The Agency for Healthcare Research and Quality (AHRQ) has opened the comment period for the draft report titled “Prehospital EMS Blood Transfusion and Fluid Interventions for Hemorrhagic Shock.” The draft report aimed to conduct a systematic review to, “asses[s] the effectiveness and potential harms of blood transfusion and fluid interventions for hemorrhagic shock in the prehospital setting. [The peer reviewers] examined four interventions — whole blood, packed red blood cells (PRBC), plasma, and crystalloid fluids — comparing their benefits and harms when used for resuscitation as well as different transfusion strategies across traumatic and nontraumatic conditions. The review also analyzed critical evidence gaps and implementation factors affecting prehospital transfusion programs. This systematic review is intended to serve as a resource for the development of evidence-based prehospital care guidelines, protocols, and related policies.”
Key findings in the draft report include:
- “[n]o mortality benefit of whole blood, PRBC, or plasma over that of usual care;
- [c]rystalloid fluids may be more effective when compared with plasma;
- [t]he Advanced Resuscitative Care (ARC) Bundle strategy (i.e., PRBC, TXA, and calcium) appears to be more effective than usual care in reducing mortality;
- there may be as much as 11 percent increase in the risk of mortality for every minute of delay in the field; [and]
- [p]rovision of calcium in addition to resuscitation fluids prevents hypocalcemia.”
Additional highlights of the draft report are, “[t]he absence of evidence for effectiveness in almost all scenarios highlights the complexity of the implementation of blood transfusion in the prehospital setting and serves to emphasize that the focus of future research and current policy decisions needs to be on the systems that interact to provide prehospital medical care. Findings from the Contextual Question identified the following factors which may provide leverage points for systems-level change that could set the stage for the next level of efficacy research:
- “[s]ourcing and stewardship of blood and blood products;
- [t]echnology for temperature management;
- [p]ersonnel training and education;
- [a]dministrative and clinical oversight;
- [c]osts and funding;
- [c]ommunity and organizational buy-in;
- [e]vidence related to safety, feasibility, and cost effectiveness; [and]
- [e]vidence comparing benefits and harms of whole blood versus blood products on patient outcomes and for implementation of prehospital blood transfusion programs.”
The draft report concluded that, “[t]he objective of this systematic review and meta-analysis was to identify and synthesize the available evidence to support the development of evidence-based recommendations and guidelines for prehospital blood and blood product transfusion. From the beginning, all participants, contributors, and stakeholders involved in this process were aware that the outcome would not be a simple set of algorithmic protocols. This topic converges vast variation in multiple factors influencing prehospital shock resuscitation (patient characteristics, emergency types, provider level) in an emergent environment that defies control, thereby limiting the ability to systematically apply and study interventions. The findings indicate there is insufficient evidence to know what resuscitation products and approaches work best for whom at the clinical level, and the priority needs to be research at the implementation level to develop systems for the practical delivery of interventions that can improve patient outcomes.”
The comment period for the draft report will remain open through September 18th. Improving patient access to blood transfusions on ambulances is a top priority in ABC’s Advocacy Agenda. ABC will continue to provide updates on its advocacy efforts as they become available. Previously, ABC responded to an AHRQ request for “Supplemental Evidence and Data Submission on Prehospital EMS Blood Transfusion and Fluid Interventions for Hemorrhagic Shock.” In those comments to AHRQ, ABC highlighted the important role that its member blood centers play in prehospital blood transfusion programs nationwide and described impediments to implementing and maintaining such programs.
Specifically, the comments included aggregate survey data from ABC members regarding prehospital blood transfusion programs from 2022 to 2024 that demonstrated the impact of community blood centers to prehospital blood transfusion programs. Of note, ABC member blood centers had increased their participation in prehospital blood transfusion programs from 18 in 2022 to 34 member blood centers in 2024. The total number of reported blood products distributed via these programs also increased from 14,882 units in 2023 to 32,202 units in 2024 with low titer group O whole blood (LTOWB) making up 13,452 units in 2024 versus 5,015 in 2023. ABC also explained in the comments that, [t]he most consistent barrier for ABC member blood centers regarding prehospital blood transfusion programs, “is [a] lack of funding [with] operational costs at blood centers already [being] strained. [While additional barriers] that contribute to the reluctance by blood centers to implement a prehospital blood program are the risk of product wastage and the logistical burdens of rotating product between locations to prevent wastage.”