3.6 Massive Transfusion Protocol

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Description of Indicator

Relationship to Quality Medical care should be effective
Type of Indicator Hospital structure, Hospital level
Proposed Data Source Survey
Definition Hospitals with a protocol to guide massive transfusions*
Numerator Hospitals with a protocol to guide management of injured patients age 18 years and older requiring massive transfusion*
Denominator Not applicable
Benchmark Not applicable
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.


This indicator is intended to identify trauma centers with a protocol to guide the management of massive transfusions.


Panel Review
Panelists indicated that the goal of the indicator was to encourage early initiation of protocol-based coordinated resuscitation of the severely injured patient. They highlighted that there is limited data to support the definition of a massive transfusion.
The panel emphasized the importance of pairing the indicator with the subsequent indicator “Massive Transfusion Protocol Activation”.


Trauma Center Review
It was noted that a massive transfusion protocol is standard in some trauma centers and therefore assessment of protocol utilization was important. Some of the trauma centers questioned the proposed massive transfusion definition and suggested that the number (majority of suggestions were for more units over the four hour time period) and type of blood products (suggestions to include plasma and platelets) could be revised.


Review of Literature & Evidence
Face Validity: No studies identified.
Construct Validity: One study demonstrated a possible association between the quality indicator Time to Blood Transfusion in Hemorrhagic Shock and mortality54. Two studies demonstrated that implementation of a trauma quality improvement program that included the indicators Transfusion for Anemia44, Resuscitation without Blood44 and Time to Blood Transfusion in Hemorrhagic Shock35 was associated with reduced hospital mortality.
Reliability: No studies identified.
Risk Adjustment: Not applicable.
Utilization: Transfusion associated indicators are used by a small number of trauma centers: USA 2% (3/200), Canada 0% (0/35), Australasia 25% (3/12).
Three studies recommended that transfusion of 0.5 to 1 unit of packed red blood cells per hour over 12 to 24 hours be defined as a massive transfusion55,56,57. One study showed an association between a massive transfusion protocol and a reduction in multi-organ failure and infectious complications as well as an increase in ventilator free days58.


The indicator is an amalgamation of three indicators: Transfusion for Anemia, Time to Blood Transfusion in Hemorrhagic Shock Patients and Resuscitation without Blood, previously proposed by Al-Naami et al.54, Chadbunchachai et al.44 and Ruchholtz et al.35.


35. Ruchholtz S, Waydhas C, Lewan U, et al. A multidisciplinary quality management system for the early treatment of severely injured patients: implementation and results in two trauma centers. Intensive Care Med. 2002;28(10):1395-1404.
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.
54. Al-Naami MY, Al-Faki AA, Sadik AA. Quality improvement data analysis of a mass casualty event. Injury. 2003;34(11):857-861.
55. Gonzalez EA, Moore FA, Holcomb JB, et al. Fresh frozen plasma should be given earlier to patients requiring massive transfusion. J Trauma. 2007;62(1):112-119.
56. Inaba K, Branco BC, Rhee P, et al. Impact of plasma transfusion in trauma patients who do not require massive transfusion. J Am Coll Surg. 2010;210(6):957-965.
57. Inaba K, Lustenberger T, Rhee P, et al. The impact of platelet transfusion in massively transfused trauma patients. J Am Coll Surg. 2010;211(5):573-579.
58. Cotton BA, Au BK, Nunez TC, Gunter OL, Robertson AM, Young PP. Predefined massive transfusion protocols are associated with a reduction in organ failure and postinjury complications. J Trauma. 2009;66(1):41-48.