Nursing Research And Evidence Based Practice

Chapter 1: Introduction


Hemorrhage is a paramount issue that can precipitate a fatal patient outcome. Massive

transfusion is a vital, high-risk treatment for extreme blood loss. The replacement of a

patient’s blood volume by rapidly transfusing blood products is particularly unpredictable.

There can be various precipitating events causing massive bleeding, all of which require quick

recognition, expeditious response, and concise treatment. Blood management and resuscitation

during hemorrhage requires a team of knowledgeable participants, with assigned roles, the

proper equipment for rapid administration and an atmosphere with structure and order (Milligan,

Higginson, & Smith, 2011).

Each massive transfusion is different, which creates a certain level of stress and

uncertainty among responding staff. When staff is inexperienced with massive transfusion

protocols or unfamiliar with the requirements, their performance can fluctuate. Performance

could be stronger under a moderate amount of stress, or they could shut down and question their

abilities. Massive transfusions require team participation, protocols, and an algorithm to follow,

in addition to hands-on training, which can ease the fight-or-flight response, support confidence

and improve patient outcomes (Stout, 2013).


The use of evidence-based protocols implemented by an experienced team reduces

variability, enhances correct blood administration, and improves outcomes. The initial

demonstration of these benefits was clearly showcased by the armed services in the early 1900s

(Roberts, Chandler, & Mayles, n.d.). Their precise management of hemorrhage using a massive

bleeding protocol led to improved survivability of severe trauma in the field (Roberts, Chandler,

& Mayles, n.d.). Hemorrhage and death are familiar outcomes on the battlefield. However,

proactive care and early blood administration have prevented some deaths that were previously

seen as inevitable. Today, hospitals around the world have adopted massive transfusion protocols

based on previous, documented evidence and tracking of the military protocols and outcomes

(Roberts et al., n.d.).

Having protocols for patients undergoing massive bleeding can reduce mortality,

increase teamwork and facilitate proper product usage (Engelbrecht et al., 2013). Massive

transfusion protocols continue to evolve. Research shows the composition of protocols, massive

transfusion delivery methods, and product ratios differ by the institution (Etchill, Sperry,

Zuckerbraun, Alrcon, Brown, Schuster, Kaplan, Piper, Peitzman & Neal, 2016). In addition, the

authors noted variability in products dispensed. In some protocols, there are no plasma or

platelets dispensed during the first response, no crystalloid administration guidelines, and

calcium is not part of the protocol. Although institutions have a massive bleeding protocol, it

may need to be updated to include recent developments (Etchill et al., 2016).

The four goals during hemorrhage are; early hemostasis, restoration of oxygen-carrying

capacity, prevention of coagulopathy, and identification and treatment of the injury. With

various causes of hemorrhage, we can use massive hemorrhage clinical guidelines to determine

proper indication, correct dosing and precise timing for this high-risk procedure. The four goals

of hemorrhage, cannot be reached without collaboration and involvement of a designated rapid

response team, trained specifically in massive blood replacement. The influence of a designated,

trained team could be an advantage for early interventions and the resuscitation of the patient

(Treml, Gorlin, Dutton, & Scavone, 2017).

This Capstone project will evaluate a group of registered nurses and their response

during a simulated massive transfusion. The group will use the WellSpan York Hospital

Massive Transfusion Protocol (MTP) Algorithm (Appendix A). This protocol was developed by

Dr. Michelle Erickson in 2010 and updated in 2016 after newly published data. Dr. Erickson

updated the component algorithm and order in which products were transfused. In addition, a

Transfusion Safety Officer position was added to improve staff education with blood

transfusions. However, with each massive transfusion activation, errors continue to occur.

Some of the inaccuracy is due to a lack of communication, knowledge deficits, improper

equipment, nursing shortages and lack of bedside assistance for medication administration,

laboratory monitoring, and recording. The need to educate and train a team solely responsible for the massive response team is imperative.

During a crisis, such as massive hemorrhage, mistakes happen. Miscommunication, lack

of knowledge and uncertainty of how to properly institute a massive transfusion are areas for

improvement, and a partnership with clinicians is essential. Research proves the Crew Resource

Management (CRM) training model improves team dynamics and decreases errors (Hughes,

Benenson, Krichten, Clancy, Ryan & Hammond, 2014). This training model was originally used

in the field of aviation to improve safety. However, hospitals have tailored this model to be

used in critical situations and areas of high stress. CRM is currently taught to the trauma

and code response teams at WellSpan York Hospital. Following training, there is evidence of

better communication, knowledge of role assignment and improved relations between team

members (Hughes et al., 2014). CRM training has proven to provide safer patient care and

favorable patient outcomes (Hughes et al., 2014).

Statement of the Problem

Protocols are created to help guide the massive transfusion; however, providers do not

always follow the guidelines (Bawazeer, Ahmed, Izadi, McFarlan, Nathens, & Pavenski, 2015).

A deficiency of available resources, type of injury, delayed response of medical personnel and

understanding of proper protocol usage can have a detrimental effect on patient outcomes.

During a massive transfusion, the crisis can cause chaos and confusion. A checklist of directions

can be effective and serve as reminders of the next steps (Hilton, Daniels, Goldhaber-Fiebert,

Lipman, Carvalho, & Butwick, 2016). A massive transfusion requires close monitoring and

active management. One must monitor laboratory values, vital signs, medical intervention,

intake amounts, and blood product ratios (Pham, & Shaz, 2013).

