H O W D O I . . . ?
How do we provide blood products to trauma patients?
Shan Yuan, Alyssa Ziman, Mary Anne Anthony, Elsa Tsukahara, Courtney Hopkins, Qun Lu, and
hospitalized annually for injuries sustained secondary
to trauma, with these patients receiving approximately
10% to 15% of the 14.6 million red blood cell (RBC) units
transfused in the United States.2,3Exsanguination is an
important cause of mortality for trauma patients, and
the successful management of severely injured patients
depends in part on adequate and timely transfusion sup-
port.4Therefore, it is not surprising that the provision of
optimal transfusion support for trauma patients has gen-
erated much interest and discussion, especially in recent
years with newly emerging data from both civilian and
Transfusion support in acute trauma can be challeng-
ing and demanding on the resources of the blood bank.
patients, particularly those with the greatest risk of mor-
tality, can arise before or within minutes of their arrival to
the hospital. Recent data from one large trauma center in
the United States showed that 62% of all RBC units were
administered in the first 24 hours of admission, with 18%
given uncrossmatched due to the urgency of transfusion.
rauma is the leading cause of death in individu-
and is expected to become the second leading
cause of death by 2020 across all age groups.1
Although the majority (91%) of trauma patients were not
transfused, the few (3%) that were massively transfused
(i.e., receiving more than 10 units of RBCs) received more
than 71% of all RBC units given. Furthermore, this sub-
group of patients also had a high mortality rate of 39%.5
Occasionally, a single patient can require such massive
transfusion support that a significant amount of available
blood bank resources can be consumed with the patient’s
care. For example, at our center, among trauma victims
who survived in the past 12 months, the maximum
was 112 units of RBCs, 70 units of plasma, 40 units of
cryoprecipitate, and 6 units of apheresis platelets (PLTs).
Such data illustrate that for acute trauma cases, the
transfusion service needs to provide large amounts of
appropriate blood products quickly and communicate
effectively with the clinical team to allow for early recog-
nition of patients with massive transfusion requirements
to keep up with their blood product needs.
Although there has been much interest recently in
what constitutes the optimal transfusion strategy for
trauma patients (e.g., role of early plasma transfusion or
use of alternative hemostatic agents), there is little infor-
mation available addressing the logistic issues posed by
trauma patients on the transfusion service. All blood
banks supporting trauma patients face challenges that
include how to minimize delays associated with patient
registration and completion of requisition forms, how to
provide adequate patient safety measures to avoid mis-
identification and mistransfusion, how to facilitate effec-
tive communication between the blood bank and the
clinical team, how to rapidly deliver blood products to
patient care locations, and finally, how to remain orga-
nized and well coordinated in the fast-moving and
stressful environment of trauma care. We present here a
description of our trauma transfusion program, which has
evolved during the past two to three decades of support-
ing a Level I trauma center. It is our belief that features of
our program, which address the common challenges
listed above, can be adapted to suit the unique character-
our trauma transfusion program that were identified as
areas for improvement after we provided transfusion
support to multiple victims from a recent train accident.
ABBREVIATIONS: BBID = blood bank identification;
ED = emergency department; ID = identification;
MRN = medical record number; RR-UCLA = Ronald Reagan
UCLA Medical Center.
From the Division of Transfusion Medicine, Department of
Pathology & Laboratory Medicine, David Geffen School of
Medicine at UCLA, Los Angeles, California.
Address reprints requests to: Shan Yuan, MD, Department of
Pathology & Laboratory Medicine, David Geffen School of Medi-
cine at UCLA, 10833 Le Conte Avenue, Los Angeles, CA 90095;
Received for publication December 4, 2008; revision
received January 16, 2009; and accepted January 23, 2009.
