Retooling the Massive Transfusion Protocol at a Veterans Affairs Medical Center

Massive transfusion protocols (MTPs) ensure the timely and life-saving delivery of blood products to patients who are rapidly exsanguinating. Although essential, MTPs are also highly resource-intensive. Effective MTP implementation must balance the resources of the hospital with the needs of the patient population that they serve, as well as avoid instances of unjustified activations. Toward this goal, we implemented a set of policy improvements to our institution's MTP aimed at ensuring appropriate clinical activation.

Following interdisciplinary discussions with clinical teams, we revamped our institution's MTP in the spring of 2019, focusing on the improved training of junior clinicians by requiring final approval of all MTP activations by attendings and fellows, and providing opportunities to review MTP execution during quarterly meetings. Other changes included implementing blood warmers and streamlining the MTP ordering process. We then performed a retrospective study to evaluate the effects of our refurbished MTP on the frequency, characteristics, and outcomes of massive transfusions activated at the Washington DC Veterans Affairs Medical Center between March 2018 to February 2019 and March 2019 to February 2020 (before and after the policy change, respectively). Descriptive statistics were used to summarize the data. Fisher exact test, Wilcoxon test, and Poisson test were used to compare differences in categorical variables, continuous variables, and the rate of MTP activation, before and after policy changes were implemented, respectively. This study is exempt from the Institutional Review Board's review.

We did not detect statistically significant changes in patient and MTP-related parameters, nor survival outcomes following policy improvement. However, we observed a decreasing trend in MTP activations, and concomitantly, a significant increase in the number of days between MTP activations, from 12.5 days (median) in the first year to 41 days (median) in the second year (P = 0.0274).

In summary, we developed an MTP tailored to the needs of our Veterans Affairs Medical Center, providing a reliable system for blood product administration to patients with real massive transfusion requirements while reducing unjustified MTP activations. We credit the reduction in MTP activations mainly to improved education and training of clinicians, which, in turn, changed their ordering behaviors. Fewer unjustified MTP activations decrease the potential for wastage of resources such as blood and blood components and preserves work hours of staff for patients with true transfusion needs. We believe our strategy may have a widespread and compounding effect on improving blood stewardship nationwide, given our trainees' propensity to work at medical centers across the country and educate future trainees of their own.