Tools and resources

Adoption support resource – insights from the NHS

3 Current practice

3 Current practice

Standard laboratory tests

Standard laboratory blood tests for coagulation include prothrombin time, a measure of the extrinsic pathway of coagulation, and activated partial thromboplastin time, which measures the intrinsic pathway of coagulation.

Although these tests can measure coagulation factor function, they are generally unable to assess platelet function, clot strength and fibrinolysis. Depending upon local logistics, results may take between 40 and 90 minutes which can delay subsequent treatment.

Viscoelastometric testing enables clinicians to get a picture of the entire process of blood coagulation using whole blood and so enables them to target therapy appropriately. This reduces the risk associated with unnecessary blood transfusions, helps to manage blood stocks and can help with early identification of patients that require repeat surgery.

Management of major haemorrhage

The management of major haemorrhage within the NHS is variable. During the development of this resource, NICE has been shown protocols developed by local transfusion committees, in collaboration with clinicians and laboratory staff, which are reported to help improve the consistency of diagnosis and treatment.

Such protocols and algorithms detail a step-by-step approach to the emergency treatment of major haemorrhage and usually include guidance on each element within the process. They are aimed at guiding the following staff:

  • the attending doctor or nurse who may be the first person to recognise the need to activate the protocol.

  • senior clinical staff called as part of the emergency response or resuscitation team.

  • laboratory staff and other supporting services within the hospital, such as porters and managers.

The current treatment of massive haemorrhage usually includes the transfusion of large volumes of blood and blood components based upon a protocol-driven approach. However, the North West Regional Blood Transfusion Committee has highlighted some potential concerns relating to this approach, as detailed below.

Pros and cons of formula-driven massive transfusion protocols

Pros

May reduce mortality from bleeding.

May improve speed of delivery of blood components.

Reduced communications back and forth between clinical area and lab.

May target and prevent onset of coagulopathy.

Reduce dependency on lab testing in acute resuscitation phase.

Cons

Based on level III and IV evidence mainly in major trauma.[a]

Exposure to additional units of fresh frozen plasma and platelets will increase risk of complications such as transfusion-related acute lung injury, organ failure, thrombosis and sepsis[b].

Inappropriate triggering of formula-driven care in non-massive transfusion patients.

Increased wastage of fresh frozen plasma and platelets.

Depletion of platelet and plasma stocks.

[a] Callum JL, Nascimento B, Tien H, Rizoli S Editorial: "Formula-Driven" Versus "Lab-Driven" Massive Transfusion Protocols: At a State of Clinical Equipoise Transfusion medicine Reviews 2009 23 247-254

[b] Inaba K, Branco BC, Rhee P, Blackbourne LH, Holcomb JB, Teixeira PG, Shulman I, Nelson J, Demetriades D. Impact of plasma transfusion in trauma patients who do not require massive transfusion. J Am Coll Surg. 2010 Jun;210(6):957-65

As can be seen in the Insights from the NHS section, by including the use of viscoelastometric point-of-care testing as part of major haemorrhage protocols, clinicians may be able to address some of the issues listed above. The administration of blood components can be guided by the early results, the risks reduced, wastage minimised and the management of blood stocks improved.

The North West Regional Blood Transfusion Committee has carried out work to produce a massive haemorrhage toolkit for hospital transfusion teams and committees. The toolkit includes flow charts outlining the management of massive haemorrhage in adults and children and a 7-step guide to coordinating the response. The flow charts and guide can be downloaded from the website and adapted by NHS trusts to meet their individual requirements and local needs.

Summary of NICE recommendations

Diagnostics Guidance 13: evaluated 3 viscoelastometric point-of-care testing devices (ROTEM, TEG and Sonoclot systems) used to help detect, manage and monitor haemostasis. The guidance states:

1.1 The ROTEM system and the TEG system are recommended to help detect, manage and monitor haemostasis during and after cardiac surgery. Healthcare professionals using these systems surgery should have appropriate training and experience with these devices.

1.2 The Sonoclot system is only recommended for use in research to help detect, manage and monitor haemostasis during and after cardiac surgery. Research is recommended into the clinical benefits and cost effectiveness of using the Sonoclot system during and after cardiac surgery.

1.4 There is currently insufficient evidence to recommend the routine adoption of viscoelastometric point-of-care testing (ROTEM, TEG and Sonoclot systems) in the NHS to help detect, manage and monitor haemostasis in the emergency control of bleeding after trauma and during postpartum haemorrhage. Research is recommended into the clinical benefits and cost effectiveness of using viscoelastometric point-of-care testing to help in the emergency control of bleeding after trauma or during postpartum haemorrhage.

Tips for adopting viscoelastometric point-of-care testing

Tips for NHS trusts thinking about adopting or carrying out research into viscoelastometric point-of-care testing:

  • Consider the implementation of viscoelastometric point-of-care testing as part of a wider patient blood management approach. See North Manchester General Hospital case study for more details.

  • Include the use of viscoelastometric point-of-care testing as part of a major haemorrhage protocol. Specific protocols may need to be developed depending upon whether viscoelastometric testing is or is not available.

  • Develop local protocols that include the use of viscoelastometric testing within the chosen patient pathways, such as cardiothoracic surgery. See The Royal Brompton case study for more details.

  • Plan where the device will be situated to ensure that this is both convenient and that the environment is suitable (equipment can be sensitive and care needs to be taken regarding its location).

  • Have a number of named people as champions for the technology who can be designated as 'super-users'. They will act as the main points of contact for the manufacturer and will be responsible for day-to-day management and problem solving.

  • Ensure that the number of staff selected to perform tests will allow them to maintain their skills and knowledge regarding the equipment and the procedure. Carrying out these tests requires basic laboratory skills such as pipetting and the use of reagents. Although these skills can be taught in a relatively short period, staff will need to maintain their skills through regular use of the technology. See Education for further details.

  • Ensure that clinicians are fully educated in the interpretation of results and in their application to practice. Interpretation can depend on the test used and the population being tested. It is important for clinicians to use these skills on a regular basis to maintain quality. See North Manchester General Hospital case study for more details.

  • Ensure that trust laboratories and the point-of-care committee are included in all decisions regarding purchase of equipment, maintenance and quality control schemes. See Quality control for more information.

  • In order to demonstrate continued cost savings, conduct regular audits of blood component usage. See Golden Jubilee National Hospital or North Manchester General Hospital for examples.

For more information refer to Insights from the NHS for the experiences of NHS trusts currently using viscoelastometric point-of-care testing.


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