role
1. to liaise with the clinical team leader and others to ensure the guideline is followed
2. to ensure the appropriate measures take place in a timely, planned, organised manner
3. to document and time the key points & events
Massive Transfusion Guideline : Version 3 2014
Review date: 2016 (unless requirements change)
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4. to offload administrative and telephone work from the clinical leader
5. to ensure any problems with structure or process are highlighted, to be addressed &
sorted
6. to ensure a copy of the timings/events form is sent to the transfusion practitioner
(x1793, bleep 0123, blood bank) for audit and quality assurance
There is a checklist element to this role, ticking the cockpit drill domains. Other clinicians
should understand this role and despite the pressure & tension of the urgent clinical
situation, should remain professional & courteous when asked questions they feel are
obvious and simple.

Appointing roles
o The clinical leader has overall leadership for the resuscitation. If there is sufficient
manpower and skill-mix, the clinical leader should remain “hands-off” the patient to
maintain situational awareness. The roles of clinical leader & coordinator are
complimentary. The most senior doctor may choose to take either role or neither role,
allowing a trainee to take the helm.
o Coordinator may be a doctor, senior nurse or an experienced ODP.
o The ED has tabards to identify the team roles, and they include: team leader, doctor
one, doctor two, nurse one, nurse two, airway doctor and ODP, radiographer and
scribe. Runners are separately detailed by team leader.

Noise & overcrowding
o The clinical area can become overcrowded and excessively noisy. Clinical leader may
ask people to stand back or leave; radio or music should be turned off.
o Clearly these events are rare and afford useful learning opportunities.
o Stressful situations require quick thinking staff and quiet, calm and efficient support.

Haematology Consultant: bleep 1972, day mobile 07775 800240, at night via operator
Equipment
 Forced air warmers and Rapid Infusion Devices – Level 1 are available in ED, Theatre, Critical
Care, Maternity. These devices are crucial & are needed urgently.
Reversal of Pharmacological Anticoagulation
A) Warfarin
 Vit K 1-2 mg increments & Octaplex (Human Prothrombin Complex) 2000 units.
 Vit K in doses of 5-10 mg will prevent later rewarfarinisation for some time.
B) Anti-platelet drugs
 Platelet transfusion likely to be most effective measure. Avoid DDAVP in this situation.
C) Heparin
 Heparin has a short half-life & protamine causes significant hypotension.
 Consider Protamine with care & reluctance. Probably ineffective in treating SC heparin.
D) LMW Heparin (e.g. clexane)
 FFP is of no use in reversing heparin of any sort. In theory it could increase the anticoagulant
effect by providing further antithrombin.
 Consider protamine but effect is variable, has intrinsic anticoagulant effects itself and may
cause hypotension. Give slowly <5mg/min I.V. and do not exceed guidelines below.
1.5mg/kg (Treatment
LMWH Heparin regime
40mg (Prophylactic dose)
dose)
Time since LMWH dose < 8 hrs
8-12hrs > 12 hrs < 8 hrs 8-12hrs > 12 hrs
Protamine Dose
50 mg
20 mg
None
50 mg 20 mg
None
E) Factor Xa Inhibitors (e.g. Rivaroxaban) & Thrombin Inhibitors (e.g. Dabigatran)

Not easily reversed. Seek advice from haematologist.
Treatment of hypocalcaemia
 10-20ml 10% calcium gluconate (kinder to peripheral veins) or calcium chloride 10% 10ml.
Massive Transfusion Guideline : Version 3 2014
Review date: 2016 (unless requirements change)
10
Haemodynamic Monitoring






Monitor pulse rate, BP, CRT, peripheral perfusion/warmth, urine output, mentation.
Pain, anxiety or awareness, cold climate, beta blockade may influence these signs.
Consider resuscitation using a goal of a palpable radial pulse. Permissive hypotension i.e.
targeting a modest BP, as in blunt trauma care, may have a place but is bad for head
injuries and there is evidence of poor outcomes if persists beyond an hour.
Do not waste time on an arterial line in a shocked, hypovolaemic patient – resuscitate first.
Monitor the continuing blood loss if this is feasible.
Central venous pressure measurements are much less useful than historical prejudice
suggests.

