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    v1.0.28
    OpenPayerPolicy UpdatesPediatrics/NeonatologyKansas KDHE Pediatric Massive Transfusion Coverage…
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    CurrentKansas Department of Health and EnvironmentPolicy N/A

    Pediatric Massive Transfusion Protocol (PMTP) Coverage Criteria

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    Governs activation and management of a pediatric massive transfusion protocol for patients under 30 kg at MultiCare Health System Mary Bridge Children's Hospital requiring rapid administration of multiple blood components.

    Policy Summary
    PayerKansas Department of Health and Environment
    PolicyPediatric Massive Transfusion Protocol (PMTP) Coverage Criteria
    Policy CodePolicy N/A
    Change TypeNo material changes
    Effective DateN/A
    Next Review DateN/A
    Key ActionPhysician may initiate PMTP when blood loss >30 mL/kg and patient <30 kg and must order the Pediatric Massive Transfusion Order Set in EPIC and notify Transfusion Service.
    SourceLink
    POLICY UPDATE CHANGES

    No material clinical or coverage changes in this revision.

    <30 kgweight threshold
    30 mL/kgbleed threshold
    1 RBC, 1 FFP, 1 PLTcomponent set
    INR<1.7; fibrinogen>100resuscitation goals

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    Do not reissue <4hplatelet timing

    Pediatric Massive Transfusion Protocol Coverage Criteria

    Activation criteria

    Initiation: Covered/authorized when ALL of the following are met

    Activation criteria: A physician directly involved in the care of the patient initiates the Pediatric Massive Transfusion Protocol (PMTP).

    Activation applies to patients <30 kg at the specified facility and requires ordering the 'Pediatric Massive Transfusion Order Set' in EPIC and notifying Transfusion Service.

    Hemorrhage threshold: Patient's blood loss is greater than 30 mL/kg (massive bleed).blood loss >30 mL/kg
    Patient inclusion by weight and site: Patient weight is less than 30 kg and the patient is at the specified facility (MHS Mary Bridge Children's Hospital).weight <30 kg

    Protocol scope limited to patients <30 kg at MHS Mary Bridge Children's Hospital.

    Issuance and repeat sets

    While PMTP is active, repeat the following until canceled by physician or goals met

    Issuance loop: Transfusion Service prepares and issues a set containing 1 PRBC (RBC), 1 thawed plasma (FFP), and 1 platelet component (PLT). A new set will be prepared immediately after each set is issued and repeated after each issue until canceled by the physician.per-set: 1 PRBC, 1 FFP, 1 PLT

    Transfusion Service will verify required orders (TFFP, TPLT, XM) are present; if orders are absent, caller will be asked to place the PMTP order. Ensure someone is sent to transport blood components.

    Platelet issuance restriction: Do not issue a new platelet until the prior platelet component has been completely transfused or 4 hours have passed, whichever comes first.timing: prior PLT complete or 4 hours

    Transfusion Service and clinical staff must track platelet transfusion status.

    Operational requirements: Provider must order the 'Pediatric Massive Transfusion Order Set' in EPIC, assign an RN designee and runner, ensure adequate vascular access, draw required stat specimens (crossmatch and Massive Transfusion Panel), and notify Transfusion Service with patient identifiers and caller contact information.

    Discontinuation and goal-directed resuscitation

    Discontinue PMTP when patient meets resuscitation goals at or around the following:

    End-point goals: INR <1.7; fibrinogen >100 mg/dL; platelets >50,000/μL; hematocrit (HCT) >27%; core temperature >35.9°C; base deficit <5.0.exact values listed

    Continuation of the MTP should be reassessed after each set of blood components.

    Laboratory availability fallback: If laboratory values are available, guide transfusion according to the lab values; if laboratory values are not available or delayed, continue transfusing all components from the MTP until labs can direct therapy.lab availability

    Provides guidance when labs are delayed or unavailable.

    This PMTP applies only to pediatric patients weighing <30 kg treated at MultiCare Health System Mary Bridge Children’s Hospital. Activation is limited to situations meeting the protocol’s massive-bleed threshold of blood loss >30 mL/kg and must be initiated by a physician directly involved in the patient’s care. The protocol is intended specifically to permit rapid ordering and coordinated issuance of multiple blood components at once for these patients and is not intended for use outside the specified facility or patient population.

