BEST PRACTICE SUBMISSION
Age of Blood: Reducing the Age of Red Blood Cells and Transfusion in Critically Ill and
Trauma Patients
Points of Contact: Ms. Jill Nessen, Trauma Nurse Coordinator
DSN 314.590.5184 jill.nessen.civ@mail.mil
Group Involved with the Project: LRMC Trauma Research Center, LRMC Pathology and Blood
Services, LRMC Blood Utilization Committee, LRMC Blood Donation Center, and LRMC
Education Department
CPT William Chappell, Administrative Resident
LTC Damon Baine, Preceptor
Landstuhl Regional Medical Center
Executive Summary
Critically ill and trauma patients, including combat casualties, frequently require the
transfusion of blood products including red blood cells as life sustaining treatments. A number
of clinical studies have demonstrated the adverse physiologic effects of “old” red blood cells,
including, but not limited to, increased length of stay (LOS), risk for deep venous
thromboembolism, and increased mortality in critically ill and trauma patients (Aubron, Nichol,
Cooper & Bellomo, 2013). In 2010, the LRMC blood bank reported an increase in the average
age of blood, in days, from 18 to 38 for 941 transfused red blood cell units to 1809 critically ill
trauma patients admitted to the ICU. As a result, a multidisciplinary team initiated a number of
performance improvement initiatives aimed at reducing the age of blood for this patient
population. Included in these initiatives included revised policy reducing the age of blood for
trauma patients to fewer than 30 days, the addition of a “Newest Blood” stamp on the blood
request form, and educational initiatives aimed at nurses and providers administering blood to
trauma patients. Based on these initiatives, the maximum age of blood usage was decreased from
30 to 25 days. In addition, the average age of red blood cells transfused in ICU patients
decreased to 15 days, a 44% reduction since 2010, statistically significant at the 0.05 α-level
(p<.001).
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Objective of the Best Practice
The administration of blood products, specifically red blood cells, is a common practice
among critically ill and trauma patients in the intensive care unit (ICU). According to multiple
retrospective, single-center studies, reducing the age of administered red blood cells to below
fourteen (14) days is correlated with reduced risk of adverse effects of multi-system organ
failure, infection, renal impairment, greater length of stay (LOS), and mortality (Aubron et al,
2013). In a large medical center admitting a significant number of critically ill and trauma
patients, practices aimed at reducing the age of blood transfused to this population, and possibly
others, offers an important opportunity to reduce adverse events and improve patients outcomes.
Background
Since 2003, Landstuhl Regional Medical Center (LRMC) has served as critical role IV
trauma medical center (MEDCEN) for combat casualties evacuated from Iraq and Afghanistan
theaters of operation. LRMC plays a critical role in the stabilization and treatment of these
casualties for return to duty or further medical evacuation to the continental United States
(CONUS) for definitive, coordinated care. Due to the extensive nature of the wounds associated
with combat, specifically the type of injuries seen in these two theaters including multiple
traumatic amputations, severe internal organ trauma, and burns, that require a large portion of
these casualties require transfusion of blood products. These factors are further confounded by
the difficulty in accessing fresh blood due to the cumbersome regulatory and administrative
processes involved in transport and receipt of blood products in Europe. The primary difficulties
associated with timely receipt of blood products revolved around the requirement that donated
blood to be sent to the United States for testing, as the regulatory requirements in Europe are
much less stringent, and do not include many tests required by the Food and Drug
Administration (FDA). It is not until these test results are received that the blood product can be
released for transfusion. As a result of this requirement, the average time to shelf (time between
blood donation and the time is released for transfusion) for donated blood products was six days.
Much research has been conducted surrounding the age of blood and clinical outcomes in
the critically ill patient population, many of which have identified associations between older
blood and poor clinical outcomes.
In 2011, the LRMC Pathology and Blood Services department identified an uptick in the
age of transfused red blood cells among critically ill and trauma patients admitted to the ICU.
Specifically, in 2011 there were 941 units of red blood cells transfused in 1809 trauma patients
admitted to the ICU. During one period, it was noted that the average age of blood transfused
had increased from 18 to 38 days. During the identified period between May 2010 and February
2011, the mean age of blood transfused in the ICU was 28.5 (Figure 1). As a result of this trend,
a multidisciplinary team began implementing initiatives aimed at getting the freshest blood to
critically ill and trauma patients (J. Nessen, personal communication, April 20, 2014)
Literature Review
Anemia is extremely common in the critically ill patient population. In fact according to
research by Corwin et al. (2004), nearly 95% of patients admitted to the intensive care unit (ICU)
have hemoglobin below normal by the third hospital day. As a result, this patient population is
more likely to receive multiple red blood cell (RBC) transfusion. In the prospective, multi-center
observational cohort study, Corwin et al. (2004) reported that among patients admitted to the
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ICU; more than 50% will receive RBC transfusions during their stay, and for those with lengths
of stay (LOS) greater than seven days, this occurrence increased to 85%.
Much research has demonstrated the effects of storage on red blood cell structure and
function. Sometimes referred to as “storage lesions”, these changes that occur after 14 days of
storage have been shown to decrease oxygen delivery capability and increase the likelihood of
occluding the microcirculation (Vandromme, McGwin, & Weinberg, 2009). These changes,
among others, have been linked to a number of adverse clinical outcomes in critically ill and
trauma patients including decreased tissue oxygenation, increased hospital and ICU LOS,
increased risk for post-injury infection and multisystem organ failure, and increased mortality
(Vandromme et al., 2009). In another study, Offner et al. concluded that among severely injured
trauma patients, transfusion of red blood cells older than 14 days and 21 days were independent
risk factors of post-injury infection (2002). Further analysis demonstrated that for each unit of
red blood cells transfused the risk for major post-injury infection increased by 13% (Offner et al.,
2002).
