title: Trauma-induced coagulopathy: impact of the early coagulation support protocol on blood product consumption, mortality and costs.
abstract: BACKGROUND
  Hemorrhage is the principal cause of death in the first few hours following severe injury. Coagulopathy is a frequent complication of critical bleeding. A network of Italian trauma centers recently developed a protocol to prevent and treat trauma-induced coagulopathy. A pre-post cohort multicenter study was conducted to assess the impact of the early coagulation support (ECS) protocol on blood products consumption, mortality and treatment costs.
  
  
  METHODS
  We prospectively collected data from all severely injured patients (Injury Severity Score (ISS) >15) admitted to two trauma centers in 2013 and compared these findings with the data for 2011. Patients transfused with at least 3 units of packed red blood cells (PRBCs) within 24 hours of an accident were included in the study. In 2011, patients with significant hemorrhaging were treated with early administration of plasma with the aim of achieving a high (≥1:2) plasma-to-PRBC ratio. In 2013, the ECS protocol was the treatment strategy. Outcome data, blood product consumption and treatment costs were compared between the two periods.
  
  
  RESULTS
  The two groups were well matched for demographics, injury severity (ISS: 32.9 in 2011 versus 33.6 in 2013) and clinical and laboratory data on admission. In 2013, a 40% overall reduction in PRBCs was observed, together with a 65% reduction in plasma and a 52% reduction in platelets. Patients in the ECS group received fewer blood products: 6.51 units of PRBCs versus 8.14 units. Plasma transfusions decreased from 8.98 units to 4.21 units (P <0.05), and platelets fell from 4.14 units to 2.53 units (P <0.05). Mortality in 2013 was 13.5% versus 20% in 2011 (13 versus 26 hospital deaths, respectively) (nonsignificant). When costs for blood components, factors and point-of-care tests were compared, a €76,340 saving in 2013 versus 2011 (23%) was recorded.
  
  
  CONCLUSIONS
  The introduction of the ECS protocol in two Italian trauma centers was associated with a marked reduction in blood product consumption, reaching statistical significance for plasma and platelets, and with a non-significant trend toward a reduction in early and 28-day mortality. The overall costs for transfusion and coagulation support (including point-of-care tests) decreased by 23% between 2011 and 2013.
authors.affiliation: Department of Shock and Trauma Center, S Camillo-Forlanini Hospital, Circonvallazione Gianicolense 87, Roma, 00152, Italy. gnardi@scamilloforlanini.rm.it.
authors.forename: Giuseppe
authors.initials: G
authors.lastname: Nardi
authors.affiliation: Departement of Clinical Pathology and Transfusion Medicine, Bufalini Hospital, Via Ghirotti 286, Cesena, 45072, Italy. vanessa.agostini@ausl-cesena.emr.it.
authors.forename: Vanessa
authors.initials: V
authors.lastname: Agostini
authors.affiliation: Department of Hematology and Transfusion Medicine, S Camillo-Forlanini Hospital, Circonvallazione Gianicolense 87, Roma, 00152, Italy. mrondinelli@scamilloforlanini.rm.it.
authors.forename: Beatrice
authors.initials: B
authors.lastname: Rondinelli
authors.affiliation: Department of Anesthesia and ICU, Trauma Service, Bufalini Hospital, Via Ghirotti 286, Cesena, 45072, Italy. lelegaiola@gmail.com.
authors.forename: Emanuele
authors.initials: E
authors.lastname: Russo
authors.affiliation: Department of Shock and Trauma Center, S Camillo-Forlanini Hospital, Circonvallazione Gianicolense 87, Roma, 00152, Italy. barbarabastianini@gmail.com.
authors.forename: Barbara
authors.initials: B
authors.lastname: Bastianini
authors.affiliation: Department of Anesthesia and ICU, Trauma Service, Bufalini Hospital, Via Ghirotti 286, Cesena, 45072, Italy. gbini@ausl-cesena.emr.it.
authors.forename: Giovanni
authors.initials: G
authors.lastname: Bini
authors.affiliation: Departement of Clinical Pathology and Transfusion Medicine, Bufalini Hospital, Via Ghirotti 286, Cesena, 45072, Italy. sbulgarelli@ausl-cesena.emr.
authors.forename: Simona
authors.initials: S
authors.lastname: Bulgarelli
authors.affiliation: Department of Shock and Trauma Center, S Camillo-Forlanini Hospital, Circonvallazione Gianicolense 87, Roma, 00152, Italy. ecingolani@scamilloforlanini.rm.it.
authors.forename: Emiliano
authors.initials: E
authors.lastname: Cingolani
authors.affiliation: Department of Anesthesia and Intensive Care, University of Siena, Strada delle Scotte 14, Siena, 53100, Italy. draledonato@gmail.com.
authors.forename: Alessia
authors.initials: A
authors.lastname: Donato
authors.affiliation: Department of Anesthesia and ICU, Trauma Service, Bufalini Hospital, Via Ghirotti 286, Cesena, 45072, Italy. ggambale@ausl-cesena.emr.it.
authors.forename: Giorgio
authors.initials: G
authors.lastname: Gambale
authors.affiliation: Department of Shock and Trauma Center, S Camillo-Forlanini Hospital, Circonvallazione Gianicolense 87, Roma, 00152, Italy. giulia.ranaldi@libero.it.
authors.forename: Giulia
authors.initials: G
authors.lastname: Ranaldi
mesh_terms: D000328:Adult; D001777:Blood Coagulation; D001778:Blood Coagulation Disorders / Q000191:economics / Q000209:etiology / Q000401:mortality*; D016913:Blood Component Transfusion / Q000191:economics / Q000379:methods*; D005260:Female; D006470:Hemorrhage / Q000628:therapy*; D017052:Hospital Mortality; D006801:Humans; D015601:Injury Severity Score; D007558:Italy; D008297:Male; D008875:Middle Aged; D010949:Plasma; D011446:Prospective Studies; D012151:Resuscitation / Q000379:methods; D016019:Survival Analysis; D016896:Treatment Outcome