Page 49 - JSOM Spring 2023

Methods manage these complications. Paramedics authorized to admin-
ister blood received and additional hour of Just In Time Train-
This is a retrospective case series of prehospital and inpatient ing before implementation of the pilot.
electronic health records (EHR) for patients age >18 years of
age who were transported to the ED by the Prisma Health Patient Care Protocol
Ambulance Service (PHAS) and received prehospital blood The prehospital blood protocol was developed with collabora-
products, from 1 January 2020 to 31 August 2021. All cases tion from the medical and executive directors of EMS, Trauma
occurred within the South Carolina Upstate region (western Services, and Laboratory Services at Prisma Health-Upstate.
SC) and the majority of patients were transported to hospi- The protocol and alert criteria were reflective of the standards
tals within the Prisma Health Network (encompassing greater for similar inpatient treatment (Figure 1).
Greenville County and Oconee County, SC). Other facilities to
which a smaller number of patients were transported include Patients warranting transfusion were identified by their mech-
Bon Secours Health System – St. Francis Downtown (Green- anism of injury or nature of illness and were required to meet
ville, SC) and AnMed Health Medical Center (Anderson, SC). at least two physiological parameters indicative of significant
This study was approved by the Prisma Health-Upstate Insti- blood loss. If able, patients were consented using a hospital-
tutional Review Board under the expedited category. established standardized blood consent form. Implied consent
was utilized in emergent scenarios in which patients were un-
The SC Department of Health & Environmental Control – able to provide consent and blood transfusion was considered
Bureau of EMS (SCDHEC EMS) approved PHAS to provide an emergent standard of care. When at all possible, patients
prehospital blood transfusion as a pilot project according to were screened for a history of transfusion reaction, and any
strict criteria as dictated by protocol. Prior to this initiative, patient with a reported history of such did not receive blood
blood products were not transfused by ground ambulance sys- products.
tems in the state of SC.
A full set of vital signs were obtained and documented as is
Setting standard for the prehospital patient evaluation. Tempera-
PHAS is a hospital-based EMS system in the upstate region of tures were obtained by an oral thermometer prior to blood
SC providing basic life support (BLS), advanced life support administration. In this review, this initial value served as the
(ALS), and critical-care transport. PHAS is the sole 911 EMS “pre-transfusion temperature.”
responder for Oconee County, SC, which is geographically
674 mi , and has an estimated population of 72,633 people. Following establishment of bilateral IV access and a bolus of
2
From within Oconee County, average transport time to a fluid if appropriate, adult patients were administered a goal
Level-1 trauma center (Greenville Memorial Hospital) is 46 volume of two units of O-positive PRBC and two units of FFP.
minutes and 54 seconds. Through mutual-aid agreements, Blood products were warmed using the Quantum following
PHAS also provides 911 services for Anderson, Greenville, manufacturer instructions. All patients were continuously
11
Laurens, and Pickens, SC counties. PHAS is also the sole in- monitored for any adverse events during transport. EMS care
terfacility and critical-care provider for eight acute-care hospi- was considered complete following a thorough patient handoff
tals. From 1 January 2020 to 31 August 2021, PHAS answered to the accepting ED team with, at minimum, an explanation
70,902 requests for service and transported 58,500 patients. of why blood was transfused, and verbal report with written
documentation of all products transfused. If blood product
Blood Alert Process was still infusing, the paramedic would report how much total
PHAS operates a tiered response plan with 25 transport am- product was given.
bulances and four ALS quick-response vehicles equipped with
blood products. Requests for service are answered by an Emer- Prehospital blood products were maintained in the Credo
gency Medical Dispatch (EMD) certified communications ProMed (Peli BioThermal, https://pelibiothermal.com/products
center. PHAS blood products are dispatched automatically by /credo-promed) transport bag. Temperatures were moni-
EMD protocol, or upon the request of the 911 system provider tored by ThermoWorks alarming thermometers (https://www
of either Greenville, Laurens, or Pickens counties. All blood dis- .thermoworks.com/) and LogTag (https://logtagrecorders.com
patches are initially alerted to the medical and operational di- /us/) thermal recording technology. All unused prehospital
rectors and EMS supervisors through a text-page “Blood Alert.” blood units were exchanged on a strict 24-hour schedule at
This occurs in real time (at the time of EMS request for transfu- the hospital blood bank. Data were downloaded weekly into
sion) and is sent via the regional communications center. This is reports that were electronically sent to the hospital blood bank
a communication requirement of all transfusions as set forth in for review and quality monitoring.
the PHAS Blood Transfusion protocol and allows for the direc-
tors to track the patient’s chart electronically once it has been Emergency Department Care
signed by the EMS crew. All patient care is documented in an ED care was based on physician assessment and standard
electronic patient care report system with a searchable database. of care within that health system. All patients were carefully
monitored for any post-transfusion events. For critically ill
Training trauma or obstetrical patients that were taken to the operating
All PHAS paramedics received eight hours of in-person train- room (OR), care in the ED may have been relatively brief.
ing, including four hours of psychomotor and medical sim-
ulations. This training included indications for emergent Temperatures in the ED were generally taken at the time of
prehospital transfusion and the blood-transfusion protocol arrival (initial nursing triage and assessment) by the oral route,
(Figure 1). Additionally, all PHAS clinicians were educated on although some were taken cutaneously (axillary), rectally, or
possible adverse reactions to transfusion, as well as how to via temperature-sensing bladder catheter. These temperatures

Prehospital Blood Transfusion Effect on Body Temperature | 47