Recent research in the New England Journal of Medicine found delivery of plasma by prehospital air-medical transport helicopters could improve outcomes by lowering 30-day mortality rates.1 In North Carolina helicopters from New Hanover Regional Medical Center’s AirLink/VitaLink Critical Care Transport now carry plasma in addition to packed red blood cells, offering the latest in evidence-based and lifesaving care. EMS World recently met with Kevin T. Collopy, BA, FP-C, NRP, CMTE, clinical outcomes manager for AirLink/VitaLink, to discuss this use of prehospital plasma.
EMS World: What have been the biggest obstacles to providing prehospital blood products (both packed red blood cells and plasma), and what are your recommendations for EMS agencies looking to follow your lead?
Collopy: We never truly faced any obstacles once we decided carrying prehospital blood and plasma would provide value for our patients. We began working on this project in early 2017, and from the start we shared a vision with our NHRMC blood bank of beginning with carrying packed red blood cells and adding the additional capability of plasma once we demonstrated consistency in meeting all the regulations surrounding blood storage.
Before we could begin carrying blood products, our blood bank provided us a list of standards from AABB (the American Association of Blood Banks), the governing association that sets blood-handling and storage standards designed to ensure every blood product administered to a patient is safe. Anyone looking to begin carrying blood really needs to seek the aid of a laboratory that understands these regulations. For example, blood must be stored at specific temperatures. The refrigerators in which blood is stored have to be tested to prove they maintain appropriate temperatures before they can be used, and then these refrigerators must be monitored daily to ensure the blood always stays within safe temperature ranges.
Because donated blood is a finite resource, we needed to demonstrate we could properly handle, store, and complete the documentation of blood handling before we began carrying plasma as well. After a year of successfully handling blood safely and dozens of safe administrations by our AirLink teams, the transition to both blood products was fairly easy.
What challenges have you faced with introducing packed red blood cells and plasma to your helicopters, and what are your ongoing concerns for maintaining the ability to offer this treatment?
There are two management challenges requiring ongoing monitoring. In trying to keep to a vision of no blood waste, blood regularly needs to be returned to the blood bank well before it expires. It’s important we coordinate carefully to ensure a timely exchange that allows blood nearing expiration dates to be exchanged in time to be used at the hospital. We try to exchange all blood a week prior to its expiration date so the hospital has enough time to use it. Typically, when teams arrive after a patient transport, they will exchange the blood as necessary.
The second obstacle is ensuring an adequate supply of blood products within our region. If enough blood isn’t available, we may not be able to get additional blood to have on our helicopters. To help overcome this we partnered with the American Red Cross to host blood drives throughout the region. In 2018 we hosted five and collected more than 180 units of blood! We’ve already planned six blood drives for 2019 and hope to collect around 250 units. Our hope is that by helping increase the amount of blood available throughout the year, we can ensure there’s always an adequate supply for those who need it most.
Regarding maintaining the program, cost is a concern. Since ambulance reimbursement is considered a bundled payment, we cannot itemize and charge patients for supplies used. Each unit of blood administered has a cost to it (as well as any wasted blood) in addition to all the equipment needed to store blood and provide ongoing monitoring. The start-up investment for offering blood was just over $16,000, and all equipment has a limited lifetime, so budgeting for replacement is important. This is something that can catch programs looking at offering blood by surprise without proper planning.
Walk me through the additional training AirLink providers needed to safely administer prehospital packed red blood cells and plasma during transport.
Before beginning training our compliance team developed three new policies and a new blood-administration protocol. The policies described the agreement between AirLink and our blood bank, identified the responsibilities of each department, and listed the requirements for our team’s transfer, storage, and administration of blood. To aid in daily use of these policies, standard work was developed describing the step-by-step process for our flight teams to record refrigerator temperatures and inspect blood.
With a policy in place describing how to administer blood, the clinical blood-administration protocol identified the clinical indications for prehospital blood transfusion as well as signs and symptoms of transfusion reactions. Transfusion reactions are the recipient’s rejection of donated blood, and a variety of rejections can occur with different severities.
