Table 1 Developing a preparedness plan for trauma and critical bleeding

Challenges

• Access to high-quality science upon which to design a transfusion policy. Clinical studies are needed to rapidly and reliably predict which patients will need large-volume transfusion support; and to evaluate laboratory-guided versus ratio-based transfusion.

• Access to resources needed for creating, implementing, monitoring, and updating the protocol.

• Access to information technology resources needed to execute rapid, large-volume transfusion.

• Access to resources required to train and educate a wide variety of staff including physicians, nurses, operating room and blood bank staff, and administrators. Ongoing training is needed especially in areas where trauma care is not a routine occurrence.

• Access to equipment required for delivery of urgent large-volume transfusion.

• Access to sufficient blood supply. Smaller hospitals may not be able to stock sufficient blood for large-volume resuscitation. The distance from the regional supplier may cause depletion of local blood stocks and threaten appropriate blood support of other patients. Transfusion policies that assign O-negative red blood cells and AB plasma to trauma patients may deplete regional reserves of these uncommon blood groups.

• Governance/agreement between multiple parties with different perspectives. Policies need hospital executive support and agreement by a variety of stakeholders from different departments. Clinicians involved in policy-making need a systems perspective in addition to that representing individual patient care.

Practical considerations

• Communication between the clinical team, the blood bank, the laboratory, and treatment locations (emergency room, operating room, interventional radiology suite, and so forth) of critical stages in the patient's treatment.

• Rapid assessment of patients who are at risk for critical bleeding.

• Efficient and useful mechanisms for notification of key hospital services required for delivery of urgent transfusion support.

• Proper patient and specimen identification for unconscious patients.

• Adequate large-bore catheter venous access.

• Early administration of antifibrinolytic agents.

• Policy for immediate release of uncrossmatched red blood cells.

• Rapid delivery of a properly labeled patient sample for ABO/Rh.

• Policy for waiving restrictions on special blood component attributes (for example, irradiated blood or cytomegalovirus-seronegative blood).

• Organized, sequential delivery of additional red blood cells, fresh frozen plasma, and platelets to the patient's location.

• Laboratory, nursing, and messenger staff allocations.

• Rapid turnaround systems for laboratory testing of hematology, coagulation, and critical metabolic parameters.

• Plan for inventory restocking with regional blood supplier.

• Development of predefined guidelines on when to withdraw support.

Process improvement

• Inclusion of all relevant participants including nonclinical participants (for example, porter services, managers of equipment and supply).

• Practice runs that simulate as much as possible actual trauma events.

• Periodic process review, critique, and change.

• Data collection including blood product wastage, especially O-negative red blood cells and AB plasma.

• Periodic assessment of spillover effects upon nontrauma patients whose transfusion care is altered as a consequence of the policy used to support trauma patients with critical bleeding.