Oesophageal Doppler may give a better indication of vascular filling
Massive Transfusion Guideline : Version 3 2014
Review date: 2016 (unless requirements change)
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Surname, 1st name
DoB
Location
Hosp #
Cause of bleeding
Time
1
:
Time of declaration of Major Haemorrhage Alert
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
:
:
:
:
:
:
:
:
:
:
:
:
:
:
:
:
:
:
:
:
:
:
:
:
:
:
HCSW/Porter summoned (if already present = P)
Blood samples taken & labelled (4 ID items)
Blood samples despatched to lab
Lab phoned
Arrival of Red Box Pack A
Surgery considered
Surgery starts
Reveral of any pharmacological contributors (warfarin etc)
Rapid infusor device started
Cell saver started
Forced air warmer started (Bair Hugger equivalent)
HCSW/Porter summoned (if already present = P)
Phase 2 blood samples taken & labelled (4 ID items)
Phase 2 blood samples sent to lab
Phone call to consultant haematologist
Arrival of Red Box Pack B
HCSW/Porter summoned (if already present = P)
Phase 3 blood samples taken & labelled (4 ID items)
Phase 3 blood samples sent to lab
Phone call to consultant haematologist
Arrival of 3rd set of blood products
HCSW/Porter summoned (if already present = P)
4th blood samples taken & labelled (4 ID items)
4th blood samples sent to lab
Phone call to consultant haematologist
Arrival of 4th set of blood products
Massive Transfusion Guideline : Version 3 2014
1
Time
Method
Haemacue
Hb
Plats
APTR
INR
Fibrinogen
ABG/VBG?
[Hb]
pH
H+
Po2
Pco2
Std Bic
BXS
Sat
Lactate
Glucose
Na+
K+
CliCa2+
Review date: 2016 (unless requirements change)
2
3
4
5
6
12
Make notes of problems in (1) the structure & organisation and (2) the process of delivery of care to this patient). What could have
been improved?
(use the numbers to help identify times and events)
5. TRAINING REQUIREMENTS
Massive haemorrhage issues will be included in the Trust blood awareness education programme, overseen by the Transfusion
Practitioner. Blood awareness education is already a bi-annual requirement for Trust staff, as part of the Trust’s Training Needs
Analysis.
6. REFERENCES AND ASSOCIATED DOCUMENTATION
External
 Coagulopathy: its pathophysiology and treatment in the injured patient. World J Surg;2007:31:1055-64. Tieu BH et al
 Early prediction of massive transfusion in trauma: simplified ABC (Asssessment of Blood Consumption). J Trauma
2009;66:346-52. Nunez TC et al
 Fresh frozen plasma should be given earlier to patients requiring massive transfusion. J Trauma 2007:62;112-9. Gonzalez
EA et al
 Guidelines for prehospital fluid resuscitation in the injured patient. J Trauma 2009:67;389-402. Cotton BA et al
 The cellular, metabolic and systemic consequences of aggressive fluid resuscitation strategies. Shock 2006:26;115-21.
Cotton BA et al.
 Massive transfusion practices around the globe and suggestion for a common massive transfusion protocol. J Trauma
2006:60;S91-S96
Massive Transfusion Guideline : Version 3 2014
Review date: 2016 (unless requirements change)
13
 Improvements in early mortality and coagulopathy are sutained better in patients with blunt after institution of a massive
transfusion protocol in a civilian level 1 trauma centre. Trauma 2009;66:1616-24. Dente CJ et al
 Predefined massive transfusion protocols are associated with a reduction in organ failure and postinjury complications.
2009;61:41-9. Cotton BA et al
 Damage control hematology: the impact of a trauma exsanguinations protocol on survival and blood product utilization. J
Trauma 32008:1177-83. Cotton BA et all
 Trauma associated severe haemorrhage (TASH)-score: probability of mass transfusion as surrogate of life threatening
haemorrhage after major trauma. J Trauma 2006:1228-1237
 Resuscitation and transfusion principles
doi:10.1016/j.bire.2009.07.003. Spinella PC et al
for
traumatic
haemorrhagic
shock.
Blood
reviews
2009:
Internal
 Blood Transfusion Policy
 Policy for the Management of Serious Incidents Requiring Investigations (SIRIs)
7. EQUALITY IMPACT STATEMENT
Portsmouth Hospitals NHS Trust is committed to ensuring that, as far as is reasonably practicable, the way we provide services to the
public and the way we treat our staff reflects their individual needs and does not discriminate against individuals or groups on any
grounds.
This policy has been assessed accordingly
Massive Transfusion Guideline : Version 3 2014
Review date: 2016 (unless requirements change)
14
8. MONITORING COMPLIANCE WITH PROCEDURAL DOCUMENTS
Minimum requirement to
be monitored
Each massive haemorrhage
event: to ensure appropriate
process followed in 100% of
the time
Lead
Tool
Hospital
Transfusion
Team
Audit Data Collection
Form
Frequency of Report
of Compliance
Reporting arrangements
Lead(s) for acting on
Recommendations
Policy audit report to:

Annually
Hospital Transfusion Committee
Chair of Hospital Transfusion
Committee
Policy audit report to:

Policy audit report to:

This document will be monitored to ensure it is effective and to assurance compliance.
The effectiveness in practice of all procedural documents should be routinely monitored (audited) to ensure the document objectives are being
achieved. The process for how the monitoring will be performed should be included in the procedural document, using the template above.
The details of the monitoring to be considered include:






The aspects of the procedural document to be monitored: identify standards or key performance indicators (KPIs);
The lead for ensuring the audit is undertaken
The tool to be used for monitoring e.g. spot checks, observation audit, data collection;
Frequency of the monitoring e.g. quarterly, annually;
The reporting arrangements i.e. the committee or group who will be responsible for receiving the results and taking action as required.
In most circumstances this will be the committee which ratified the document. The template for the policy audit report can be found on
the Trust Intranet Trust Intranet -> Policies -> Policy Documentation
The lead(s) for acting on any recommendations necessary.
Massive Transfusion Guideline : Version 3 2014
Review date: 2016 (unless requirements change)
15
Checklist for the Review and Ratification of Procedural Documents and
Consultation and Proposed Implementation Plan
To be completed by the author of the document and attached when the document is submitted for
ratification: a blank template can be found on the Trust Intranet
CHECKLIST FOR REVIEW AND RATIFICATION
TITLE OF DOCUMENT BEING REVIEWED: Massive Transfusion Guideline
1
2
Title
Y
Is the title clear and unambiguous?
Y
Will it enable easy searching/access/retrieval??
Y
Is it clear whether the document is a policy, guideline, procedure,
protocol or ICP?
Y
4
6
Is there a standard front cover?
Y
Is the document in the correct format as per Policy for the
Development and Management of Procedural Documents?
Y
Does the scope include the paragraph relating to ability to comply,
in the event of a infection outbreak, flu pandemic or any major
incident?
Y
Are the roles and responsibilities clearly explained?
Y
Does it fulfill the requirements of the relevant NHSLA Risk
Management Standard? (where applicable)
Y
Evidence Base
Y
Approval Route
Does the document identify which committee/group has approved
it?
Y
Is the Ratification Checklist complete overleaf
Y
Are minutes of ratification committee attached showing ratification?
Y
Process to Monitor Compliance and Effectiveness
Are there measurable standards or KPIs to support the monitoring
of compliance with the effectiveness of the document?
7
Y
Dissemination and Implementation
Is a completed proposed implementation plan attached?
7
Y
Review Date
Is the review date identified?
6
Y
Content
Is the type of evidence to support the document explicitly
identified?
5
COMMENTS
Introduction
Are reasons for the development of the document clearly stated?
3
YES/NO
N/A
Y
Equality and Diversity
Is a completed Equality Impact Assessment attached?
Y
If answers to any of the above questions is ‘no’, then please do not send it for ratification
Massive Transfusion Guideline : Version 3 2014
Review date: 2016 (unless requirements
change)
16
Checklist for the Review and Ratification of Procedural Documents and
Consultation and Proposed Implementation Plan
CONSULTATION AND PROPOSED IMPLEMENTATION PLAN
Contact Details