Volume 49, June 2009
WHERE IT ALL HAPPENS: OUR BLOOD
BANK AND TRAUMA SERVICE
The Ronald Reagan UCLA Medical Center (RR-UCLA) is a
520-bed academic hospital and a designated Level I adult
and pediatric trauma center. The emergency department
(ED) provides care to more than 1000 trauma patients
annually. From July 2006 to June 2007, 283 or approxi-
mately 30% of all trauma patients admitted to the ED
required transfusion support; 34 or 12% of those trans-
fused received more than 10 units of RBCs within the first
For our trauma center, as part of our general inven-
tory management, we reserve 30 units of O– RBCs at all
times. During times of shortage, all orders for O– RBCs are
prospectively audited using patient’s hemoglobin con-
and nonreproductive-aged (>50 years of age) female D–
trauma and nontrauma patients can be switched to
receive D+ RBCs. Only as a last resort, and after careful
consideration of patient’s clinical status and inventory
level, do we switch younger female D– patients to receive
D+ RBC products.
STREAMLINING PATIENT IDENTIFICATION
AND BLOOD PRODUCT REQUISITION: THE
istration and preparation of requisition forms, each
trauma patient is assigned a premade gender-specific
trauma packet upon arrival at the RR-UCLA ED.
The trauma packet contains all essential forms, labels,
and identification (ID) bands needed to complete regis-
tration and laboratory and radiology requisitions, as well
as blood transfusion requests. Items pertinent to blood
transfusion support in the trauma packet include the
• Hospital ID band with preassigned medical record
trauma ID. Information regarding gender is used by
the blood bank in deciding whether D+ units can be
Multiple self-adhesive encounter labels preprinted
with preassigned MRN and temporary trauma ID.
Blood bank order form with preaffixed encounter
Nonstandard blood release request with preaffixed
encounter label, which allows for expedited release of
blood products without completion of routine com-
Blood bank ID (BBID) wristband (Typenex Medical
LLC, Chicago, IL) as a second form of patient ID.
are placed on the patient, BBID labels removed directly
from the BBID bracelet are affixed to the forms and the
specimen tube, thus providing a link between the patient,
paperwork are sent to the blood bank via pneumatic tube
to allow rapid processing.
DOING IT QUICKLY BUT SAFELY:
PROVISION OF UNCROSSMATCHED RBCS
Trauma patients often receive uncrossmatched group O
RBCs before any compatibility testing can be completed.
To meet the immediate needs of these patients, the
RR-UCLA ED maintains a minimum of 4 units of O– RBCs
in a monitored refrigerator in the trauma suite at all times.
If multiple victims are expected, this number is increased
to 12. This refrigerator is monitored by the blood bank
with a door alarm and temperature sensor linked to the
centralized wireless temperature monitoring system
installed in the blood bank (Isensix, San Diego, CA). If the
alarm sounds in the blood bank, blood bank staff calls
the ED to ascertain the reason for the alarm and, if appli-
cable, obtain patient identity and the trauma tier designa-
tion. Not uncommonly the door alarm is the blood bank’s
first notification of a bleeding trauma patient.When units
are removed, ED staff affixes both patient encounter and
BBID labels to the bottom portion of the transfusion slip
attached to the unit and returns this portion to the refrig-
erator to allow inventory reconciliation and documenta-
tion by the blood bank.
In addition, two temporary storage coolers, each con-
taining 4 units of group O– RBCs are maintained in the
blood bank at all times.These units may be used to supply
a specific patient requiring urgent transfusion regardless
of location, or to quickly restock the ED refrigerator. For
our most critical trauma patients (Tier III, described
below), a cooler is immediately sent to the bedside in the
With the emergence of data supporting early plasma
transfusion for trauma patients, our blood bank main-
tains a prethawed inventory of 10 group A and 5 group O
plasma units at all times to enable immediate release to
group A and O patients (estimated to be 85% of our
patient population). Owing to inventory limitations,
frozen group B and AB plasma products are only thawed
If the need for urgent transfusion arises before the
patient specimen is available, the blood bank will prepare
and issue universal donor components (group O RBCs
and/or AB plasma) as long as patient ID is provided.
Transfusion requests in this type of scenario can be com-
municated to the blood bank through a completed blood
bank order form with “no specimen” written on the form.
If a specimen is available, the ABO/Rh type is determined
in 5 minutes using the manual tube method, and
YUAN ET AL.
Volume 49, June 2009
uncrossmatched but type-specific blood components are
issued to conserve universal donor products.
