Strategies to Obtain and Deliver Blood Products into Critically Injured Children: A Survey of Pediatric Trauma Society Members

Abstract

Objectives

Timely transfusion is associated with improved survival and a reduction in in-hospital morbidity. The benefits of early hemorrhagic shock recognition may be limited by barriers to accessing blood products and their timely administration. We examined how pediatric trauma programs obtain blood products, the types of rapid infusion models used, and the metrics tracked to improve transfusion process efficiency in their emergency department (ED).

Methods

We developed and distributed a self-report survey to members of the Pediatric Trauma Society. The survey consisted of six initial questions, including the respondent’s role and institution, whether a blood storage refrigerator was present in their ED, the rapid infuser model used to transfuse critically injured children in their ED, if their program tracked four transfusion process metrics, and if a video recording system was present in the trauma bay. Based on these responses, additional questions were prompted with an option for a free-text response.

Results

We received 137 responses from 77 institutions. Most pediatric trauma programs have a blood storage refrigerator in the ED (n = 46, 59.7%) and use a Belmont^® rapid infuser to transfuse critically injured children (n = 45, 58.4%). The American College of Surgeons Level 1 designated trauma programs, or state-based equivalents, and ‘pediatric’ trauma programs were more likely to have video recording systems for performance improvement review compared with lower designated trauma programs and ‘combined pediatric and adult’ trauma programs, respectively.

Conclusions

Strategies to improve the timely acquisition and infusion of blood products to critically injured children are underreported. This study examined the current practices that pediatric trauma programs use to transfuse critically injured children and may provide a resource for trauma programs to cite for transfusion-related quality improvement.

INTRODUCTION

Strategies to improve hemorrhage-associated survival and in-hospital morbidity have primarily focused on timely transport to trauma centers, early recognition of hemorrhage, balanced component resuscitation, and physical hemorrhage control.[1–8] Although prehospital transfusion can improve survival and reduce the amount of packed red blood cells (pRBCs) transfused, several practical considerations have limited its use for civilian trauma, including the logistics and cost associated with storage and the challenge of recognizing hemorrhagic shock early after injury.[8] When prehospital transfusion is not available, rapid transport to a trauma center and management of hemorrhage early after arrival is needed because delays even in minutes from injury to transfusion can be associated with a higher odds of mortality in adults.[7–9] A similar association likely exists for injured children and adolescents, but this association is difficult to study for several reasons. Hemorrhage is uncommon after pediatric injury. Only about 3% of injured children receive a blood transfusion within four hours of arrival to a trauma center.[8] Early recognition of uncontrolled hemorrhage is also difficult because children display robust physiological compensatory mechanisms that can mimic the body’s normal adrenergic responses to injury.[8, 10–15] As a result, transfusion may be delayed to later stages of shock when transfusion is less effective at reversing the shock state. Without prompt access to blood products and proficiency in rapid infusion methods, early hemorrhage recognition and component resuscitation may be less effective in improving hemorrhage-associated outcomes.

Several system barriers may influence the timeliness of obtaining blood products and delivering them to the patient, including the location of blood product storage, the process required to obtain these products when not immediately available, and the rate at which blood products are infused.[8] In this study, our primary aim was to identify the strategies pediatric trauma programs use to access and infuse blood products for use in the emergency department (ED). We also evaluated which hemorrhage-related process improvement metrics each institution uses to track transfusion delays.

MATERIALS AND METHODS

Survey

We developed a self-report survey in accordance with the Checklist for Reporting Results of Internet E-Surveys (CHERRIES) guidelines. We used REDCap (Vanderbilt University, Nashville, TN) to develop the survey and collect responses. The survey consisted of six initial questions, including the respondent’s institution and role, the presence of a blood refrigerator in the ED, the type of rapid infuser used in the ED, the metrics of the transfusion process tracked by the trauma program, and the presence of a video recording system in the resuscitation room (see Survey, Supplementary Digital Content 1). Depending on the respondent’s answers to these questions, the survey prompted additional questions, including the content and amount of blood products contained in the ED blood refrigerator, and the method and criteria for transporting blood products to the ED when no blood refrigerator was present (see Survey, Supplementary Digital Content 1). All sections were composed of multiple-choice answer options, with relevant sections including a free-text open response option. Our Institutional Review Board exempted the survey from full review, and the Pediatric Trauma Society (PTS) Research Committee approved the survey.

