MTP Tabletop Simulation — Thompson Health OR
Facilitator Mode
Phase 1 of 4
Initial Trigger — Transfer from OB

28-year-old post-partum (vaginal delivery) transferred from OB for surgical stabilization of postpartum hemorrhage. Received: TXA, 1 unit PRBC, JADA device on OB — no stabilization. Altered LOC. NRB oxygen running. 2nd unit PRBC nearly complete. Two large-bore IVs.

BP 82/48 HR 142 SpO₂ 91% NRB Altered LOC

Patient is arriving to OR in hemorrhagic shock with active MTP underway.

You are the circulating RN. The patient is arriving from OB in hemorrhagic shock. What are the OR team's immediate priorities?
Actions Required — Receiving the Patient

Critical handoff elements to confirm:

  • MTP is active — do not assume it needs to be reactivated
  • Current products given (how many PRBC, FFP so far)
  • Quantitative blood loss (QBL)
  • IV access status (number, gauge, location)
  • Interventions already attempted (uterotonics, TXA, JADA)
  • Type & Screen status
  • Anesthesia assumes management of hemodynamics and product administration upon patient arrival to OR
  • Product administration documented on anesthesia record
  • Circulating RN supports with verification, documentation, and Blood Bank coordination
  • Circulating RN confirms MTP status, blood product orders/documentation, and T&S status from OB handoff
  • If the OR team needs to activate/continue MTP from OR, activate through the OR workflow/Blood Bank communication; anesthesia provider places needed blood product orders and documents follow-through
  • Confirm Type & Screen status — required for type-specific products
  • CRITICAL SAFETY: If no historical blood type on file, an initial AND confirmatory T&S specimen must be collected at DIFFERENT times. Mislabeled specimens can result in patient death.
  • OR charge coordinates with Blood Bank for cooler pickup
  • Perioperative aide or nursing supervisor assigned as runner
  • Runner sent to Blood Bank with patient label
  • Call Blood Bank x6544: patient name, DOB, MRN, OR location, OR phone number
Phase 2 of 4
Products & Administration in OR

First OR MTP products arrive. The cooler contains cold products only; thawed FFP is released separately/as available. Anesthesia is managing the patient.

First products are here. What does the circulating RN verify? What are the product rules in the OR setting?
Cooler Verification
  • Cooler must be 1–10°C — cannot exceed 10°C
  • Above 10°C: do NOT use products, return entire cooler to Blood Bank
  • Check temperature FIRST before opening or verifying contents
  • Cooler: PRBCs and any Cold Stored Platelets (CSP) — bright yellow sticker
  • FFP is thawed at 37°C and released separately/as available, often 2 units at a time
  • Do not place thawed FFP into the MTP cooler; it can raise the cooler temperature and make PRBCs/CSP unusable
  • Cryoprecipitate AHF issued after 4 FFP

In the OR setting:

  • Two-provider verification before each unit: anesthesia provider and circulating RN
  • Two-patient identifiers verified
  • Tag signed by both providers
  • Emergency release paperwork signed by anesthesia provider
  • Blood Bank actions: emergency release paperwork, specific products prepared, Red Cross notification if needed
  • As remaining products are available, Blood Bank will call for product pickup — Charge RN/circulating RN coordinates the designee
  • It is the OR team's responsibility to delegate a perioperative aide/runner to pick up blood products
  • Vital signs: must be documented at correct frequency during active MTP
  • Product release pattern: 4 PRBC in the cooler, 4 FFP thawed/released separately (often 2 at a time), and 1 dose platelets
  • PRBC and FFP: administer with warmer, can use rapid infuser
  • Documentation/verification before each unit: signed/verified with 2 patient identifiers, tag signed, emergency release paperwork signed by provider
Phase 3 of 4
No Type & Screen in OR

A patient is undergoing surgery and does not have a preoperative Type & Screen drawn. Due to abnormal anatomy, an artery is nicked. Anesthesia wants to preemptively initiate MTP and have 2 units of blood sent.

The danger is not only speed. The OR team has to move quickly while protecting patient identity, specimen collection, emergency release paperwork, and the path toward crossmatched blood.

Special Circumstance — No T&S Available

Anesthesia verbalizes that MTP should be initiated and 2 units of blood should be sent now.

What needs to happen in the room, in eRecord, and with Blood Bank?

Self-guided question
What is the safest OR response when MTP is initiated but no pre-op Type & Screen exists?

