Clinical Documentation

Massive Transfusion Protocol (MTP)

Posted on Nov 1, 2021 in Clinical Documentation | 0 comments

The Summit campus will go live with Massive Transfusion Protocol (MTP) procedures at ~9AM on 11/10/21.  Below is a brief overview of the MTP process versus orders for uncrossmatched emergency release RBC’s and STAT crossmatched RBC’s.  Educational information can also be found at the Massive Blood Transfusion Education Site:

When to use an MTP: 

  • Transfusion of greater than 5 units of RBC in 1 hour
  • Loss or anticipated loss of 1 blood volume within 24 hrs or 50% of blood volume in 3 hrs
  • Bleeding rate  ≥ 150 mL/minute

Activate MTP by calling the Blood Bank (x6563), then place MTP order in Epic

When an MTP is ordered:

  • The blood bank staff stops working on all other orders
  • Prepares packages of blood/blood components per chart below, until MTP is deactivated
Package #Blood Components included
14 RBCs, UNXM or XM, Type O or Type compatible1 Plateletpheresis
24 RBCs, UNXM or XM, Type O or Type compatible4 Plasma (Type AB, A, or Type compatible)2 pre-pooled Cryo (or 10 single Cryo)
34 RBCs, UNXM or XM, Type O or Type compatible4 Plasma (Type AB, A, or Type compatible)1 Plateletpheresis
 Continue with Package 2, 3, 2…….

                **UNXM = Uncrossmatched, XM = Crossmatched

  • Benefits of MTP packages:
    • More timely availability of blood/blood products
    • Maintains 1:1 RBC:Plasma ratio for adequate coagulation
  • Do NOT deviate from established MTP packages à may not get desired benefits noted above; causes confusion for Blood Bank staff (non-standard workflow, question if MTP is needed)
  • Must bring patient ID label to Blood Bank to pick up products
  • Call Blood Bank to deactivate MTP when physician determines MTP can be halted, to minimize wastage of thawed plasma/cryo. 

For Urgent non-MTP blood release:  Call Blood Bank

  • If only UNXM PRBCs are needed, do not activate MTP.  Call Blood Bank to request emergency released UNXM PRBCs and place order for Emergency Blood.  PRBC units will be available just as quickly as those ordered as part of an MTP.
  • If XM PRBCs are needed, order STAT T&C.  Depending on the blood bank testing already done (and the antibody screen is negative), units will be available as follows:
Testing doneUnits available
T&S and ABO recheck~ 15 minutes
T&S only~ 20 minutes after ABO recheck sample received in blood bank
No testing~ 1 hour

Placing an Order for MTP in Epic

1.  Access the Blood Navigator.  You may need to look under More.

2. At the top of the Blood Navigator, check Massive Transfusion and click Open Order Sets

Sutter Community Connect

Posted on Sep 2, 2021 in Clinical Documentation | 0 comments


Posted on Mar 2, 2018 in Clinical Documentation | 0 comments

The central line bundle will be followed. Refer to Infection Control “Central Line Associated Blood Stream Infections (CLABSI) Prevention Bundle” policy.

During insertion of the central line, the nurse will assist the physician and observe adherence to practices indicated in the Central Line Insertion Procedure (CLIP) checklist. The nurse will document in the e.H.R. CLIP checklist.

For PICC insertions, the PICC nurse will document in the e.H.R. CLIP checklist.

Prior to insertion of a CVC, patients and/or families are educated about CLABSI prevention.

When a line-related infection is suspected and cultures are indicated, refer to “Specimen: Culturing of Vascular Access Device” policy.

Veronica Bargas, RN

Kudos to Physicians with Excellent Verbal Order Signing Compliance

Posted on Jan 10, 2018 in Clinical Documentation | 0 comments

Universal Protocol Implementation

Posted on Oct 10, 2017 in Clinical Documentation | 0 comments

On behalf of Dr. Stephen Lockhart, MD, PhD, Chief Medical Officer, Sutter Health

Effective September 19, 2017, a new enhanced Universal Protocol was implemented in all Acute Care Hospitals and Ambulatory Surgery Centers that affect clinicians in surgical and non-surgical areas where invasive procedures are performed.

In 2016, an increased trend of wrong patient, wrong procedure, and wrong site events was identified within the Sutter system.  As a result, representatives from across the system came together to create a model process so that every patient will experience the same highly reliable process, every time, no matter where they undergo an invasive procedure in Sutter Health.

The Universal Protocol provides a process to ensure staff and providers catch potential errors before, during, and after the procedure. That way we ensure our patients receive the safest care.

We do many invasive procedures in non-surgical areas and the risk of having a ‘wrong’ event is as great in these locations. Therefore, these safety standards apply in all care areas where invasive procedures are performed. We understand that you and your team may have never experienced one of these events. The goal of the Universal Protocol is to ensure you never have to, because that pain is something no patient, no team, and no individual provider should have to endure.

Thank you for your support and active participation in these efforts to eliminate patient harm by incorporating these new expectations into your standard work.  Please note the following enhancements:

The Anesthesiologist signs the block site with the letter ‘B’ circled (see attachment for example)

  • The Anesthesiologist leads the team in the Sign-In
  • The Proceduralist marks the site in the pre-op area with their initials, or on body diagram
  • The Proceduralist leads the team in the Time-Out
  • The Registered Nurse leads the Sign-Out

With your support we can ensure that these ‘Wrong’ events become ‘Never’ events at Sutter Health and we can fulfill the trust our patients place in us when they select us to provide their care.

The below infographic highlights several key expectations incorporated into the new Universal Protocol 3 step process – Sign In; Time Out; Sign Out.  Please take a moment to review the highlighted areas on the attached document.






















Stephen Lockhart, MD, PhD
Chief Medical Officer, Sutter Health

Clinical Documentation Improvement CDI Update

Posted on Apr 7, 2017 in Clinical Documentation | 0 comments

In the past year there has been noticeable improvement in physician clinical documentation.

By this I mean that our documentation is more precise as more of us indicate Acuity, Co-Morbidities, Linkage and Specificity for each diagnosis. (I call this mnemonic “the other ACLS”).

For example: in the case of your patient with COPD who uses oxygen at home and is a CO2 retainer who is admitted because of increasing dyspnea, worse ABG, unchanged CxR, you would document “acute on chronic hypoxemic and hypercarbic respiratory failure due to an acute exacerbation of COPD”.

In order to build on this improvement trend, Sutter has contracted with Nuance Corporation to assist physicians with ongoing clinical documentation optimization. The service is in the form of CDI queries—these are similar to the existing Sutter CDI queries, with a somewhat simplified format. For now, you might see both types of CDI queries. You will find these queries in the “progress note” section in EPIC. The important thing is to answer the queries promptly, so remember to check your inbox for unanswered queries before you go off service. (CDI queries are usually generated while the patient is still in the hospital, whereas coding queries are sent by coding personnel and are created after discharge).

 I cannot overstate how much physician documentation matters—it’s the way we convey how ill our patients are and verifies our treatments and our patients’ clinical progress. Our documentation also affects assignment of proper DRGs, severity of illness and risk of mortality scores and observed:expected calculations and other quality metrics.

 CDI queries can serve as educational reminders to make sure our documentation is as accurate and complete as possible.

 From Merry Beth Gong, MD, CDI Physician Champion