Implementation Methods
Beginning in 2011, a multidisciplinary team including trauma researchers, pathology and
blood service personnel, blood bank personnel, and nursing education began implementing
several initiatives aimed at reducing the average age of blood transfused in trauma patients
admitted to the ICU. Among these initiatives included improving communication among care
providers, streamlining the provider requests for blood products, and optimizing the blood bank
inventory. The initial implementation included a change to the LRMC memorandum for blood
product utilization that required trauma patients admitted to the ICU receive packed red blood
cells that are fewer than thirty (30) days old from the date of collection. Along with this policy
change, a “Newest Blood” stamps was created for use on the blood component request form
(SF518) to be used when ordering and transfusing blood products to trauma patients, ensuring
that the less than thirty day requirement was met.
The blood bank implemented the use of a dedicated “Trauma shelf” for storage of all
blood products aged less than thirty days in order to ensure appropriate stock levels and reduce
the storage of blood that was contributing to the transfusion of older blood. Additionally, the
LRMC blood bank collaborated with the leadership from the blood donation center in order to
improve the assessment and response to blood product needs by scheduling and organizing blood
drives around the blood banks total component inventory.
Landstuhl hospital leadership in collaboration with the education department began
incorporating education and training on these requirements and processes during the initial
orientation that all employees receive. Education and training was also incorporated into the
Clinical Nurse Transition Program (CNTP), which all new nurses attend. During this training,
these nurses receive comprehensive hands on training over the transfusion process, including
documentation, collection, labeling and administration of blood products. Additionally, a large
poster size mockup of the blood product request form highlighting the “Newest Blood” stamp
was placed on the units to guide them through the completion of the form and remind staff of the
importance of the initiative. LRMC’s education department also began including this training
into the semi-annual nursing skills fair offered to LRMC personnel.
Additionally, a Blood Utilization Committee (BUC) was created with the aim of
overseeing and optimizing blood product usage at LRMC. This committee works in tandem with
the blood bank, the Pathology and Blood Services department, the Blood Donor Center and the
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LRMC Education Department in order to maintain all lines of effort engaged in reducing the use
of aged blood in trauma patients.
Finally, the Pathology and Blood Services department worked with local and
international shipping agencies in order to improve the identification of blood component
samples to decrease the lab result turnaround time.
Results
Based on these initiatives, storage of red blood cells was significantly reduced which
allowed the leadership to implement a policy change reducing the maximum age of blood to
trauma patients admitted to the ICU from thirty (30) days to twenty-five (25) days. Additionally,
retrospective analysis of age of blood trends between 2010 and 2013 showed a continuous
decrease in average age of blood transfused in LRMC ICU trauma patients. The average age of
blood between May 2010 and February 2011 was 28.5 days or the ICU. After implementation of
these initiatives, the mean age of blood between March 2011 and December 2013 was 19.6,
representing a 45% decrease (Figure 1). Using Minitab v16, a two sample T-test was performed
which showed a statistically significant difference in pre and post implementation means, t(13) =
3.90, p<0.002 (Table 1).
The Pathology and Blood Services department, in collaboration with local and
international shipping agencies, was able to improve lab result turnaround time by adding
additional blood product identification to the shipments that alerted these agencies of the priority
status. These efforts resulted in an overall reduction of blood product time-to-shelf from six to
three days.
Conclusion
There is significant evidence that transfusion of older blood in critically ill and trauma
patients admitted to the ICU is associated with increased risk for adverse outcomes and increased
mortality. Using a multidisciplinary approach aimed at reducing the storage of blood
component, average age of blood transfused in this population was significantly decreased. This
comprehensive, evidence-based initiative represents a best practice that can be adapted and
replicated in healthcare facilities that care for critically ill and/or trauma patients in the ICU
environment, with potential for improving patient outcomes.
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Appendix
Pre-Implementation
Post-Implementation
Figure 1. Mean age of blood (in days) of transfused blood for trauma patients (ICU) pre and post
initiative implementation (May 2010 – December 2013).
Reproduced using data from LRMC Blood Utilization Committee
Table 1 . t-Test: Two-Sample Assuming Unequal Variances
ICU Age of Blood (Pre) ICU Age of Blood (Post)
Mean
Variance
Observations
Hypothesized Mean Difference
df
t Stat
P(T<=t) one-tail
t Critical one-tail
P(T<=t) two-tail
t Critical two-tail
28.50
43.61
10
0
13
3.9009
0.0009
1.7709
0.0018
2.1604
19.6176
28.0009
34
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References
Aubron, C., Nichol, A., Cooper, J., Bellomo, R. (2013). Age of red blood cells and transfusion
in critically ill patients. Annals of Intensive Care, 3(2), doi: 10.1186/2110-5820-3-2
Corwin, H., Surgenor, S., Gettinger, A. (2003). Transfusion practice in the critically ill. Critical
Care Medicine, 31(12), 668-671
Offner, P., Moore, E., Biffl, W., Johnson, J., Silliman, C. (2002). Increased rate of infection
associated with transfusion of old blood after severe injury. Archives of Surgery, 137(6),
711-717
Vandromme, M., McGwin, G., Weinberg, J. (2009). Blood transfusion in the critically ill: Does
storage age matter? Scandinavian Journal of Trauma, Resuscitation and Emergency
Medicine, 17(35), doi: 10.1186/1757-7241-17-35