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Prehospital Blood Transfusion Programs

Severe bleeding is the leading cause of preventable death among trauma patients, including those involved in a motor-vehicle crash. Scientific evidence makes clear that providing blood at the scene—before arrival at the hospital—can save many more lives. For every minute of delay in administering prehospital blood to a trauma patient, mortality increases by 11%.

What Is a Prehospital Blood Transfusion Program?

A prehospital blood transfusion program enables EMS agencies to supply lifesaving blood and/or blood components to trauma patients and anyone else who may need it at the scene of an incident.

Why Establish a Prehospital Blood Transfusion Program?

The benefits of adding prehospital blood transfusion programs in your community can be profound. Both military and civilian scientific research makes clear that many lives could be saved if blood was delivered sooner to those experiencing trauma. In particular, there’s an opportunity to offer lifesaving blood as part of improving post-crash care, one of five parts of a Safe System Approach to eliminating roadway deaths.

A joint position statement from the American College of Surgeons Committee on Trauma, the American College of Emergency Physicians and the National Association of EMS Physicians published in July 2023 in the Annals of Emergency Medicine cites research showing that “prehospital blood product resuscitation has demonstrated greater than predicted survival with a 37% reduction in 30-day mortality among severely injured civilian patients.”

Three Benefits of a Prehospital Blood Transfusion Program

By bringing whole blood transfusions to the point of injury, EMS teams can act faster, stabilize critical patients sooner, and ultimately save more lives.

  • Improved patient outcomes – Trauma patients who received whole blood in the field were four times more likely to survive than those who did not.

  • Enhanced EMS capabilities – A prehospital blood transfusion program allows clinicians to more quickly and efficiently stabilize complex trauma patients.

  • Faster progress toward reducing roadway fatalities – Between 2013 and 2022, fatal traffic crashes increased by 30%. As trauma-related deaths rise, giving emergency responders the ability to administer blood before patients reach the hospital can significantly improve survival rates.

What Does a Prehospital Blood Transfusion Program Look Like?

Around the country, EMS organizations are creating a prehospital blood transfusion program to serve their trauma patients. Some are established in a single agency, while others serve a region, which may increase the number of stakeholders who will support the effort, like 911 centers, which may dispatch prehospital blood resources to an incident.

Use the resources below to better understand how others approach their prehospital blood transfusion program to help find the way that will work best for you. It’s important, too, to understand how your state’s EMS scope of practice may need to change to allow clinicians to administer blood as well as possible related changes to legislation and licensure.

Six Elements of a Prehospital Blood Transfusion Program

Community, regional and hospital blood banks, hospital administrators, EMS, state/local EMS medical director, trauma/ER personnel and state agencies with jurisdictional authority provide initial and ongoing input and feedback. They can assist in overcoming regulatory, administrative and logistical barriers.

Across the country, blood is often in short supply, and one crash patient can require as many as 100 units of blood. Working with regional hospitals and blood banks ensures adequate blood products are available to EMS, and agency-based blood drives can also increase supply.

Vehicles carrying blood products must have blood-administration equipment, fluid warmers and temperature-monitored coolers that maintain appropriate storage conditions.

Sharing scientific literature supporting the value of prehospital blood transfusion in more trauma patients is critical, as is allocating funds and time to develop a prehospital blood administration training curriculum and paying clinicians salaries to participate in training and ongoing education, evaluation and credentialing.

Initial and ongoing data analysis on blood usage patterns, patient outcomes, system efficiency, local/state gaps in blood availability and access, inventory levels and transportation infrastructure tracks a prehospital blood transfusion program’s effectiveness.

These include documented, locally compliant processes and criteria for clinician (paramedic) transfusion of prehospital blood; storage, packaging, transport, and resupply of blood; disposition of unused blood; billing and reimbursement; and patient hand over from EMS to hospital staff.

Resources

Chang R, Kerby JD, Kalkwarf KJ, Van Belle G, Fox EE, Cotton BA, Cohen MJ, Schreiber MA, Brasel K, Bulger EM, Inaba K, Rizoli S, Podbielski JM, Wade CE, Holcomb JB; PROPPR Study Group. Earlier time to hemostasis is associated with decreased mortality and rate of complications: Results from the Pragmatic Randomized Optimal Platelet and Plasma Ratio trial. J Trauma Acute Care Surg. 2019 Aug;87(2):342-349. doi: 10.1097/TA.0000000000002263. PMID: 31349348; PMCID: PMC6771437.

