BACKGROUND: Massive transfusion (MT) protocols improve survival in patients with exsanguinating hemorrhage. Both the increased plasma to red blood cells (RBC) and platelets to RBC ratios, and the "protocolization" of product delivery seem to be critical components of the reduction in mortality. The purpose of this study was to identify the incidence and impact of MT protocol noncompliance and to intervene in provider-related events associated with poor compliance and outcomes. METHODS: A MT protocol was initiated in 2006 at a Level I trauma center. All cases of protocol activation were reviewed by a multidisciplinary performance improvement (PI) group for compliance and the need for "real-time" protocol adjustments. Educational conferences, Grand Rounds presentations, and individual provider education were performed on a quarterly basis. Compliance of seven measures were evaluated as follows: type and screen sent from emergency department (ED), activation of protocol in ED, activation by trauma attending, administration of 2:3 plasma to RBC, administration of 1:5 platelets to RBC, protocol discontinuation on leaving operating room, and no products wasted. Univariate, multivariate, and time-series analyses were performed. RESULTS: All 125 MT protocol activations occurring from February 2006 to January 2008 were reviewed. Full compliance for all PI measures during the entire period was 27%. There were no differences in demographics, injury severity, or physiologic scores between patients for whom activations were compliant and those who were noncompliant. Full compliance was an independent predictor of survival (86.7% vs. 45.0%, p < 0.001). Both activation of the protocol in the ED and achievement of prespecified ratios of plasma: RBC (2:3) and platelets: RBC (1:5) were independent predictors of 24-hour and 30-day survivals. All PI measures demonstrated improved compliance during the study period with the exception of ED activation. Failure to send type and screen from the ED is an independent predictor of wasted blood products. CONCLUSION: Early activation of a MT protocol and achieving predefined ratios was associated with improved survival. ED activation and direct blood bank notification by the trauma attending were associated with a reduction in blood product wastage. A multidisciplinary PI process helps to identify provider/specialty noncompliance and to assess the impact of these factors, and it was associated with improvement in compliance and MT outcomes over time.
BACKGROUND: Massive transfusion (MT) protocols improve survival in patients with exsanguinating hemorrhage. Both the increased plasma to red blood cells (RBC) and platelets to RBC ratios, and the "protocolization" of product delivery seem to be critical components of the reduction in mortality. The purpose of this study was to identify the incidence and impact of MT protocol noncompliance and to intervene in provider-related events associated with poor compliance and outcomes. METHODS: A MT protocol was initiated in 2006 at a Level I trauma center. All cases of protocol activation were reviewed by a multidisciplinary performance improvement (PI) group for compliance and the need for "real-time" protocol adjustments. Educational conferences, Grand Rounds presentations, and individual provider education were performed on a quarterly basis. Compliance of seven measures were evaluated as follows: type and screen sent from emergency department (ED), activation of protocol in ED, activation by trauma attending, administration of 2:3 plasma to RBC, administration of 1:5 platelets to RBC, protocol discontinuation on leaving operating room, and no products wasted. Univariate, multivariate, and time-series analyses were performed. RESULTS: All 125 MT protocol activations occurring from February 2006 to January 2008 were reviewed. Full compliance for all PI measures during the entire period was 27%. There were no differences in demographics, injury severity, or physiologic scores between patients for whom activations were compliant and those who were noncompliant. Full compliance was an independent predictor of survival (86.7% vs. 45.0%, p < 0.001). Both activation of the protocol in the ED and achievement of prespecified ratios of plasma: RBC (2:3) and platelets: RBC (1:5) were independent predictors of 24-hour and 30-day survivals. All PI measures demonstrated improved compliance during the study period with the exception of ED activation. Failure to send type and screen from the ED is an independent predictor of wasted blood products. CONCLUSION: Early activation of a MT protocol and achieving predefined ratios was associated with improved survival. ED activation and direct blood bank notification by the trauma attending were associated with a reduction in blood product wastage. A multidisciplinary PI process helps to identify provider/specialty noncompliance and to assess the impact of these factors, and it was associated with improvement in compliance and MT outcomes over time.
Authors: Jeannie L Callum; Calvin H Yeh; Andrew Petrosoniak; Mark J McVey; Stephanie Cope; Troy Thompson; Victoria Chin; Keyvan Karkouti; Avery B Nathens; Kimmo Murto; Suzanne Beno; Jacob Pendergrast; Andrew McDonald; Russell MacDonald; Neill K J Adhikari; Asim Alam; Donald Arnold; Lee Barratt; Andrew Beckett; Sue Brenneman; Hina Razzaq Chaudhry; Allison Collins; Margaret Harvey; Jacinthe Lampron; Clarita Margarido; Amanda McFarlan; Barto Nascimento; Wendy Owens; Menaka Pai; Sandro Rizoli; Theodora Ruijs; Robert Skeate; Teresa Skelton; Michelle Sholzberg; Kelly Syer; Jami-Lynn Viveiros; Josee Theriault; Alan Tinmouth; Rardi Van Heest; Susan White; Michelle Zeller; Katerina Pavenski Journal: CMAJ Open Date: 2019-09-03
Authors: Matthew J Pommerening; Michael D Goodman; John B Holcomb; Charles E Wade; Erin E Fox; Deborah J Del Junco; Karen J Brasel; Eileen M Bulger; Mitch J Cohen; Louis H Alarcon; Martin A Schreiber; John G Myers; Herb A Phelan; Peter Muskat; Mohammad Rahbar; Bryan A Cotton Journal: Injury Date: 2015-02-04 Impact factor: 2.586
Authors: Rachael A Callcut; Bryan A Cotton; Peter Muskat; Erin E Fox; Charles E Wade; John B Holcomb; Martin A Schreiber; Mohammad H Rahbar; Mitchell J Cohen; M Margaret Knudson; Karen J Brasel; Eileen M Bulger; Deborah J Del Junco; John G Myers; Louis H Alarcon; Bryce R H Robinson Journal: J Trauma Acute Care Surg Date: 2013-01 Impact factor: 3.313
Authors: Bryan A Cotton; Neeti Reddy; Quinton M Hatch; Eric LeFebvre; Charles E Wade; Rosemary A Kozar; Brijesh S Gill; Rondel Albarado; Michelle K McNutt; John B Holcomb Journal: Ann Surg Date: 2011-10 Impact factor: 12.969
Authors: Zayde A Radwan; Yu Bai; Nena Matijevic; Deborah J del Junco; James J McCarthy; Charles E Wade; John B Holcomb; Bryan A Cotton Journal: JAMA Surg Date: 2013-02 Impact factor: 14.766
Authors: Mohammad H Rahbar; Deborah J del Junco; Hanwen Huang; Jing Ning; Erin E Fox; Xuan Zhang; Martin A Schreiber; Karen J Brasel; Eileen M Bulger; Charles E Wade; Bryan A Cotton; Herb A Phelan; Mitchell J Cohen; John G Myers; Louis H Alarcon; Peter Muskat; John B Holcomb Journal: J Trauma Acute Care Surg Date: 2013-07 Impact factor: 3.313