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Abstract
OBJECTIVES To assess recent advances in interfacility critical care transport. DATA SOURCES PubMed English language publications plus chapters and professional organization publications. STUDY SELECTION Manuscripts including practice manuals and standard (1990-2021) focused on interfacility transport of critically ill patients. DATA EXTRACTION Review of society guidelines, legislative requirements, objective measures of outcomes, and transport practice standards occurred in work groups assessing definitions and foundations of interfacility transport, transport team composition, and transport specific considerations. Qualitative analysis was performed to characterize current science regarding interfacility transport. DATA SYNTHESIS The Task Force conducted an integrative review of 496 manuscripts combined with 120 from the authors' collections including nonpeer reviewed publications. After title and abstract screening, 40 underwent full-text review, of which 21 remained for qualitative synthesis. CONCLUSIONS Since 2004, there have been numerous advances in critical care interfacility transport. Clinical deterioration may be mitigated by appropriate patient selection, pretransport optimization, and transport by a well-resourced team and vehicle. There remains a dearth of high-quality controlled studies, but notable advances in monitoring, en route management, transport modality (air vs ground), as well as team composition and training serve as foundations for future inquiry. Guidance from professional organizations remains uncoupled from enforceable regulations, impeding standardization of transport program quality assessment and verification.
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Addams J, Arbabi S, Bulger EM, Stansbury LG, Tuott EE, Hess JR. How we built a hospital-based community whole blood program. Transfusion 2022; 62:1699-1705. [PMID: 35815552 DOI: 10.1111/trf.17018] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/28/2022] [Revised: 06/14/2022] [Accepted: 06/15/2022] [Indexed: 11/28/2022]
Abstract
BACKGROUND Whole blood (WB) is an attractive product for prehospital treatment of hemorrhagic shock and for initial in-hospital resuscitation of patients likely to require massive transfusion. Neither our regional blood provider nor our hospital blood bank had recent experience collecting or using WB, so we developed a stepwise process to gather experience with WB in clinical practice. METHODS When our Transfusion Committee suggested a WB program, we worked with our regional blood provider to collect cold-stored, leukoreduced, low-titer anti-A, and anti-B group O RhD positive WB (low-titer group O WB [LTOWB]) and worked with our city Fire Department to integrate it into prehospital care. This work required planning, development of protocols, writing software for blood bank and electronic medical records, changes in paramedic scope of practice, public information, training of clinicians, and close clinical follow-up. RESULTS Between June 2019 and December 2021, we received 2269 units of LTOWB and transfused 2220 units; 24 (1%) were wasted, two were withdrawn, and 23 were in stock at the end of that time. Most (89%) were transfused to trauma patients. Usage has grown from 48 to 120 units/month, covers all 5 Fire Districts in the county, and represents about ¼ of all hospital trauma blood product use. CONCLUSIONS Developing a WB program is complex but can be started slowly, including both pre-hospital and hospital elements, and expanded as resources and training progress. The investments of time, effort, and funding involved can potentially improve care, save blood bank and nursing effort, and reduce patient charges.