    Coding and Key Clinical Thresholds

    inv-05: Massive bleed threshold
    Massive bleed threshold> 30 mL/kg
    Context for useUsed as activation threshold for Pediatric Massive Transfusion Protocol (PMTP)
    Associated actionPhysician directly involved in care may initiate PMTP when blood loss >30 mL/kg
    inv-06: Patient weight inclusion
    Patient weight inclusion< 30 kg
    ApplicabilityProtocol applies to patients <30 kg at MultiCare Health System Mary Bridge Children's Hospital only
    Relation to activation

    Provider Orders, Notifications, and Operational Notes

    Prior Authorization

    Activation by treating physician — no prior authorization

    Physician directly involved in the patient’s care may activate the Pediatric Massive Transfusion Protocol (PMTP) without prior authorization when the patient’s blood loss is greater than 30 mL/kg and the patient is <30 kg at the specified facility.

    Step Therapy

    Cryoprecipitate timing — order after second round/threshold

    Order one cryoprecipitate in EPIC after the second round of PMTP blood component sets has been received for transfusion, or after a total transfusion of 2 RBCs, 2 FFP, and 90 mL platelets.

    Documentation Required

    Background and Purpose

    The Pediatric Massive Transfusion Protocol (PMTP) is intended to provide rapid, balanced blood-component resuscitation for pediatric patients <30 kg experiencing a massive hemorrhage (defined as blood loss >30 mL/kg) to reduce intractable coagulopathy. Under the PMTP, Transfusion Service prepares and issues predefined sets of components — typically 1 RBC, 1 thawed plasma (FFP), and 1 platelet component (PLT) per set — with immediate preparation of replacement sets until the physician cancels the protocol or resuscitation goals are reached. Resuscitation should be reassessed after each set and discontinued at or around stated end-points such as INR <1.7; fibrinogen >100 mg/dL; platelets >50,000/µL; HCT >27%, along with core temperature and base deficit targets.

    Definitions and Protocol Components

    inv-12: Blood loss greater than 30 mL/kg
    DefinitionBlood loss greater than 30 mL/kg is defined as a massive bleed
    Use in protocolServes as the primary trigger for initiating the Pediatric Massive Transfusion Protocol (PMTP)
    Combined criteriaMust be present with patient weight <30 kg for PMTP activation
    inv-13: PMTP blood component set
    PMTP blood component setOne RBC, one thawed plasma (FFP), and one platelet component (PLT) per issuance
    Issuance frequencyA new set is prepared immediately after each set is issued until canceled by the physician
    Policy Summary
    PayerKansas Department of Health and Environment
    PolicyPediatric Massive Transfusion Protocol (PMTP) Coverage Criteria
    Policy CodePolicy N/A
    Change TypeNo material changes
    Effective DateN/A
    Next Review DateN/A
    Key ActionPhysician may initiate PMTP when blood loss >30 mL/kg and patient <30 kg and must order the Pediatric Massive Transfusion Order Set in EPIC and notify Transfusion Service.
    SourceLink
    On This Page
    Pediatric Massive Transfusion Protocol Coverage CriteriaCoding and Key Clinical ThresholdsProvider Orders, Notifications, and Operational NotesBackground and PurposeDefinitions and Protocol Components
    orders: TFFP, TPLT, XM present

    If lab monitoring is delayed, follow the protocol guidance for transfusing components when lab values are not yet available.

    Weight <30 kg is required along with blood loss >30 mL/kg for PMTP initiation

    Orders and signatures required — EPIC order, notify Transfusion Service, and required signatures

    Place the 'Pediatric Massive Transfusion Order Set' in EPIC and notify Transfusion Service when activating PMTP; provide patient name (or trauma ID), patient MRN, and name of the physician initiating the MTP. Ensure required orders (TFFP, TPLT, XM) are present and obtain physician signature on the Emergency Request for Uncrossmatched Blood if uncrossmatched RBCs are issued.

    • Notify Transfusion Service of the RN designee name and phone number and send a runner with the blood component pickup slip containing patient name and MRN.
    • Collect and send stat crossmatch and Massive Transfusion Panel specimens as indicated on the MTP Order Set.
    Denial Risk

    Missing orders may prevent issuance — Transfusion Service will request orders

    If PMTP orders (TFFP, TPLT, XM) are absent when Transfusion Service is contacted, Transfusion Service will ask the caller to place the PMTP order; absence of required orders may prevent Transfusion Service from issuing blood component sets.

    Platelet transfusion note
    Transfuse 45 mL for each full RBC unit transfused; do not issue a new platelet until prior platelet fully transfused or 4 hours have passed