Improving Access to Prehospital Blood May Save 10,000 Lives a Year

That transfusion, a small, rough injection of blood from one human into another, offered little clinical help. But blood transfusion remains a potent clinical intervention, and for many decades, uncountable advancements have improved clinical outcomes and saved many lives.

What’s the next step in ensuring that patients experiencing exsanguination survive?

At the ACS, it is the promotion of an approach to blood transfusion abandoned decades ago and revived this century: whole blood, provided as soon as possible after bleeding starts. Through the ACS Committee on Trauma (COT), the College is advocating for universal access to prehospital blood, preferably whole blood, for all patients.

At a news conference held during Clinical Congress 2024, Jeffrey D. Kerby, MD, PhD, FACS, the Brigham Family Endowed Professor and director of the Division of Trauma & Acute Care Surgery at The University of Alabama at Birmingham (UAB) Marnix E. Heersink School of Medicine, and Chair of the COT, explained the need for prehospital access to blood.

“We have an opportunity to save thousands of lives a year with a single intervention,” said Dr. Kerby. “Trauma is the leading cause of death for patients under age 45, and bleeding to the point of exsanguination is the leading cause of death in that population. Whole blood can have a major impact on our trauma patients.”

Why Blood Isn’t Always Whole

Developments in transfusion amid armed conflict are an essential underpinning of the history of transfusion. During World War I, when a surge in patient needs compelled innovation, the first program of widespread blood transfusion came into use.¹ Full-scale blood banking was first used during World War II; by the Vietnam War, the US military moved into the use of blood components.

This approach became possible in 1940 after Edwin Cohn, a biochemistry professor from Harvard Medical School in Cambridge, Massachusetts, developed fractionation, the process of breaking down plasma into components and products.¹ This process was seen as a vital upgrade of the use of whole blood because it improved efficiency. A single unit could now be used to help multiple patients, rather than just one, by giving each the plasma, platelets, or red blood cells they needed.

In 1961, plasmapheresis was created, enabling separation of plasma,¹ and by the end of the Vietnam War, use of fractionated blood products for trauma care had become standard. For the next 40-some years, protocols typically advised a mix of crystalloid, packed red blood cells, plasma, and platelets—with the latter three ideally but most often not present in a 1:1:1 ratio, as they are in whole blood.

In some ways, separating blood into component parts proved a triumph. Fractionation advanced scientific knowledge of the importance of specific blood components and led to innovations in the treatment of diseases such as hemophilia. Component usage also eased logistical constraints because of fractionated blood products’ longer shelf life (50 days or more versus 35 for whole blood) and the option to freeze plasma. These blood products also are an improvement on resuscitation with crystalloid fluid solutions that lack oxygen-carrying capacity. Citing weekslong complications often seen with large-volume, crystalloid-first resuscitation strategies, Dr. Kerby said, “In resuscitation, we now equate crystalloid to poison.”

However, even blood component resuscitation may deliver inferior outcomes relative to whole blood. US Army Colonel Jennifer M. Gurney, MD, FACS, who is chief of the US Department of Defense Joint Trauma System and active in ACS advocacy on whole blood access, shared her own experience in trauma care.

“Any military surgeon will say this to you: when you transfuse warm, fresh, whole blood, it’s like a religious experience,” said Dr. Gurney. “The physiology of patients who are bleeding to death changes almost instantly, and you feel like you’ve got another few minutes to fight for that patient in terms of getting hemorrhage control.”

Shifting Back to Whole Blood and Delivering It Faster

Indeed, the “religious” experience of using fresh, warm whole blood led to the movement back to using whole blood more widely. During the conflicts in Iraq and Afghanistan, the US military shifted to the use of whole blood in combat surgical hospitals and forward surgical teams, in part to facilitate transfusions via immediate donations from onsite military personnel.

The outcomes related to this shift were highly compelling. A 2022 study led by Dr. Gurney found that in a cohort of 1,105 injured military personnel, the adjusted odds ratio of mortality at 6 hours after injury was 0.27 (95% confidence interval, 0.13-0.58) for those who received warm fresh whole blood, compared with those who received component therapy only.² In other words, for every patient who survived after receiving blood components, four patients who received whole blood survived. The outcome aligns with the findings of earlier studies, which found improvements in 24-hour and 30-day mortality with whole blood use.³

The strong improvement in patient survival with the use of warm, fresh whole blood prompted a shift to the nearest practical equivalent, stored low-titer O whole blood, in civilian practice.

