Development of a national out-of-hospital transfusion protocol: a modified RAND Delphi study

Assessing the one-month mortality impact of civilian-setting prehospital transfusion: A systematic review and meta-analysis

BACKGROUND

Based on convincing evidence for outcomes improvement in the military setting, the past decade has seen evaluation of prehospital transfusion (PHT) in the civilian emergency medical services (EMS) setting. Evidence synthesis has been challenging, due to study design variation with respect to both exposure (type of blood product administered) and outcome (endpoint definitions and timing). The goal of the current meta-analysis was to execute an overarching assessment of all civilian-arena randomized controlled trial (RCT) evidence focusing on administration of blood products compared to control of no blood products.

METHOD

The review structure followed the Cochrane group's Preferred Reporting Items for Systematic Review and Meta-Analysis (PRISMA). Using the Transfusion Evidence Library (transfusionevidencelibrary.com), the multidatabase (e.g. PubMed, EMBASE) Harvard On-Line Library Information System (HOLLIS), and GoogleScholar, we accessed many databases and gray literature sources. RCTs of PHT in the civilian setting with a comparison group receiving no blood products with 1-month mortality outcomes were identified.

RESULTS

In assessing a single patient-centered endpoint-1-month mortality-we calculated an overall risk ratio (RR) estimate. Analysis of three RCTs yielded a model with acceptable heterogeneity (I2 = 48%, Q-test p = 0.13). Pooled estimate revealed civilian PHT results in a statistically nonsignificant (p = 0.38) relative mortality reduction of 13% (RR 0.87, 95% CI 0.63-1.19).

CONCLUSIONS

Current evidence does not demonstrate 1-month mortality benefit of civilian-setting PHT. This should give pause to EMS systems considering adoption of civilian-setting PHT programs. Further studies should not only focus on which formulations of blood products might improve outcomes but also focus on which patients are most likely to benefit from any form of civilian-setting PHT.

A comparative analysis of current out-of-hospital transfusion protocols to expert recommendations

Aim

This study aimed to compare current out-of-hospital transfusion (OHT) protocols in Canadian civilian critical care transport organizations (CCTO) to expert recommendations and explore the variability and potential benefits of standardizing OHT practices across Canada.

Methods

A comprehensive cross-sectional study was conducted, encompassing all seven Canadian CCTOs that provide OHT. The study assessed adherence to expert recommendations and examined specific aspects of the transfusion process, such as indications for transfusion and cessation criteria.

Results

The study found an 89% adherence to expert recommendations for OHT among Canadian CCTOs. It highlighted a strong alignment between current practices and recommendations, possibly attributed to collaborative frameworks like the CAN-PATT network. However, notable variability and ambiguity were observed in transfusion indications and cessation criteria. The study also emphasized the potential benefits of standardizing OHT practices, such as improved policy formulation, better interpretation of emerging literature, and evaluation of OHT efficacy.

Conclusion

This cross-sectional study assessed how Canadian CCTOs implement OHT practices compared to expert-recommended practices. The findings underscore the importance of structured protocols in trauma management. Given the consistency in OHT protocol adoption and the comprehensive approach across CCTOs, there's a solid foundation for managing trauma patients in prehospital and transport settings across Canada. As OHT practices continue to evolve, sustained efforts are vital to refine, adapt, and elevate patient care standards in trauma management.

Current state of technical transfusion medicine practice for out-of-hospital blood transfusion in Canada

BACKGROUND AND OBJECTIVES

Canadian out-of-hospital blood transfusion programmes (OHBTPs) are emerging, to improve outcomes of trauma patients by providing pre-hospital transfusion from the scene of injury, given prolonged transport times. Literature is lacking to guide its implementation. Thus, we sought to gather technical transfusion medicine (TM)-specific practices across Canadian OHBTPs.

MATERIALS AND METHODS

A survey was sent to TM representatives of Canadian OHBTPs from November 2021 to March 2022. Data regarding transport, packaging, blood components and inventory management were included and reported descriptively. Only practices involving Blood on Board programme components for emergency use were included.

RESULTS

OHBTPs focus on helicopter emergency medical service programmes, with some supplying fixed-wing aircraft and ground ambulances. All provide 1-3 coolers with 2 units of O RhD/Kell-negative red blood cells (RBCs) per cooler, with British Columbia trialling coolers with 2 units of pre-thawed group A plasma. Inventory exchanges are scheduled and blood components are returned to TM inventory using visual inspection and internal temperature data logger readings. Coolers are validated to storage durations ranging from 72 to 124 h. All programmes audit to manage wastage, though there is no consensus on appropriate benchmarks. All programmes have a process for documenting units issued, reconciliation after transfusion and for transfusion reaction reporting; however, training programmes vary. Common considerations included storage during extreme temperature environments, O-negative RBC stewardship, recipient notification, traceability, clinical practice guidelines co-reviewed by TM and a common audit framework.

CONCLUSION

OHBTPs have many similarities throughout Canada, where harmonization may assist in further developing standards, leveraging best practice and national coordination.