✓ The team protects the emergency release and specimen workflow. The OR team activates through Blood Bank communication; anesthesia places blood product/T&S orders. The circulating RN calls x6544, confirms patient information, notifies charge, and labels the pink-top tube with patient sticker plus handwritten date/time/collector initials.

Key points: A perioperative aide runner takes the T&S and a separate patient sticker to the lab, returns with the O-negative cooler, and the aide/circulating RN confirm cooler temperature. Once the first O-negative unit is started, anesthesia draws the confirmatory T&S and the runner takes it to lab with a separate sticker.

Teaching moment: O-negative blood may be necessary, but it does not replace the T&S process. Crossmatched/type-specific units are better for the patient and preserve O-negative supply. The runner needs a patient label and must be able to provide two identifiers to Blood Bank.

Phase 4 of 4
Transfer to ICU & MTP Discontinuation

Surgical bleeding controlled. Decision: patient to ICU post-op. FFP currently infusing. No more products in cooler.

BP 96/60 HR 108
Patient is transferring to ICU with active MTP. What needs to happen before, during, and after transfer?
Transfer to ICU with Active MTP
  • The RN notifies the Charge Nurse, who reaches out to the Nursing Supervisor and OB to notify of ICU status for the patient
  • Anesthesia is notified to discuss with the ICU attending
  • The RN circulator, or Charge RN, requests an ICU bed be brought to the OR for patient transfer with monitors
  • Discuss who is responsible for infusion and documentation of blood products in the intraoperative setting
  • Documentation should be on code documentation or anesthesia documentation (in OR, anesthesia manages)

Transfer team from OR to ICU:

  • Circulating RN
  • Anesthesia provider
  • Anesthesia tech
  • Perioperative aide and/or respiratory therapy

Blood products may continue infusing during transport — ensure IV access and lines are secured.

Both circulating RN and anesthesia give handoff to ICU RN. Required elements:

  • Total products given by type
  • MTP status (still active)
  • Surgical procedure performed
  • Current hemodynamic status and trend
  • Active infusions
  • Total QBL

Patient now in ICU. MTP still technically active. Bleeding is controlled.

MTP needs to be discontinued. Walk through the full process — who does what?
MTP Discontinuation
  • Blood Bank continues preparing products until notified — do not delay this call
  • Provider OR designee (can be the ICU RN) calls x6544 to discontinue
  • This is the most time-critical step
  • Provider closes related blood product orders/documentation in eRecord as appropriate
  • All remaining products returned to Blood Bank
  • MTP cooler returned to Blood Bank
  • Document: total units by product type, MTP start/end time, vital signs at discontinuation
  • MTP paper record (emergency release paperwork, product tags) → sent to medical records
  • Unit tag(s) attached to Blood Bank Cumulative Transfusion Record
  • After discharge: paper record scanned into the medical record
Structured Debrief
Reflection & Discussion

Use these questions to guide the team discussion. In self-guided mode, reflect on each question before moving on.

1. What went well during the OR scenario?
Consider: Was the handoff from OB clear? Did anesthesia and circulating RN coordinate effectively?
2. Where was there difficulty?
Consider: Was it clear who manages what in OR vs. OB? Were verification steps followed under time pressure?
3. Was the policy/process clear for the OR setting?
OR has unique dynamics — anesthesia provider places orders, circulating RN verifies. Were these roles clear?
4. Were roles clearly defined during the transfer?
Who gives the handoff? Who manages infusions during transport? Is the transfer team composition standard?
5. Was the correct process followed in the scenario?
Were verification, documentation, and communication steps done correctly and in the right order?
6. Were the complications caught?
Platelet administration error — did the circulating RN speak up? Cooler temperature — was it checked immediately on arrival?
7. What safety issues or potential safety issues came up?
In the fast-paced OR environment, where are the highest-risk moments for MTP errors?
8. Do current OR workflows align with written guidance? Why or why not?
Does what actually happens during an OR MTP match what CC.03.004 says should happen?
9. What would make MTP easier to execute in the OR?
Pre-assigned perioperative aide as runner? Cooler temp check protocol on arrival? Standardized OR-to-ICU handoff checklist?
Policy Reference

CC.03.004 — Clinical Practice Guideline: Massive Transfusion Process for Adult Patient

Blood Bank: x6544

Post-Simulation Survey
Confidence Check
Before this simulation

How confident were you in your ability to manage an MTP in the OR?

1 = not at all → 5 = very confident
After this simulation

How confident do you feel now in your ability to manage an MTP in the OR?