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Q Bulletin, Volume 1, No. 32 (Supplement 1), Jan - Dec 202412th National QA Convention, 8 %u2013 10 October 2024QLL-117Augmentation of the Massive Transfusion Protocol at Hospital Tengku AmpuanRahimah: Cost and Care BenefitsAnis Zarina Z, Afif AF, Nafishah AJabatan Perubatan Transfusi Darah, Hospital Tengku Ampuan Rahimah, SelangorSELECTION OF OPPORTUNITIES FOR IMPROVEMENT:Massive transfusion is a critical, life-saving process for actively bleeding patients receiving large volumesof blood products promptly. The Massive Transfusion Protocol (MTP) is designed to standardise theworkflow among clinician and transfusion service, aiming for clear communication and efficient deliveryof products to the patient while minimising wastage.KEY MEASURES FOR IMPROVEMENT:MTP was first practiced at Hospital Tengku Ampuan Rahimah in 2013. However, several issues havearisen, including delays in blood samples reaching the laboratory, inefficiencies in the activation anddeactivation and wastage of returned blood products.PROCESS OF GATHERING INFORMATION:Manually written data, digital Blood Bank Information System records of laboratory testing and feedbackfrom clinician during annual Hospital Transfusion Committee meeting.ANALYSIS AND INTERPRETATION:Data was collected and analysed from 2018-2022 and the number of blood products returned compared tothe number of blood products supplied ranged from 3.5% to 25.4%, depending on the type of bloodproduct. The cost for returned blood products was highest in 2019 reaching RM5580.STRATEGIES FOR CHANGE:Discussions were held among the transfusion service and other clinicians to strengthen the workflow,resulting in a revised version of protocol in 2023. Training and distribution of the revised MTP guidelinewere done. Key Performance Indicators such as time-interval between MTP activation and sample arrival,timing of blood products issuance, quantity of blood products returned and timing of MTP deactivationwere included in the guideline as a tool to gauge each MTP activation and improve performance.EFFECT OF CHANGE:After six months of implementation, the blood products returned and wastage had decreased by 50%compared to previous years and successfully saved about RM1450. The clinician reported that the MTPprocess was more streamlined with the implementation of the revised protocol.THE NEXT STEP:A yearly clinical review shall be conducted to monitor and ensure the judicious use of blood products andto identify the protocol%u2019s weakness for continuous improvement.209 | Page