3.7 Massive Transfusion Protocol Activation

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Description of Indicator

Relationship to Quality  Medical care should be timely and effective
Type of Indicator Hospital process, Hospital level
Proposed Data Source Trauma Registry, Blood Services
Definition Activations of massive transfusion* protocol per 100 patients
Numerator All injured patients age 18 years and older prescribed a massive transfusion* AND with massive transfusion* protocol activation
Denominator All injured patients age 18 years and older prescribed a massive transfusion*
Benchmark Not specified at present
Risk Adjustment† Age, gender, ISS, TRISS, mechanism of injury, W-RTS

* 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 of massive transfusion be satisfied when a 5th unit of packed red blood cells is prescribed within a 4-hour time period.

This indicator is a corollary to the preceding quality indicator, Massive Transfusion Protocol. It is intended to monitor the utilization of protocols for management of massive transfusions.

Panel Review
Similar to the previous indicator, the panel discussed the challenges of establishing a definition for massive transfusion (number, type and timeframe of blood products transfused). The panel reiterated that the proposed definition was designed to ensure timely and coordinated resuscitation in injured bleeding patients.

Trauma Center Review
Similar to the previous indicator, the trauma centers expressed concern about the proposed definition. Some centers noted that the proposed definition was not consistent with local protocols for massive transfusion. In addition, centers suggested that the indicator definition be revised to evaluate the “administration” rather than the “prescription” of blood.

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 mortality55. 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†: A list of potential variables for risk adjustment are available from studies examining massive transfusion58.
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).

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.
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.