title: Room for (performance) improvement: provider-related factors associated with poor outcomes in massive transfusion.
abstract: BACKGROUND
  Massive transfusion (MT) protocols improve survival in patients with exsanguinating hemorrhage. Both the increased plasma to red blood cells (RBC) and platelets to RBC ratios, and the "protocolization" of product delivery seem to be critical components of the reduction in mortality. The purpose of this study was to identify the incidence and impact of MT protocol noncompliance and to intervene in provider-related events associated with poor compliance and outcomes.
  
  
  METHODS
  A MT protocol was initiated in 2006 at a Level I trauma center. All cases of protocol activation were reviewed by a multidisciplinary performance improvement (PI) group for compliance and the need for "real-time" protocol adjustments. Educational conferences, Grand Rounds presentations, and individual provider education were performed on a quarterly basis. Compliance of seven measures were evaluated as follows: type and screen sent from emergency department (ED), activation of protocol in ED, activation by trauma attending, administration of 2:3 plasma to RBC, administration of 1:5 platelets to RBC, protocol discontinuation on leaving operating room, and no products wasted. Univariate, multivariate, and time-series analyses were performed.
  
  
  RESULTS
  All 125 MT protocol activations occurring from February 2006 to January 2008 were reviewed. Full compliance for all PI measures during the entire period was 27%. There were no differences in demographics, injury severity, or physiologic scores between patients for whom activations were compliant and those who were noncompliant. Full compliance was an independent predictor of survival (86.7% vs. 45.0%, p < 0.001). Both activation of the protocol in the ED and achievement of prespecified ratios of plasma: RBC (2:3) and platelets: RBC (1:5) were independent predictors of 24-hour and 30-day survivals. All PI measures demonstrated improved compliance during the study period with the exception of ED activation. Failure to send type and screen from the ED is an independent predictor of wasted blood products.
  
  
  CONCLUSIONS
  Early activation of a MT protocol and achieving predefined ratios was associated with improved survival. ED activation and direct blood bank notification by the trauma attending were associated with a reduction in blood product wastage. A multidisciplinary PI process helps to identify provider/specialty noncompliance and to assess the impact of these factors, and it was associated with improvement in compliance and MT outcomes over time.
authors.affiliation: Department of Surgery, Center for Translational Injury Research, The University of Texas Health Science Center, Houston, Texas 77030, USA. bryan.a.cotton@uth.tmc.edu
authors.forename: Bryan A
authors.initials: BA
authors.lastname: Cotton
authors.forename: Lesly A
authors.initials: LA
authors.lastname: Dossett
authors.forename: Brigham K
authors.initials: BK
authors.lastname: Au
authors.forename: Timothy C
authors.initials: TC
authors.lastname: Nunez
authors.forename: Amy M
authors.initials: AM
authors.lastname: Robertson
authors.forename: Pampee P
authors.initials: PP
authors.lastname: Young
mesh_terms: D000328:Adult; D016913:Blood Component Transfusion / Q000379:methods; D001803:Blood Transfusion / Q000379:methods*; D002985:Clinical Protocols; D005260:Female; D006470:Hemorrhage / Q000401:mortality / Q000628:therapy*; D006801:Humans; D015601:Injury Severity Score; D016015:Logistic Models; D009102:Multiple Organ Failure / Q000517:prevention & control; D016017:Odds Ratio; D017063:Outcome Assessment, Health Care; D011446:Prospective Studies; D019984:Quality Indicators, Health Care; D012189:Retrospective Studies; D013714:Tennessee; D014193:Trauma Centers / Q000458:organization & administration; D014947:Wounds and Injuries / Q000401:mortality / Q000628:therapy; D055815:Young Adult