Implementation of an Algorithm for Goal-Directed Hemostatic Resuscitation in Trauma

Abstract

Problem & Purpose Hemorrhage is the leading preventable cause of death following an injury and causes 30 to 40 percent of all trauma deaths. Trauma patients are highly susceptible to life-threatening coagulopathies which potentiate bleeding and require specialized diagnostics to identify and manage. Thromboelastography (TEG) effectively identifies trauma-induced coagulopathies, and offers customized strategies for hemostatic resuscitation, resulting in less blood product transfused, better survival rates, and shorter lengths of stay. The purpose of this evidence-based quality improvement project was to facilitate the process of goal-directed hemostatic resuscitation in trauma patients requiring massive transfusions by protocoling the use of an algorithm for rapid TEG (rTEG) guided hemostatic resuscitation during massive transfusion events (MTE). Methods For a Level I Trauma Center admitting unit with rTEG capabilities, an evidence-based algorithm for rTEG interpretation and application was modified to include rTEG in the existing MTE criteria. Multi-modal educational resources for rTEG interpretation were provided, and processes impeding unit workflow and practices to facilitate integration of rTEG in to active trauma resuscitation were addressed. Total number of blood products given during MTEs were compared with unpaired T-tests between implementation (September – October 2019) and baseline (September – October 2018) timeframes. Staff perceptions of TEG value and application in trauma were assessed before and after implementation of the algorithm. Results Despite numerous challenges throughout project implementation, staff were significantly more comfortable with interpreting TEGs (p=0.002) and teaching TEG interpretation to other nurses (p=0.04) following implementation of the algorithm. Cryoprecipitate (CRYO) administration increased despite having less MTEs in the implementation period, which may reflect increased awareness of hemostatic resuscitation strategies (ratio of CRYO to MTE in 2018: 0.48; 2019: 0.78). No significant difference was found between the volumes of blood products transfused during implementation and baseline timeframes. Conclusion Algorithmic approaches to rTEG application in trauma resuscitation should be considered to enhance nurses’ confidence in rTEG interpretation. Protocoling the use of TEG in traumarelated MTEs may improve adherence to evidence-based goal-directed hemostatic resuscitation strategies through the use of hemostatic blood products. Point-of-care rTEG procedures require extensive multi-disciplinary collaboration, which can be facilitated by a designated process champion.