Is earlier better? When it comes to administering a lifesaving intervention, studies are showing that blood products are more effective when administered before hospital.
Among medically evacuated US military combat causalities in Afghanistan, blood product transfusion prehospital or within minutes of injury was associated with greater 24-hour and 30-day survival than delayed transfusion or no transfusion. Time to initial transfusion, regardless of location (prehospital or during hospitalization), was associated with reduced 24-hour mortality only up to 15 minutes after MEDEVAC rescue. (https://pubmed.ncbi.nlm.nih.gov/29067429/).
The Prehospital Air Medical Plasma (PAMPer), considered to be a landmark study, showed that plasma transfusions were safe and resulted in a 30% reduction in mortality, lower median prothorombin ration, and improved survival compared to standard resuscitation. (https://www.nejm.org/doi/full/10.1056/NEJMoa1802345).
Even in systems where there are transport times of 8-10 minutes, prehospital blood transfusions are yielding a marked decrease in mortality at 24 hr and total in-hospital mortality. (https://pubmed.ncbi.nlm.nih.gov/38189675/).
What do the experts say about establishing a program?
A joint consensus opinion by the American College of Surgeons Committee on Trauma, the American College of Emergency Physicians, and the National Association of EMS Physicians highlights points of consensus (https://www.tandfonline.com/doi/full/10.1080/10903127.2023.2195487#d1e189
- Bleeding control must be achieved or attempted for life-threatening hemorrhage
- Blood products should be used when available
- Update local protocols based on a performance improvement process.
- Ongoing continuing education to reinforce initial training skills is strongly encouraged
The Trauma Hemostasis and Oxygenation Research (THOR) (https://rdcr.org/) and The American Association of Blood Bankers (AABB) ( https://www.aabb.org/home ) provided a framework for implementation of prehospital blood programs using a 4 Pillar approach (https://pubmed.ncbi.nlm.nih.gov/34669564/):
- Rationale for the Use, and Description, of Blood Products That Can be Transfused in the Prehospital Setting
- Storage of Blood Products Outside of the Hospital Blood Bank and How to Move Them to the Patient in the Prehospital Setting
- Prehospital Transfusion Criteria and Administration Personnel
- Documentation of Prehospital Transfusion and Hand Over to the Hospital Team
Is there a Cost- benefit to implementing a prehospital blood program?
A secondary analysis of PAMPer identified that prehospital thawed plasma during air medical was cost-effective with an incremental cost-effectiveness ratio of $50 467.44 per QALY compared with standard care (https://www.ncbi.nlm.nih.gov/pmc/articles/PMC8459310/).
An accounting analysis suggests that by Year 10 of a ground ambulance whole blood transfusion program, the average cost to save a life will be approximately US$5,136.51.
(https://www.cambridge.org/core/journals/prehospital-and-disaster-
medicine/article/abs/epidemiological-and-accounting-analysis-of-ground-ambulance-whole-
blood-transfusion/B1B5CB6AE061A4B2436AFB3DFC74F033)
Where can I find examples of “How” to do prehospital blood?
There is no “one size fits all” approach. The following describe processes which worked best for their system. Using the 4 pillars outlined in the THOR-AABB Working Group Recommendations for a Prehospital Blood Product Transfusion Program, a ground-based agency in Maryland successfully
implemented a program. https://onlinelibrary.wiley.com/doi/10.1002/emp2.13142.
South Texas used a regional approach when implementing LTOWB to HEMS and ground agencies. https://academic.oup.com/milmed/article/186/Supplement_1/391/6119408
Seattle Fire Department EMS receives their blood through a Level 1 Trauma Center (https://doi.org/https://doi.org/10.1111/trf.17018).
Northeast Georgia Level II Trauma Center supports three rural EMS agencies
(https://doi.org/10.1177/00031348231157833).
Being good stewards of the blood is a critical element of any prehospital blood program. San Antonio Fire Department looks at stewardship in a large urban Fire-Based EMS system (https://doi.org/10.1080/10903127.2021.1992052).
Who is the regulatory body responsible for the blood system in the United States?
The Code of Federal Regulations (CFR) Title 21, “Food and Drugs”, gives the FDA authority over US blood banks and defines many requirements for them. (https://www.ecfr.gov/current/title-21/chapter-I/subchapter-F/part-640). Circular of Information for the Use of Human Blood and Blood Components. On March 22, 2022 FDA issued guidance formally recognizing the December 2021 Circular as an “extension of labeling” which provides specific instructions for the administration and use of blood and blood components intended for transfusion as required in 21 CFR 606.122 (https://www.aabb.org/news-resources/resources/circular-of-information.)
Credit: Dr. Randall M. Schaefer (Lieutenant Colonel, US Army, Retired), DNP, RN, ACNS-BC, CEN
