Did interventions in a massive transfusion protocol program change transfusion practice?

Abstract

Abstract Current literature supports improved clinical outcomes in the setting of trauma when a Massive Transfusion Protocol (MTP) adheres to transfusion at, or close, to a 1:1 ratio (RBC:Plasma). At our institution, between 2008 and 2015, the number of MTP activations increased ten-fold, accompanied by increased wastage of blood products and stress on the transfusion service. In response, in 2016-2018, we undertook an extensive root-cause analysis, and deployed multiple interventions, including clinician education and multiple process changes to the MTP, which succeeded in reining in inappropriate activation of the MTP, as we have previously published. Heretofore, we have not addressed whether these interventions also affected the ratio of blood products transfused during MTPs activated at our institution. Here, we test the hypothesis that the changes deployed in 2016-2018 were associated with improved adherence to the desired 1:1 ratio. The study is a retrospective analysis of massive transfusion data collected from 2008 to 2022. We reviewed RBC and Plasma units transfused to all patients receiving blood products through the MTP during this period. All patients transfused seven or more RBC and/or Plasma units following MTP activation were included in the study (total n = 443). Activations were classified by year. For each patient, the (RBC:Plasma) ratio transfused was calculated and assessed for adherence to a 1:1 ratio, with a ratio of 2:1 or greater classified as “suboptimal”. Our institution does not use Whole Blood. MTP usage at our institution gradually increased from 2008, when the MTP was established, to 2016, when the MTP procedure was revised. Suboptimal transfusion ratios (RBC:Plasma) also increased from 2008-2016. Between 2008 and 2013, 15% of patients received suboptimal ratios following MTP activation. In 2014-2016, suboptimal ratios were observed in 25% of MTPs. Following multiple interventions, the frequency of MTP activation dropped precipitously, as described, and was accompanied by a decrease in the percentage of suboptimal ratios; in 2020 to 2022, 11% of MTPs involving seven or more transfused units had a suboptimal ratio. In summary, the dramatic increase in activations of the MTP observed between 2008 and 2016 at our medical center was accompanied by an increase in suboptimal RBC:Plasma transfusion ratios. Interventions deployed between 2016 and 2018 led not only to reduced blood wastage, and lower stress of BB staff, but also to improved adherence to best transfusion practices, in the form of appropriate (RBC:Plasma) ratios transfused during MTPs.