Name and details of key person
developing information and
responsible for review
Development Team and Peer
Review
Groups /committees / individuals
involved in the development and
consultation process
Implementation Plan
Author(s)
This should be signed by the main
author
Name
PETER MCQUILLAN
Job Title
CONSULTANT/CHAIR OF HTC
Department
CRITICAL CARE DEPT
CSC/Location
CHAT
Telephone
Email
Peter.mcquillan@porthosp.nhs.uk
HOSPITAL TRANSFUSION COMMITTEE, HOSPITAL TRANSFUSION
TEAM
What training is
required to
support
implementation?
TRUST INDUCTION, TRANSFUSION UPDATES,
GRAND ROUNDS
Outline any
additional
activities to
support
implementation
Name
Job Title
P. MCQUILLAN
CONSULTANT
Signature
If, as the author, you are happy that the document complies with Trust policy, please sign above and send the document,
with this paper, with the Equality Impact Assessment to the chair of the committee/group where it will be ratified. To aid
distribution all documentation should be sent electronically wherever possible.
Name of Ratification Committee
HOSPITAL TRANSFUSION COMMITTEE
Date of Ratification
(minutes enclosed)
25/04/2014
Name/Signature
of Chair
P.MCQUILLAN
Once the committee/group is happy to ratify this document, would the chair please sign above and send the policy together
with this document, the Equality Impact Assessment, and the relevant section of the minutes to the Risk Analyst. To aid
distribution all documentation should be sent electronically wherever possible.
Massive Transfusion Guideline : Version 3 2014
Review date: 2016 (unless requirements
change)
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Equality Impact Screening Tool
To be completed and attached to any procedural document when submitted to the
appropriate committee for consideration and approval for service and policy
changes/amendments.
Stage 1 - Screening
Title of Procedural Document: MASSIVE TRANSFUSION GUIDELINE
Date of Assessment
25/04/2013
Responsible
Department
HTC
Name of person
completing
assessment
Kay Heron
Job Title
Transfusion Practitioner
Does the policy/function affect one group less or more favourably than another on the basis
of :
Yes/No
 Age
N
 Disability
Learning disability; physical disability; sensory
impairment and/or mental health problems e.g.
dementia
N
 Ethnic Origin (including gypsies and travellers)
N
 Gender reassignment
N
 Pregnancy or Maternity
N
 Race
N
 Sex
N
 Religion and Belief
N
 Sexual Orientation
N
Comments
If the answer to any of the above questions is
NO, the EIA is complete. If YES, a full impact
assessment is required: go on to stage 2, page 2
More Information can be found be following the link
below
www.legislation.gov.uk/ukpga/2010/15/contents
Massive Transfusion Guideline : Version 3 2014
Review date: 2016 (unless requirements
change)
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Stage 2 – Full Impact Assessment
What is the impact
Level of
Impact
Mitigating Actions
(what needs to be done to
minimise / remove the impact)
Responsible
Officer
Monitoring of Actions
The monitoring of actions to mitigate any impact will be undertaken at the appropriate level
Specialty Procedural Document:
Specialty Governance Committee
Clinical Service Centre Procedural Document:
Clinical Service Centre Governance Committee
Corporate Procedural Document:
Relevant Corporate Committee
All actions will be further monitored as part of reporting schedule to the Equality and Diversity
Committee
Massive Transfusion Guideline : Version 3 2014
Review date: 2016 (unless requirements
change)