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Affiliation(s)
- Joel Addams
- Department of Laboratory Medicine and Pathology, University of Washington School of Medicine, Seattle, Washington, USA
| | - Saman Arbabi
- Department of Surgery, University of Washington School of Medicine, Seattle, Washington, USA.,Harborview Injury Prevention Research Center, Harborview Medical Center, Seattle, Washington, USA
| | - Eileen M Bulger
- Department of Surgery, University of Washington School of Medicine, Seattle, Washington, USA
| | - Lynn G Stansbury
- Harborview Injury Prevention Research Center, Harborview Medical Center, Seattle, Washington, USA.,Department of Anesthesia and Pain Medicine, University of Washington, Seattle, Washington, USA
| | - Erin E Tuott
- Department of Laboratory Medicine and Pathology, University of Washington School of Medicine, Seattle, Washington, USA
| | - John R Hess
- Department of Laboratory Medicine and Pathology, University of Washington School of Medicine, Seattle, Washington, USA.,Harborview Injury Prevention Research Center, Harborview Medical Center, Seattle, Washington, USA
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Sayre MR, Yang BY, Murphy DL, Counts CR, Dang M, Ubaldi P, Tuott EE, Hess JR. Providing whole blood for an urban paramedical ambulance system. Transfusion 2021; 62:82-86. [PMID: 34787330 DOI: 10.1111/trf.16749] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/26/2021] [Revised: 09/29/2021] [Accepted: 10/31/2021] [Indexed: 11/28/2022]
Abstract
INTRODUCTION Hemorrhage is the second leading cause of death among urban trauma patients, and the provision of prehospital blood-based resuscitation can be lifesaving. We developed an efficient system to support blood-based resuscitation by an urban advanced life support ambulance system. METHODS We worked with our state health department for permission for fire department paramedics to initiate blood transfusion and built protocols for field whole blood resuscitation. Our regional trauma center transfusion service provided 2 units of O positive, low-titer, leukoreduced whole blood in an internally monitored and sealed ice box weighing 10 pounds to the fire department paramedic supervisor. When notified, the supervisor transported the blood to the sites of anticipated need. Total blood use and wastage were recorded. RESULTS Following two public hearings, we obtained state-wide approval for the initiation of emergency uncrossmatched blood transfusion by paramedics. Over a 1-year period beginning August 27, 2019, 160 units of whole blood were made available for use, and 51 units were transfused to 39 patients, 30 of whom were trauma patients. Other recipients include patients in shock from massive gastrointestinal, peripartum, or other suspected bleeding. Unused units were returned to the providing transfusion service after 1 week and used for hospital patient care without loss. The estimated cost of providing blood per mission was $0.28 and per patient transfused was $1138. CONCLUSIONS With appropriate attention to detail, it is possible to provide whole blood to an urban paramedical ambulance system with efficient blood component usage, minimal blood wastage, and low cost.
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Affiliation(s)
- Michael R Sayre
- Department of Emergency Medicine, University of Washington, Seattle, WA, USA.,Seattle Fire Department, Seattle, WA, USA
| | - Betty Y Yang
- Department of Emergency Medicine, University of Washington, Seattle, WA, USA
| | - David L Murphy
- Department of Emergency Medicine, University of Washington, Seattle, WA, USA
| | - Catherine R Counts
- Department of Emergency Medicine, University of Washington, Seattle, WA, USA
| | - Maika Dang
- Department of Emergency Medicine, University of Washington, Seattle, WA, USA
| | | | - Erin E Tuott
- Department of Laboratory Medicine and Pathology, University of Washington, Seattle, WA, USA
| | - John R Hess
- Department of Laboratory Medicine and Pathology, University of Washington, Seattle, WA, USA
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Liu Z, Ayyagari RC, Martinez Monegro EY, Stansbury LG, Arbabi S, Bulger EM, Vavilala MS, Hess JR. Blood component use and injury characteristics of acute trauma patients arriving from the scene of injury or as transfers to a large, mature US Level 1 trauma center serving a large, geographically diverse region. Transfusion 2021; 61:3139-3149. [PMID: 34632587 DOI: 10.1111/trf.16679] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/11/2021] [Revised: 08/09/2021] [Accepted: 08/30/2021] [Indexed: 12/23/2022]
Abstract
BACKGROUND Advanced trauma care demands the timely availability of hemostatic blood products, posing special challenges for regional systems in geographically diverse areas. We describe acute trauma blood use by transfer status and injury characteristics at a large regional Level 1 trauma center. STUDY DESIGN AND METHODS We reviewed Harborview Medical Center (HMC) Trauma Registry, Transfusion Service, and electronic medical records on acute trauma patients for demographics, injury patterns, blood use, and in-hospital mortality, 2011-2019. RESULTS Among 47,471 patients (mean age 45.2 ± 23.0 years; 68.3% male; Injury Severity Score 12.6 ± 11.1), 4.7% died and 8547 (18%) received at least one blood component through HMC. Firearms injuries were the most often transfused (690/2596, 26.6%) and the most urgently (39.9% ≥3 units in <1 h; 40.6% ≥5 units in <4 h), and had the highest mortality (case-fatality, 12.2%) (all p < .001). From-scene patients were younger than transfers (42.9 ± 21.0 vs. 47.2 ± 24.4), predominated among firearms injuries (68.2% from-scene vs. 31.8% transfers), were more likely to receive blood (18.5% vs. 17.6%) more urgently (≥3 units first hour, 24.4% vs. 7.7%; ≥5 units first 4 h: 25.6% vs. 8.2%), were more likely to die of hemorrhage (15.5% vs. 4.3%) and from firearms injuries (310/1360, 22.8%) (all p < .001). DISCUSSION Early blood use, firearms injuries, and mortality were all greater among from-scene patients, and firearms injuries had worse outcomes despite greater and more urgent blood use, but the role of survivor bias for transfer patients must be clarified. Future research must identify strategies for providing local hemostatic transfusion support, particularly for firearms injuries.