Cotton, Bryan A. MD, MPH; Podbielski, Jeanette BSN; Camp, Elizabeth MSPH; Welch, Timothy NREMT-P; del Junco, Deborah PhD†; Bai, Yu MD, PhD; Hobbs, Rhonda MT (ASCP); Scroggins, Jamie MT (ASCP); Hartwell, Beth MD§; Kozar, Rosemary A. MD, PhD; Wade, Charles E. PhD; Holcomb, John B. MD. A Randomized Controlled Pilot Trial of Modified Whole Blood versus Component Therapy in Severely Injured Patients Requiring Large Volume Transfusions. Annals of Surgery 258(4):p 527-533, October 2013. | DOI: 10.1097/SLA.0b013e3182a4ffa0 

Gruen DS, Guyette FX, Brown JB, Okonkwo DO, Puccio AM, Campwala IK, Tessmer MT, Daley BJ, Miller RS, Harbrecht BG, Claridge JA, Phelan HA, Neal MD, Zuckerbraun BS, Yazer MH, Billiar TR, Sperry JL. Association of Prehospital Plasma With Survival in Patients With Traumatic Brain Injury: A Secondary Analysis of the PAMPer Cluster Randomized Clinical Trial. JAMA Netw Open. 2020 Oct 1;3(10):e2016869. doi: 10.1001/jamanetworkopen.2020.16869. PMID: 33057642; PMCID: PMC7563075.

Holcomb JB, Tilley BC, Baraniuk S, et al. Transfusion of Plasma, Platelets, and Red Blood Cells in a 1:1:1 vs a 1:1:2 Ratio and Mortality in Patients With Severe Trauma: The PROPPR Randomized Clinical Trial. JAMA. 2015;313(5):471–482. doi:10.1001/jama.2015.12

Lammers, Daniel & Hu, Parker & Rokayak, Omar & Baird, Emily & Betzold, Richard & Hashmi, Zain & Kerby, Jeffrey & Jansen, Jan & Holcomb, John. (2024). Preferential whole blood transfusion during the early resuscitation period is associated with decreased mortality and transfusion requirements in traumatically injured patients. Trauma Surgery & Acute Care Open. 9. e001358. 10.1136/tsaco-2023-001358. link

Lammers D, Rokayak O, Uhlich R, Sensing T, Baird E, Richman J, Holcomb JB, Jansen J. Balanced resuscitation and earlier mortality end points: bayesian post hoc analysis of the PROPPR trial. Trauma Surg Acute Care Open. 2023 Aug 9;8(1):e001091. doi: 10.1136/tsaco-2023-001091. PMID: 37575614; PMCID: PMC10414081.

Lammers DT, Holcomb JB. Damage control resuscitation in adult trauma patients: What you need to know. J Trauma Acute Care Surg. 2023 Oct 1;95(4):464-471. doi: 10.1097/TA.0000000000004103. Epub 2023 Jun 29. PMID: 37735778.

Levy MJ, Garfinkel EM, May R, Cohn E, Tillett Z, Wend C, Sikorksi RA, Troncoso R Jr, Jenkins JL, Chizmar TP, Margolis AM. Implementation of a prehospital whole blood program: Lessons learned. J Am Coll Emerg Physicians Open. 2024 Mar 21;5(2):e13142. doi: 10.1002/emp2.13142. PMID: 38524357; PMCID: PMC10958095.

Pusateri AE, Moore EE, Moore HB, et al. Association of Prehospital Plasma Transfusion With Survival in Trauma Patients With Hemorrhagic Shock When Transport Times Are Longer Than 20 Minutes: A Post Hoc Analysis of the PAMPer and COMBAT Clinical Trials. JAMA Surg. 2020;155(2):e195085. doi:10.1001/jamasurg.2019.5085.

Schaefer RM, Bank EA, Krohmer JR, Haskell A, Taylor AL, Jenkins DH, Holcomb JB. Removing the barriers to prehospital blood: A roadmap to success. J Trauma Acute Care Surg. 2024;97(2S Suppl 1):S138-S144. https://doi.org/10.1097/TA.0000000000004378

Smedley WA, Mabry CD, Collins T, Tabor J, Bowman S, Porter A, Young S, Klutts G, Deloach J, Bhavaraju A, Maxson T, Robertson RD, Holcomb JB, Kalkwarf KJ. Access to Immediately Available Balanced Blood Products in a Rural State's Trauma System. Am Surg. 2023 Jul;89(7):3157-3162. doi: 10.1177/00031348231160836. Epub 2023 Mar 6. PMID: 36877979.

Jason L. Sperry, M.D., M.P.H., Francis X. Guyette, M.D., M.P.H., Joshua B. Brown, M.D., Mark H. Yazer, M.D., Darrell J. Triulzi, M.D., Barbara J. Early-Young, B.S.N., Peter W. Adams, B.S., +18, for the PAMPer Study Group, Published July 25, 2018, N Engl J Med 2018;379:315-326 DOI: 10.1056/NEJMoa1802345.

Last Updated: 04/08/2025