Using a team approach to massive transfusion is essential for patient outcomes. However,

there are limited studies on a team approach to massive transfusion. Having a response team,

and a leader who is trained in transfusion medicine, treatments, coagulopathy, and interpretation

of laboratory values are necessary to improve patient outcomes (Quintana-Diaz, & Garcia Erce,

2016). Training a designated massive transfusion rapid response team, including nurses,

physicians, and other areas, such as trauma teams, anesthesia providers, and residents can

increase optimal patient care, bedside support, and expert input during the critical initiation of a

massive transfusion (Nunez, Young, Holcomb & Cotton, 2010).


The purpose of this project is to assess the proficiency of nurses during a massive

transfusion simulation. This Capstone Project will provide essential knowledge and skills to

nurses who respond to hemorrhaging patients. Nurses require vital information such as the

WellSpan York Hospital MTP Algorithm (Appendix A), and the MTP Nursing Checklist

(Appendix B). In addition, having a list of MTP Important Phone Numbers (Appendix C) play a

key role in assembling extra resources to assist in monitoring the patient, administering blood

products, managing medications and reporting laboratory values. Having confidence in your

practice, increasing your knowledge through simulation, and working together as a team to

provide optimal care for patients can produce a feeling of empowerment. A team approach is

necessary during massive bleeding, and with the right guidance, nurses can become a

collaborative force, adding value or additional insight that may help stop the bleeding patient.

Theoretical Framework

Conceptual frameworks are theories where we assimilate, digest, and incorporate

information after being given the details. Through nursing educating, we strive to reach learning

objectives and apply that information at the bedside. Although our surroundings, beliefs, and

experience play a role in our knowledge, there are theories that support other ideas of learning.

There are six main theories of learning: behaviorism, cognitivism, social learning, social

constructivism, multiple intelligences, and brain-based learning (Rubio, n.d.).

Cognitive Learning Theory favors discovery learning. Theorist, Jerome Bruner

believed anyone could learn if it is taught to them in ways they understand. The brain-based

learning theory suggested by the theorist, John Dewey, allows learners the opportunity for batch

learning, memory recall, and intellect from repetition. In addition to these theories, humanists

believe learning is motivated by one’s inner desire to learn and should be reinforced over time

(Rubio, n.d.).

A newer instructor strategy is educating through High Fidelity Simulation (HFS), which

allows an extensive variety of experimental learning. HFS helps the learner use their mind, be

hands-on with the activity, and interact with other team members to find solutions. Each case

scenario uses the foundation of learning framework while providing educational components to

the learner (Paige & Daley, 2009).

Nature of the Project

The nature of this project is to identify knowledge deficits among nursing staff related to

the MTP. A volunteer group of registered nurses from WellSpan York Hospital will be assessed.

The project will consist of group training. The curriculum contains a short MTP Education

Module PowerPoint presentation on MTP framework (Appendix D), evidence-based practices,

blood administration order, and medications and when they are given. Additionally, nurses will

be taught the WellSpan York Hospital MTP Algorithm (Appendix A) and review Additional

Resources (Appendix E) available to them. The group will be evaluated on their understanding

of the MTP process through pre-testing, simulation, debriefing, and education.

Significance of the Project

The project can have a significant impact on patient safety, early hemostasis, and errors.

Blood transfusions are high-risk events. Having a knowledgeable, dedicated, massive

transfusion response team can decrease mistakes, increase communication, and ensure the safest

practice for every patient. The Joint Commissions (2017) established four National Safety

Goals. These goals are correct patient identification using two identifiers and improving staff

communication. Also, medication safety, and preventing mistakes, which are similar to the four

goals during hemorrhage and can be accomplished by education, training, simulation, and having

a devoted massive transfusion response team.


Algorithm: A self-contained sequence of actions to be performed (eMedicineHealth, 2017).

Coagulopathy: A condition in which the blood’s ability to form clots is impaired (eMedicineHealth, 2017).

Crew Resource Management: A set of training procedures for use in environments where human error can have devastating effects (The Free Dictionary, 2017).

Exsanguination: Blood loss to a degree sufficient to cause death (eMedicineHealth, 2017).

Hemorrhage: To bleed profusely • Bleeding or the abnormal flow of blood (eMedicineHealth, 2017).

Hemostasis: A process which causes bleeding to stop (eMedicineHealth, 2017).

Hemovigilance: A set of surveillance procedures covering blood techniques and protocols (eMedicineHealth, 2017).

High Fidelity Simulation : An imitation of the operation of a real-world process (The Free Dictionary, 2017).

Intuitional Review Board : A committee used to approve research (eMedicineHealth, 2017).

Massive Transfusion: The replacement of >50% of total blood volume (The Free Dictionary, 2017).

Protocol: Guidelines for medical treatment (eMedicineHealth, 2017).


Hemorrhage can cause death if not treated quickly. When an MTP is initiated, everyone

involved with the care of the patient must be prepared to act fast. Approximately 50 percent of

deaths occur within the first 24 hours’ after injury because of exsanguination and coagulopathy

(Pham & Shaz, 2013). This project is based on the belief that a committed, exclusive, massive

transfusion response team, trained and educated on the proper way to deliver blood products,

medications, and other treatments to a bleeding patient will result in positive patient outcomes

and increase patient safety. Educating a team in acceptable practice during hemorrhage must

be seriously considered. In addition, it is important to understand team dynamics, collaboration,

and communication necessary to run a massive transfusion successfully. Applying a team

approach, with assigned roles and a leader can provide the patient with optimal care during their

crisis and lead to an overall better outcome.

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