With policies and protocols written, team members completed a 90-minute hands-on training session and blood-handling competencies. This training also prepared team members to recognize transfusion reactions. As a critical care transport team, all staff were already permitted to administer blood, so in our instance the big transition was the shift from initiating a referral hospital’s blood to storing and initiating our own blood products.
All team members complete an annual high-risk skills lab and review blood administration. In addition they participate in our human patient simulation lab, and during their trauma simulations they are required to verify and initiate blood in front of our program educator.
What are the implications for changes to standards of care for transport units based on the findings from the Prehospital Air Medical Plasma (PAMPer) trial published in the New England Journal of Medicine? How long do you think it might take before we see more widespread use of plasma in the prehospital setting?
This is an interesting question, and the answer is that it we’re still trying to figure it out. In general the studies on prehospital blood transfusion show a trend toward improved patient outcomes. Most of the previously published studies were small, retrospective, or not randomized. Prior to PAMPer, studies showed prehospital blood products may lower mortality, shorten ICU stays, and improve acidosis in the first 24 hours after admission. Patients receiving prehospital blood also have required fewer blood products than patients with like injuries who did not receive blood until hospital arrival. With PAMPer we have a well-designed randomized study that showed a clear improved 30-day survival when patients received volume resuscitation with plasma instead of normal saline during prehospital care.
Really, these results are not a surprise. Plasma has the same pH as the body, has relatively the same osmolality, and provides proteins and clotting factors. Normal saline, on the other hand, has a pH around 5, which makes it highly acidic, and it’s not electrolyte-balanced. Specifically the chloride in normal saline is significantly higher than in the body, and we’ve long known that aggressive resuscitation with normal saline (5–6+ liters) can lead to a hyperchloremic acidosis. Thus, it’s no surprise PAMPer demonstrated that patients do better with plasma than normal saline for rapid fluid resuscitation in hypovolemic shock.
The question now is, what do we do with this information, and how do we change the paradigm of prehospital resuscitation of the patient in hypovolemic shock? There are barriers to making plasma a national standard of care: Some states have kept blood transfusion outside the paramedic scope of care; many states operate on regional or statewide protocols; and finally there’s the issue of plasma availability and storage.
Today a hospital may have 10–40 units of plasma available, depending on its size. That same hospital may be in a region with 20 ambulances. If each ambulance were to have plasma, the locality may need a 50%–100% increase in the availability of plasma at any given time. It’s unclear that the current donor pool would support this change.
I suspect more EMS systems will begin exploring the feasibility of prehospital plasma, though. I know of several North Carolina counties that have packed red blood cells on their supervisor units and a few others that are considering adding plasma. The barriers to making this a standard of care will be supply availability and cost.
Tell me about your plans for managing supply and demand for plasma. Do you anticipate any shortages of plasma products as prehospital providers increasingly utilize them? What is being done to ensure continued access?
As more ambulances and helicopters begin carrying blood and plasma, we will increase the supply of blood on standby on these units. That supply must be replaced every 28 (plasma) to 45 (packed red blood cells) days.
Without a steady and reliable stream of volunteer donors from our communities, there will not be enough blood available to administer to those in need. I recommend any program carrying blood partner with their local blood suppliers to host blood drives. We’ve proactively managed this by partnering with the American Red Cross.
Blood drives can be held within your own team or for the community. Every donation can be split into three components: packed red blood cells, plasma, and platelets. That’s three people you can help with a single donation!
1. Sperry J, Guyette F, Brown J, Yazer M, Triulzi D, et al. Prehospital Plasma During Air Medical Transport in Trauma Patients at Risk for Hemorrhagic Shock. N Engl J Med, 2018 Jul; 379: 315–26.
Sarah Bowman, NRP, MCHS, PA-C, is a physician assistant at Columbia Valley Community Health in Wenatchee, Wash., and a recent graduate of the University of Washington School of Medicine MEDEX Northwest physician assistant program. She has worked as a paramedic in Alexandria, Va., and began her career as a volunteer EMT with the Fairfax County Fire and Rescue Department. Sarah has experience as a paramedic, physician assistant, and EMS educator.