The Implementation of a Prehospital Whole Blood Transfusion Program and Early Results.

INTRODUCTION: In far-forward combat situations, the military challenged dogma by using whole blood transfusions (WBTs) rather than component-based therapy. More recently, some trauma centers have initiated WBT programs with reported success. There are a few Emergency Medical Service (EMS) systems that are using WBTs, but the vast majority are not. Given the increasing data supporting the use of WBTs in the prehospital setting, more EMS systems are likely to consider or begin WBT programs in the future. OBJECTIVE: A prehospital WBT program was recently implemented in Palm Beach County, Florida (USA). This report will discuss how the program was implemented, the obstacles faced, and the initial results. METHODS: This report describes the process by which a prehospital WBT program was implemented by Palm Beach County Fire Rescue and the outcomes of the initial case series of patients who received WBTs in this system. Efforts to initiate the prehospital WBT program for this system began in 2018. The program had several obstacles to overcome, with one of the major obstacles being the legal team's perception of potential liability that might occur with a new prehospital blood transfusion program. This obstacle was overcome through education of local elected officials regarding the latest scientific evidence in favor of prehospital WBTs with potential life-saving benefits to the community. After moving past this hurdle, the program went live on July 6, 2022. The initial indications for transfusion of cold-stored, low titer, leukoreduced O+ whole blood in the prehospital setting included traumatic injuries with systolic blood pressure (SBP) < 70mmHg or SBP < 90mmHg plus heart rate (HR) > 110 beats per minute. FINDINGS: From the date of onset through December 31, 2022, Palm Beach County Fire Rescue transported a total of 881 trauma activation patients, with 20 (2.3%) receiving WBT. Overall, nine (45%) of the patients who had received WBTs so far remain alive. No adverse events related to transfusion were identified following WBT administration. A total of 18 units of whole blood reached expiration of the unit's shelf life prior to transfusion. CONCLUSION: Despite a number of logistical and legal obstacles, Palm Beach County Fire Rescue successfully implemented a prehospital WBT program. Other EMS systems that are considering a prehospital WBT program should review the included protocol and the barriers to implementation that were faced.

A Multidisciplinary Approach to Improve Pain Management and Satisfaction in a Trauma Population.

An adult trauma center identified pain management as a potential area for improvement. Pain management is at the height of discussion in medical centers across the United States. The Hospital Consumer Assessment of Healthcare Provider and System (HCAHPS) scores relating to pain management were consistently low (<5th percentile). This project was designed to use a collaborative and systematic approach to pain management to improve HCAHPS pain management scores. This is an evaluation of a quality improvement project using a before-and-after design with historical control. Using HCAHPS data to evaluate patients' pain management perceptions, an integrative three-pronged approach was developed and implemented: (1) development of a trauma nurse leadership program, (2) collaboration with pain management providers, and (3) modifications made to the trauma admission order set. Trauma nurse leaders educated patients and families regarding pain management goals and expectations utilizing a standardized script. HCAHPS survey data obtained before and after the intervention showed a significant improvement in patient satisfaction. HCAHPS scores on the three pain questions prior to intervention in Quarters 2 and 3 (Q2-3) 2017 had a mean of less than the 5th percentile. After intervention, HCAHPS scores on the three pain questions improved to a mean of more than the 60th percentile on Q4 2018. Implementation of a pain management strategy involving a three-pronged approach of a dedicated trauma nurse leadership program, collaboration with a pain management team, and evaluation and modification of a trauma admission order set was associated with an improvement in communication about pain with the trauma patients and HCAHPS pain satisfaction scores.