Managing Obstetrical Hemorrhage during a Pneumatic Tube System Downtime

The blood bank relocated to a new hospital facility while the labor and delivery (L&D) unit remained in the older facility, which was a 10- to 12-minute walk on the same hospital campus. The pneumatic tube system was the primary blood product transport method; however, the tube system was frequently out of service. The organization recognized a risk to obstetrical patients because it lacked a standardized process for blood product transport when the tube system was unavailable. Additionally, it found that a number of L&D staff was inadequately trained in the massive transfusion protocol (MTP).

The blood bank relocated to a new hospital facility while the labor and delivery (L&D) unit remained in the older facility, which was a 10- to 12-minute walk on the same hospital campus. The pneumatic tube system was the primary blood product transport method; however, the tube system was frequently out of service. The organization recognized a risk to obstetrical patients because it lacked a standardized process for blood product transport when the tube system was unavailable. Additionally, it found that a number of L&D staff was inadequately trained in the massive transfusion protocol (MTP).

The goal was to improve the safety and efficiency of an L&D MTP event and to reduce the turnaround time for blood product receipt if the tube system was unavailable. The organization used unannounced patient care simulations and quality improvement tools such as process mapping and failure modes and effects analysis (FMEA) during implementation. The turnaround time for receiving blood products in L&D decreased by 32 percent by using a runner, from 31 minutes to 21 minutes.

This case study is part of the Illinois Health and Hospital Association's annual Quality Excellence Achievement Awards. Each year, IHA recognizes and celebrates the achievements of Illinois hospitals and health systems in continually improving and transforming health care in the state. These organizations are improving health by striving to achieve the Triple Aim—improving the patient experience of care (including quality and satisfaction), improving the health of populations, and reducing the per capita cost of health care—and the Institute of Medicine's six aims for improvement—safe, effective, patient centered, timely, efficient, and equitable. To learn more, visit https://www.ihaqualityawards.org/javascript-ui/IHAQualityAward/

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