When issuing uncrossmatched, type-specific units
for transfusion, the potential for acute ABO-incompatible
hemolytic transfusion reaction due to a mislabeled speci-
men for blood typing is a major concern, particularly
when there are multiple patients. The use of two identifi-
ers, hospital MRN and BBID on specimens and blood
bank requisition forms, provides a safeguard. While the
hospital MRN remains with the patient throughout the
admission, the BBID wristband is usually removed as
the patient is stabilized and transferred to the floor. Once
the BBID is removed, and if there is no historical blood
type on file, then a second separately drawn specimen
(“check type”) must be submitted to the blood bank to
confirm the blood type before non–type O RBCs can be
issued.6The check type requirement is waived if the
trauma patient has received more than 10 units of type-
specific RBCs without adverse event (i.e., biologic
STRATIFYING THE TRAUMA PATIENTS:
THE TIER SYSTEM
The RR-UCLATraumaTier System facilitates communica-
tion between the trauma team and the blood bank about
the severity of the patient’s injuries and potential transfu-
sion needs and allows for expedited preparation and
delivery of blood products. The tier designation also
allows the early recognition of patients who will likely
receive massive transfusion, and therefore benefit from a
1:1 ratio of RBC and plasma transfusion. Based on the
initial assessment by the ED trauma physician, each
patient is assigned to a trauma tier. In general, stable
patients with minor injuries are categorized as Tier I,
stable patients who may need surgical interventions are
assigned asTier II, and unstable patients requiring imme-
diate transfusion are assigned as Tier III.
Based on the tier designation, the trauma transfusion
protocol is activated, which includes performance of stat
type and screen and preparation of predetermined
numbers of specific blood components for immediate
delivery. In addition, tier-specific numbers of RBC and
plasma units are prepared as “keep-ahead” orders in
anticipation of additional transfusion needs. Until can-
celed by a physician, keep-ahead units are automatically
replenished to ensure immediate product availability.
RBC and plasma units are provided at 1:1 ratio, with 1 unit
of apheresis PLTs supplied with every 10 units of RBCs.
Pools of 10-unit cryoprecipitate are prepared upon
request (see Table 1). Other hemostatic agents, such as
recombinant FVIIa or antifibrinolytic agents can also be
ordered from the pharmacy and be administered to suit-
able trauma patients.
FROM THE BLOOD BANK TO THE
BEDSIDE: TRANSPORT OF BLOOD
Several means of delivering blood products are available
at our institution. For trauma patients, most RBC and
plasma products are delivered in coolers. The coolers can
be sent directly from the blood bank to the ED, interven-
tional radiology, or operating room and then transported
along with the patient to new locations. For the conve-
nience of the clinical team, and to minimize unnecessary
opening and closing, coolers are color-coded (red for RBC
units and yellow for plasma units). Internal temperature
is monitored with a credit card–sized device (LogTag
Recorders Ltd, Hong Kong, China), so that if the tempera-
ture falls out of range, the indicator light turns from green
to red. Furthermore, the device is programmed to capture
and store temperature data every 5 minutes, and record-
ings are downloaded for subsequent analysis so the
appropriate disposition of returned unused units can be
determined. The coolers have been validated to store 6
units of RBCs or plasma for up to 8 hours.
TABLE 1. Actions taken by the blood bank based on the trauma tier designation*
• Stat type and screen
• Stat type and screen
• Prepare 4 units of RBCs
• Assign 4 units of plasma; thaw if not available in
• Send above products upon request
• Stat type and screen
• Immediately send 4 units of O– or O+ RBCs
• Prepare 10 units of RBCs
• Assign 10 units of plasma; thaw if not available in
• Send above products
• Prepare blood products only upon request.
• Keep ahead at all times 4 units of RBCs and 4 units of plasma.
III • Keep ahead 10 units of RBCs and 10 units of plasma
• Provide 1 unit of apheresis PLTs for every 10 units of RBCs
• Prepare pooled cryoprecipitate upon request
* RBC products may be type O or type specific, crossmatched or uncrossmatched. Type-specific plasma is provided after blood type is
determined. If blood type is not available, AB plasma is provided.