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Affiliation(s)
- Zhinan Liu
- Harborview Injury Prevention and Research Center (HIPRC), Seattle, Washington, USA
| | - Rajiv C Ayyagari
- Harborview Injury Prevention and Research Center (HIPRC), Seattle, Washington, USA
| | - Edison Y Martinez Monegro
- Harborview Injury Prevention and Research Center (HIPRC), Seattle, Washington, USA.,San Juan Bautista School of Medicine, Cauguas, Puerto Rico
| | - Lynn G Stansbury
- Harborview Injury Prevention and Research Center (HIPRC), Seattle, Washington, USA.,Department of Anesthesiology and Pain Medicine, University of Washington, Seattle, Washington, USA
| | - Saman Arbabi
- Harborview Injury Prevention and Research Center (HIPRC), Seattle, Washington, USA.,Department of Surgery, University of Washington School of Medicine, Seattle, Washington, USA
| | - Eileen M Bulger
- Harborview Injury Prevention and Research Center (HIPRC), Seattle, Washington, USA.,Department of Surgery, University of Washington School of Medicine, Seattle, Washington, USA
| | - Monica S Vavilala
- Harborview Injury Prevention and Research Center (HIPRC), Seattle, Washington, USA.,Department of Surgery, University of Washington School of Medicine, Seattle, Washington, USA.,Department of Pediatrics, University of Washington, Seattle, Washington, USA
| | - John R Hess
- Harborview Injury Prevention and Research Center (HIPRC), Seattle, Washington, USA.,Department of Laboratory Medicine and Pathology, University of Washington, Seattle, Washington, USA.,Harborview Medical Center Transfusion Medicine Service, Harborview Transfusion Medicine Service, Seattle, Washington, USA
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Danielson KR, Condino A, Latimer AJ, McCoy AM, Utarnachitt RB. Cardiac Arrest in Flight: A Retrospective Chart Review of 92 Patients Transported by a Critical Care Air Medical Service. Air Med J 2021; 40:159-163. [PMID: 33933218 DOI: 10.1016/j.amj.2021.02.005] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/05/2020] [Revised: 02/23/2021] [Accepted: 02/25/2021] [Indexed: 10/21/2022]
Abstract
OBJECTIVE The purpose of this study was to describe the incidence, characteristics, and outcomes of cardiac arrest in the air medical environment so that we can begin to understand predictors of in-flight cardiac arrest and identify opportunities to improve care. METHODS This retrospective observational study was undertaken at Airlift Northwest from 2013 to 2017. Descriptive statistics of adult patients with medical and traumatic etiologies of cardiac arrest were analyzed and compared. RESULTS Of the 13,915 adult patients transported during the study period, fewer than 1% (N = 92) had a cardiac arrest during transport. Of those, 42% in the overall cohort had return of spontaneous circulation on arrival at the destination hospital. Medical etiologies of cardiac arrest were more common than traumatic (65% vs. 35%), more likely to have an initial shockable rhythm (30% vs. 3%, P = .004), and more frequently arrived at the receiving hospital with return of spontaneous circulation (57% vs. 31%, P = .03). Rearrest in transport occurred frequently (39%). Most patients were hypotensive before cardiac arrest, and peri-intubation cardiac arrest occurred in 12% of patients. CONCLUSION Cardiac arrest during air medical transport is a rare event that requires a high level of critical care to treat refractory cardiac arrests, hemodynamic instability, and airway compromise.
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Affiliation(s)
| | - Anna Condino
- Department of Emergency Medicine, University of Washington, Seattle, WA
| | - Andrew J Latimer
- Airlift Northwest, University of Washington, Seattle, WA; Department of Emergency Medicine, University of Washington, Seattle, WA
| | - Andrew M McCoy
- Department of Emergency Medicine, University of Washington, Seattle, WA
| | - Richard B Utarnachitt
- Airlift Northwest, University of Washington, Seattle, WA; Department of Emergency Medicine, University of Washington, Seattle, WA
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