Survey Distribution and Data Analysis

The PTS Research Committee distributed a link to the survey via email on June 30^th, 2022 and July 14^th, 2022 to current physician, trauma program manager, nurse practitioner, physician assistant, nursing, and allied health PTS members. One month following the final distribution email, we exported the data from REDCap (Vanderbilt University, Nashville, TN) and categorized responses by institution. We identified the primary patient population each institution serves and the trauma center’s pediatric level using the American College of Surgeons (ACS) trauma center designation or the trauma center’s state governmental health organization. We classified the designation as ‘pediatric’ or ‘combined pediatric and adult’ using this approach. We categorized institutions as ‘highest designation’ if the ACS designated the trauma program as ‘Level 1’ or designated by their state in an equivalent category. Other institutions were categorized as ‘lower designation.’ For institutions with multiple responses, we reviewed these responses for discrepancies and contacted the trauma program manager via email for clarification. We performed univariate comparisons using Fisher exact test and defined significance at p<0.05 using 2-sided tests. We performed statistical analysis using SAS 9.4 (Cary, NC).

RESULTS

Survey Responses

We received 137 survey responses from 77 institutions. Most respondents identified as a trauma nurse administrator (n = 76, 55.5%), followed by physician (n = 42, 30.7%), registered nurse (n = 7, 5.1%), advanced practice provider (n = 7, 5.1%), and other (n = 5, 3.6%). Seventy-five (97.4%) institutions were in the United States and two (2.6%) in Canada. Fifty-four (70.1%) institutions had either a Level 1 trauma center designation by the ACS or an equivalent government-based designation (see Table, Supplementary Digital Content 2). Thirty-seven (48.1%) trauma centers were designated as ‘pediatric’ trauma centers and 40 (51.9%) as ‘combined pediatric and adult’ centers (see Table, Supplementary Digital Content 2).

Twenty-six (33.8%) institutions had multiple respondents, among which 23 (88.5%) had discrepancies. Most discrepancies pertained to the performance metrics tracked (n = 22, 95.7%), followed by the model of rapid infuser used in the emergency department (n = 6, 26.0%), the products contained in the ED blood refrigerator (n = 5, 21.7%), and the presence of an ED blood refrigerator (n = 2, 8.7%). We received clarifications from 20 institutions (87.0%). We excluded the discrepant responses from the remaining three institutions.

Location and Transport of Blood Products

Forty-six (59.7%) institutions have a blood storage refrigerator located in the ED with most containing only pRBCs (n = 22, 48.9%), followed by a combination of pRBCs, plasma, whole blood, and platelets (n = 21, 46.7%), and whole blood only (n = 2, 4.4%) (Table 1). The median number of units contained in these refrigerators was highest for pRBCs (4 [interquartile range (IQR) 2, 6]), followed by plasma (4 [IQR 1.5, 5]), whole blood (2 [IQR 2, 4]), and platelets (2 [IQR 2, 2]). Among the institutions without an ED blood storage refrigerator, the most common method to transport blood products to the ED was through a human transporter (n = 29, 93.5%), followed by a mechanical transport system (n = 1, 3.2%), and a combination of mechanical and human transport (n = 1, 3.2%) (Table 2). The human transporter was sent from the ED to retrieve the blood products from the blood bank at most institutions (n = 19, 65.5%) (Table 2). We observed no difference in the location and transport of blood products based on trauma center designation (see Table, Supplementary Digital Content 3)(see Table, Supplementary Digital Content 4).

