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INTRODUCTION: Whole blood resuscitation has reemerged as a resuscitation strategy for injured patients. However, the effect of whole blood-based resuscitation on outcomes has not been established. The primary objective of this guideline was to develop evidence-based recommendations on whether whole blood should be considered in civilian trauma patients receiving blood transfusions. METHODS: An EAST working group performed a systematic review and meta-analysis utilizing the GRADE methodology. One PICO question was developed to analyze the effect of whole blood resuscitation in the acute phase on mortality, transfusion requirements, infectious complications, and ICU length of stay. English language studies including adult civilian trauma patients comparing in-hospital whole blood to component therapy were included. Medline, Embase, Cochrane CENTRAL, CINAHL Plus, and Web of Science were queried. GRADEpro was used to assess quality of evidence and risk of bias. The study was registered on PROSPERO (#CRD42023451143). RESULTS: A total of 21 studies were included. Most patients were severely injured and required blood transfusion, massive transfusion protocol activation, and/or a hemorrhage control procedure in the early phase of resuscitation. Mortality was assessed separately at the following intervals: early (i.e., ED, 3-, or 6-hour), 24-hour, late (i.e., 28- or 30-day), and in-hospital. On meta-analysis, whole blood was not associated with decreased mortality. Whole blood was associated with decreased 4-hour RBC (mean difference -1.82, 95% CI -3.12 to -0.52), 4-hour plasma (mean difference -1.47, 95% CI -2.94 to 0), and 24-hour RBC transfusions (mean difference -1.22, 95% CI -2.24 to -0.19) compared to component therapy. There were no differences in infectious complications or ICU length of stay between groups. CONCLUSION: We conditionally recommend WB resuscitation in adult civilian trauma patients receiving blood transfusions, recognizing that data are limited for certain populations, including women of childbearing age, and therefore this guideline may not apply to these populations. LEVEL OF EVIDENCE: Level III, Guidelines.
RESUMEN
QUALITY PROBLEM: The timing and pace of patient discharges are not level-loaded throughout the day at many institutions including ours, an academic medical center and adult Level I trauma center located in Milwaukee, Wisconsin. INITIAL ASSESSMENT: Only 4% of patients were being discharged with rooms marked dirty by 11 AM at our institution. CHOISE OF SOLUTION: We put together a multidisciplinary team of approximately 30 stakeholders to develop a revised process that focused on coordination of discharge activities, plan of care awareness among team members, and communication with patients and families. IMPLEMENTATION: The discharge process was piloted and iteratively adjusted on a single medicine floor. EVALUATION: Our interventions made a noticeable impact on median room "ready to be cleaned" (RTBC) time without having an adverse impact on length of stay. RTBC improved by a median of 39 minutes (P = 0.019), and the proportion of rooms ready to be cleaned by 11 AM increased from 4.19% to 8.13%. LESSONS LEARNED: Having a multidisciplinary team participate in the evaluation and development of a new process was critical. Additionally, implementing solutions on a single unit allowed for rapid iteration of changes.