PROVIDING BLOOD PRODUCTS TO TRAUMA PATIENTS
Volume 49, June 2009
During a trauma case, RBC and plasma coolers are
mainly transported by a dedicated blood bank courier,
available at all times. If the courier is away making a deliv-
ery, and blood products are needed by another patient
immediately, a blood bank staff member will serve as
backup. Cryoprecipitate, PLT units, and single units of
RBCs can be sent through a pneumatic tube system,
whichhas been validated
for blood component
STAYING ORGANIZED AND INFORMED:
THE DESIGNATED “TRAUMA TECH” AND
TRAUMA TRANSFUSION CHECKLIST
Trauma cases can be associated with high work volumes
and rapid paces; therefore, to avoid miscommunication
and errors, careful planning and good organization are
essential. To facilitate prompt preparation and delivery of
blood products and communication with the clinical
team as well as within the blood bank, two blood bank
trauma case, one as the trauma tech and the other as the
backup.The trauma tech serves as the coordinator for the
case in the blood bank and the liaison with the trauma
team, and is equipped with a cordless phone, which pro-
vides an exclusive hotline for the trauma team. The
trauma tech’s responsibilities are to:
• Answer all telephone calls regarding the trauma case,
including receiving additional verbal orders and pro-
ity if there are potential delays or shortages.
Communicate with other blood bank technologists
and supervisors on blood product needs of the
Coordinate blood product preparation and delivery.
Ensure that all blood product keep-ahead levels are
Maintain the trauma transfusion checklist and log of
Sign off the case and communicate pertinent infor-
mation about the trauma to the backup trauma tech
Our trauma transfusion checklist, similar to check-
lists used in other areas of health care,8-10is designed to
ensure that critical steps are taken at appropriate times
(e.g., ensuring receipt of a type and screen specimen and
maintaining keep-ahead blood products). The checklist
can also serve as a communication tool to convey key
information among blood bank staff members, such as
the patient’s blood type, trauma tier level, and patient
location, particularly if the patient has been transported
to a different patient care area. Additionally, a completed
checklist allows retrospective review to provide valuable
practice benchmark data, such as percentages of cases
with timely submission of patient specimen and delivery
of blood products. Such data can also be used for quality
assurance and to identify opportunities for practice
WHAT WE LEARNED AND WHAT WE WANT
On September 12, 2008, a Union Pacific freight train and a
full Metrolink commuter train collided in Chatsworth, in
Los Angeles County, California, killing 25 people on board
and injuring 135. Eight of the injured victims were flown
to the RR-UCLA, all of whom survived, including 4 who
required transfusion support. This multivictim trauma
provided a rare opportunity that not only put our trauma
areas for improvement, especially when transfusion
support for multiple patients is required. The insights we
gained are summarized below:
1. While having a limited prethawed inventory of only
10 group A and 5 group O units of plasma meets the
needs of patient care of our trauma center in most
circumstances, the likelihood of needing group B or
AB plasma increases with a multivictim trauma.
Therefore, we decided that when multiple trauma
upon notification of their impending arrival to mini-
mize delays associated with thawing additional type-
Cryoprecipitate is not part of our standard trauma
transfusion protocol, but is being increasingly
requested for trauma patients at our center. Currently
we have only frozen single units of cryoprecipitate,
which must be pooled first and then issued indivi-
dually. To facilitate more rapid release of cryopre-
cipitate, we should maintain a stock of prepooled
The dedicated blood bank courier was an invaluable
resource during this multivictim trauma and allowed
for the delivery of 119 blood products to four patients
within 3 hours. Recognizing the value of a dedicated
blood bank courier in such situations, hospital
administration has agreed to mobilize hospital escort
services to provide additional blood transport per-
sonnel during a disaster.
Optimal care for trauma patients cannot be accomplished
without the reliable and timely provision of blood prod-
ucts. Our trauma transfusion program has successfully
achieved this by utilizing standardized transfusion proto-
cols based on the severity of the patient’s injury and
by addressing logistical issues such as patient ID,
YUAN ET AL.
Volume 49, June 2009
age other health systems to examine and consider the
approaches we have described in this report. It is also our
hope that discussions in this area can be generated and
other transfusion services will share their expertise and
traumas involving multiple severely injured patients.
CONFLICT OF INTEREST
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PROVIDING BLOOD PRODUCTS TO TRAUMA PATIENTS
Volume 49, June 2009
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