Table 1.

Survey Summary Statistics by Hospital

Variable	Institutions n (%)
Presence of ED blood refrigerator	46 (59.7)
Refrigerator contents@
Packed red blood cells	22 (48.9)
Whole blood	2 (4.4)
Packed red blood cells + whole blood	4 (8.9)
Packed red blood cells + plasma	10 (22.2)
Packed red blood cells + plasma + whole blood	5 (11.1)
Packed red blood cells + plasma + whole blood + platelets	2 (4.4)
Rapid infuser model(s)
Level 1 ®	26 (33.8)
Ranger ®	2 (2.6)
Belmont ®	45 (58.4)
Thermacor ®	1 (1.3)
Life Flow ®	3 (3.9)
Performance improvement metrics#
Patient arrival to blood transfusion decision	22 (29.7)
Patient arrival to blood transfusion	48 (64.9)
Blood transfusion decision to blood transfusion	27 (36.5)
Blood transfusion delays	57 (77.0)
Other	4 (5.4)
Video Review	31 (40.3)

ED: emergency department

^@:1 institution excluded due to discrepant response

^#:3 institutions excluded due to discrepant response

Table 2.

Transport Methods to Obtain Blood Products at Institutions without an Emergency Department Blood Refrigerator

Variable	Institutions n (%)
Blood bank team members brings products to trauma bay	9 (29.0)
Mechanical transportation of blood products from blood bank to trauma bay	1 (3.2)
ED transporter goes to blood bank and returns with blood products	19 (61.3)
Other	2 (6.5)

Other: Mechanical for first two units and courier if more; phlebotomist brings blood to emergency department

Model of Rapid Infuser

All institutions have a rapid infuser in their ED. The most common model was the Belmont (Belmont Medical Technologies, Billerica, MA) rapid infuser, followed by the Level 1 (Smiths Medical, Minneapolis, MN), Life-Flow (410 Medical, Durham, NC), Ranger (Saint Paul, MN), and Thermacor (Smisson-Cartledge Biomedical, Macon, GA) rapid infusers (Table 2). We observed no difference in the rapid infuser used based on trauma center designation (see Table, Supplementary Digital Content 3)( see Table, Supplementary Digital Content 4).

Performance Metrics

The most tracked performance metric was ‘delays to blood transfusion,’ followed by the times from ‘patient arrival to blood transfusion,’ the ‘decision to transfuse to blood transfusion,’ and ‘patient arrival to the decision to transfuse’ (Table 1). Seventeen (23.0%) programs tracked all four metrics, 46 (62.2%) tracked some but not all, and 11 (14.9%) tracked none. Most institutions (n = 46, 59.7%) do not use a video recording system to review activations. Institutions designated as a Level 1 trauma center by the ACS or state-designated equivalent were more likely to have a video recording system (n = 27, 50.0% vs. n = 4, 17.4%, p = 0.01) compared to lower designated centers and between institutions designated as ‘pediatric’ and ‘combined pediatric and adult’ (n = 20, 59.5% vs. n = 10, 25.0%, p = 0.01) (see Table, Supplementary Digital Content 3)(see Table, Supplementary Digital Content 4).

DISCUSSION

In this study, we surveyed 77 pediatric trauma programs to examine current practices used to transfuse critically injured children and adolescents and how these programs track transfusion-related performance metrics. We observed that most programs have a blood storage refrigerator in the ED, but only half of these programs store blood products other than pRBCs (e.g., plasma, whole blood, cryoprecipitate, and platelets). When rapid infusion of blood products is needed, most institutions use either a Belmont^® or Level 1^® rapid infuser. Trauma programs designated by the ACS as Level 1, or a state-based equivalent, more often have a video recording system present in the ED. ‘Pediatric’ trauma programs also were more likely to have a video recording system present compared to ‘combined pediatric and adult’ programs. Among the performance metrics identified in this study, most programs tracked some, but not all, and 11 institutions did not track any metric.

