Cotton Bryan A, Dossett Lesly A, Au Brigham K, Nunez Timothy C, Robertson Amy M, Young Pampee P
Department of Surgery, Center for Translational Injury Research, The University of Texas Health Science Center, Houston, Texas 77030, USA.
J Trauma. 2009 Nov;67(5):1004-12. doi: 10.1097/TA.0b013e3181bcb2a8.
Massive transfusion (MT) protocols improve survival in patients with exsanguinating hemorrhage. Both the increased plasma to red blood cells (RBC) and platelets to RBC ratios, and the "protocolization" of product delivery seem to be critical components of the reduction in mortality. The purpose of this study was to identify the incidence and impact of MT protocol noncompliance and to intervene in provider-related events associated with poor compliance and outcomes.
A MT protocol was initiated in 2006 at a Level I trauma center. All cases of protocol activation were reviewed by a multidisciplinary performance improvement (PI) group for compliance and the need for "real-time" protocol adjustments. Educational conferences, Grand Rounds presentations, and individual provider education were performed on a quarterly basis. Compliance of seven measures were evaluated as follows: type and screen sent from emergency department (ED), activation of protocol in ED, activation by trauma attending, administration of 2:3 plasma to RBC, administration of 1:5 platelets to RBC, protocol discontinuation on leaving operating room, and no products wasted. Univariate, multivariate, and time-series analyses were performed.
All 125 MT protocol activations occurring from February 2006 to January 2008 were reviewed. Full compliance for all PI measures during the entire period was 27%. There were no differences in demographics, injury severity, or physiologic scores between patients for whom activations were compliant and those who were noncompliant. Full compliance was an independent predictor of survival (86.7% vs. 45.0%, p < 0.001). Both activation of the protocol in the ED and achievement of prespecified ratios of plasma: RBC (2:3) and platelets: RBC (1:5) were independent predictors of 24-hour and 30-day survivals. All PI measures demonstrated improved compliance during the study period with the exception of ED activation. Failure to send type and screen from the ED is an independent predictor of wasted blood products.
Early activation of a MT protocol and achieving predefined ratios was associated with improved survival. ED activation and direct blood bank notification by the trauma attending were associated with a reduction in blood product wastage. A multidisciplinary PI process helps to identify provider/specialty noncompliance and to assess the impact of these factors, and it was associated with improvement in compliance and MT outcomes over time.
大量输血（MT）方案可提高失血性休克患者的生存率。血浆与红细胞（RBC）比例及血小板与RBC比例的增加，以及输血产品供应的“规范化”似乎是降低死亡率的关键因素。本研究的目的是确定MT方案不依从的发生率和影响，并干预与依从性差及预后相关的医疗人员相关事件。
2006年在一家一级创伤中心启动了MT方案。多学科质量改进（PI）小组对所有方案启动病例进行了依从性审查以及“实时”调整方案的必要性评估。每季度召开教育会议、举办全院大查房讲座并对医疗人员进行个别教育。对七项指标的依从性进行如下评估：急诊科（ED）送检血型及筛查、ED启动方案、创伤主治医生启动方案、血浆与RBC按2:3输注、血小板与RBC按1:5输注、离开手术室时停止方案以及无血液制品浪费。进行了单因素、多因素和时间序列分析。
对2006年2月至2008年1月期间发生的125例MT方案启动进行了审查。整个期间所有PI指标的完全依从率为27%。方案启动依从的患者与不依从的患者在人口统计学、损伤严重程度或生理评分方面无差异。完全依从是生存的独立预测因素（86.7%对45.0%，p<0.001）。在ED启动方案以及达到预设的血浆:RBC（2:3）和血小板:RBC（1:5）比例均是24小时和30天生存率的独立预测因素。除ED启动外，所有PI指标在研究期间的依从性均有所改善。未从ED送检血型及筛查是血液制品浪费的独立预测因素。
早期启动MT方案并达到预定义比例与生存率提高相关。ED启动方案以及创伤主治医生直接通知血库与减少血液制品浪费相关。多学科PI流程有助于识别医疗人员/专业的不依从情况并评估这些因素的影响，且随着时间推移与依从性改善及MT结局改善相关。
