3.8 Definitive Bleeding Control

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Description of Indicator

Relationship to Quality Medical care should be timely
Type of Indicator Hospital process, Hospital level
Proposed Data Source Trauma Registry, Blood Services, Administrative Data
Definition Attempted definitive (laparotomy, thoracotomy or percutaneous therapy) bleeding control within 30 minutes of massive transfusion* per 100 patients
Numerator All patients age 18 years and older with an injury diagnosis AND prescribed a massive transfusion who receive attempted definitive bleeding control (laparotomy, thoracotomy, percutaneous therapy) within 30 minutes of the massive transfusion prescription*‡†
Denominator All patients age 18 years and older with an injury diagnosis AND prescribed a massive transfusion*
Benchmark Proposed threshold: 30 minutes
Risk Adjustment Not applicable

* We propose defining massive transfusion as the transfusion of more than 4 units of packed red blood cells in a 4-hour period for the purposes of this indicator. Multiple definitions of massive transfusion exist and the proposed definition is designed to encourage early coordination of resuscitation in injured patients with bleeding. To operationalize this definition we propose that prescription for massive transfusion be satisfied when a 5th unit of packed red blood cells is prescribed within a 4-hour time period.
‡ If definitive bleeding control is attempted prior to massive transfusion criteria being satisfied in a patient who eventually satisfies the criteria then the numerator is satisfied.
† Time frame for definitive bleeding control satisfying numerator definition = Time procedure starts (skin incision for laparotomy or thoracotomy AND percutaneous needle insertion for percutaneous therapy) – Time 5th unit of packed red blood cells prescribed within a 4 hour time period.


This indicator is intended to monitor the timeliness of attempted bleeding control in bleeding patients.


Panel Review
Panelists indicated that the goal of the indicator was measuring timely access to definitive bleeding control in patients with hemorrhagic shock. The panel was unable to agree on a definition for sustained hemorrhagic shock and therefore proposed to use massive transfusion as the indication for bleeding control. The panel also advocated that the time threshold for this indicator should be as short as possible (30 to 60 minutes).


Trauma Center Review
The trauma centers noted the importance of timely bleeding control, but highlighted the potential challenges of identifying the need for bleeding control in a given patient (i.e. when to establish that initial resuscitation is insufficient).


Review of Literature & Evidence
Face Validity: No studies identified.
Construct Validity: Three studies showed no association between the quality indicator and mortality15,36,54. Two studies demonstrated that implementation of a trauma quality improvement program that included the quality indicator was associated with reduced hospital mortality44,45.
Reliability: No studies identified.
Risk Adjustment: Not applicable.
Utilization: Measures of time to attempted bleeding control are used by a moderate number of trauma centers: USA 15% (30/200), Canada 40% (14/35), Australasia 0% (0/12).
One study showed that the probability of death increased by 1% for every 3 minutes that hypotensive patients with abdominal bleeding were in the ED59.


The indicator is a combination of the indicators Laparo-/Thoracotomy in Hemorrhagic Shock and Angiography in Hemorrhagic Shock. The American College of Surgeons Committee on Trauma proposed the indicator Laparo-/Thoracotomy in Hemorrhagic Shock2. The Quality Indicator Consensus Panel proposed the indicator Angiography in Hemorrhagic Shock.


2. American College of Surgeons Committee on Trauma. Resources for Optimal Care of the Injured Patient 2006. Chicago: American College of Surgeons; 2006.
15. Copes WS, Staz CF, Konvolinka CW, Sacco WJ. American College of Surgeons audit filters: associations with patient outcome and resource utilization. J Trauma. 1995;38(3):432-438.
36. Willis CD, Stoelwinder JU, Cameron PA. Interpreting process indicators in trauma care: construct validity versus confounding by indication. Int J Qual Health Care. 2008;20(5):331-338.
44. Chadbunchachai W, Saranrittichai S, Sriwiwat S, Chumsri J, Kulleab S, Jaikwang P. Study on performance following Key Performance Indicators for trauma care: Khon Kaen Hospital 2000. J Med Assoc Thai. 2003;86(1):1-7.
45. Chadbunchachai W, Sriwiwat S, Kulleab S, Saranrittichai S, Chumsri J, Jaikwang P. The comparative study for quality of trauma treatment before and after the revision of trauma audit filter, Khon Kaen hospital 1998. J Med Assoc Thai. 2001;84(6):782-790.
54. Al-Naami MY, Al-Faki AA, Sadik AA. Quality improvement data analysis of a mass casualty event. Injury. 2003;34(11):857-861.
59. Clarke JR, Trooskin SZ, Doshi PJ, Greenwald L, Mode CJ. Time to laparotomy for intra-abdominal bleeding from trauma does affect survival for delays up to 90 minutes. J Trauma. 2002;52(3):420-424.