Accurate and timely management of uncontrolled hemorrhage requires trauma surgeons and emergency medicine providers to (1) recognize hemorrhage, (2) decide to transfuse or pursue hemorrhage control, (3) obtain blood products and bring to bedside, (4) establish vascular access, (5) deliver the blood products into the patient faster than the rate of hemorrhage, and (6) control hemorrhage through surgical or interventional approaches.[8] If one or more of these tasks is delayed, the cumulative delay to transfusion may result in a child’s death or an in-hospital morbidity, including multiorgan failure, ventilator-associated pneumonia and severe sepsis.[7, 9, 16–23] To identify barriers to timely transfusion, each trauma program can conduct a review of all trauma activations requiring blood transfusion in their ED.[8] As part of this review, potential barriers to transfusion and the time required to complete each task for successful transfusion can be determined. Although this process can be done using chart review, in-person observation, or provider recall, video review can provide a more accurate representation of the timeline and occurrence of these barriers.[8, 24] We have previously used this approach to identify several factors associated with delays to transfusion at our institution, including the transport of blood products from the blood bank, the difficulty in obtaining vascular access, provider indecision, and the set-up of the rapid infuser.[11] Based on our findings, we placed a blood storage refrigerator in the ED containing 3-units of pRBCs at all times and reduced the time from patient arrival to transfusion by 11-minutes.[11]

Remote blood storage in the ED likely provides the most immediate access to blood products but may not be feasible for several reasons including, hospital infrastructure, financial costs, and frequency of transfusions in the ED.[11, 25, 26] Several other strategies have increased the accessibility of blood products in the ED at adult trauma hospitals, including portable refrigerators, tubing systems, and human ‘runners’ sent to the blood bank to obtain blood products and deliver them to the ED.[25, 27–29] Each strategy can deliver blood products to the ED within minutes after patient arrival but the blood bank location and hospital infrastructure influenced which strategy was selected.[28] Although all trauma programs in this study reported using one or a combination of these methods, the identified strategy may not be optimized for the institution. For example, one adult trauma center’s blood bank was located in a separate building from the ED and required a median of 15-minutes to prepare and transport blood to the ED.[28] Although a dedicated human ‘runner’ transport team was used, the institution moved the transfusion service closer to the ED to expedite blood delivery following comparison with other adult trauma programs.[28]

The use of gravity-dependent fluid administration is inadequate when volume loss exceeds the rate of hemorrhage.[12–14, 30, 31] Several inexpensive strategies can increase the rate of infusion to four times faster than gravity alone, including the push-pull technique using manual syringe infusion, pressure-bag infusion, and manual compression of blood product bags.[30–38] In clinical practice, these strategies are limited by the size and location of the vascular catheter, hand fatigue that can slow the rate of infusion over time, challenges in accurately tracking fluid volume, and difficulty in monitoring for unintended air in the tubing.[34–37] Rapid infuser devices can address these limitations while also providing a higher rate of infusion and the ability to warm refrigerated blood products to normal body temperature. Although effective, these devices are expensive and require frequent use for staff to maintain proficiency.[8, 32, 33, 35–38] In our study, we observed that all trauma programs use a rapid infuser device in their ED to transfuse critically injured children and the Belmont ^® rapid infuser was the most common model used.

Our study has several limitations. First, this study is a cross-sectional study at a single time point. The results of this study may change in the future and additional follow-up is needed. Second, we did not query all ACS and state-designated trauma centers. Future work is necessary to evaluate transfusion practices at all ACS and state-designated pediatric trauma programs in the United States and Canada and validate our findings. Finally, efficacy comparison of strategies to store, obtain, and deliver blood products was beyond the scope of this study. A prospective multicenter trial is needed to identify the benefits of one method over another.

Several barriers to timely transfusion exist in the ED following the decision to transfuse and may not be easily identified without dedicated video review. This study provides information that can be used by trauma programs to implement system process changes to decrease the time to transfusion.