This change in the civilian population also resulted in positive outcomes. For example, a 2024 study of ACS Trauma Quality Improvement Program data on 12,275 patients found those who received whole blood showed a 13% decrease in the odds of 4-hour mortality for each 10% increase in the ratio of whole blood to total transfusion volume.⁴ Additional studies have had similar results.⁵

But it is a combination of whole blood and timely care that offers the greatest positive impact. A 2024 cohort study in JAMA Surgery found that transfusion of whole blood was associated with a 60% decrease in mortality at 24 hours in patients who’d received the whole blood early as an adjunct to massive transfusion with component products (versus after such transfusion).⁶

Access during ambulance care may be even more impactful. A study published in 2021 in Transfusion found that prehospital use of whole blood was associated with less intense shock on arrival in the emergency department and less mortality than a comparison group who received no prehospital transfusion, even though the cohort receiving blood was more severely injured than the comparison group.⁷

“There’s no need to do more studies. The data are very clear. Prehospital blood saves lives,” said John B. Holcomb, MD, FACS, a professor in the Division of Trauma & Acute Care Surgery at the UAB Marnix E. Heersink School of Medicine at the ACS news conference.

Challenges to Implementation

The move to a resuscitation concept emphasizing the use of prehospital blood, particularly whole blood, remains an open question for some. A session at Clinical Congress 2024 included a debate on the use of whole blood, raising two important concerns: alloimmunization and blood wastage.

The first issue, alloimmunization, can occur when a patient with Rh-negative blood receives Rh-positive blood, triggering an immune system response that creates IgG antibodies. If a transfused female patient with Rh-negative blood later becomes pregnant with a fetus that has Rh-positive blood, these antibodies can cross the placenta and destroy the unborn child’s red blood cells. Hemolytic disease of the fetus and newborn is potentially lethal and can require intensive treatment.

Of course, for female patients with Rh-negative blood experiencing a bleeding emergency, the choice may be possible alloimmunization later versus a fatal outcome immediately—and few have trouble choosing.

One survey of 107 women who had experienced alloimmunization (including 32 who had birthed infants with hemolytic disease of the fetus and newborn and 12 who had experienced fetal or neonatal loss) found robust support for whole blood transfusion.

Most notably, the respondents said they would accept alloimmunization if it created as little as a 4% better chance of survival.8 Additionally, a 2024 Journal of the American College of Surgeons study found the rate of alloimmunization is between 3% and 20% in female patients with Rh-negative blood types.9 Given that approximately 2.9% of US residents are women and girls of childbearing age (15-44 years) who are Rh-negative, population-level risk of alloimmunization may be as low as approximately 9 per 10,000 persons who require a blood transfusion.

Summarizing these findings in a presentation at Clinical Congress, Luke Neff, MD, FACS, an assistant professor in the Department of General Surgery at Wake Forest University School of Medicine in Winston-Salem, North Carolina, called alloimmunization “a boogeyman we don’t have to be afraid of.”

Meanwhile, concerns about wastage connect to the very reason fractionated blood products were originally created: to ensure donations were used before expiration by directing components to patients in need, extending shelf life with improved preservatives, and freezing plasma.

In her Clinical Congress presentation, Barbara A. Gaines, MD, FACS, the Edwin Ide Smith Professor of Pediatric Surgery and chief of the Division of Pediatric Surgery at The University of Texas Southwestern School of Medicine in Dallas, and surgeon-in-chief at Children’s Health in Dallas, suggested that hospitals with low need for blood-based resuscitation, including pediatric hospitals, often find that “wastage can be high.”

Dr. Gurney conceded wastage occurs in military contexts, calling it “the cost of readiness,” before adding, “We don’t ever want to waste blood. It’s a precious resource.”

However, according to Dr. Kerby, wastage among adult patients in civilian settings using whole blood in both emergency medical services (EMS) and hospitals can be resolved with adequate system design.

“The southwest Texas region has a whole blood program, and they have whole blood in their ground ambulances,” said Dr. Kerby. “They’ve shown very nicely that the paramedics can, indeed, identify patients who need it, so they’re not wasting it. They also have a rotation system. If a unit of whole blood in a ground ambulance is not being used as it gets closer to its expiration date, they cycle it back to the hospital.”

Improving Access through Advocacy

The concerns about blood wastage—and with it the cost of each unit of lost blood—connect to broader challenges associated with the use of blood in prehospital settings. Key issues include the need to ensure that EMS agencies can receive reimbursement for prehospital transfusions, as well as the administrative challenges of developing new blood programs.

“I think most people are not aware that ambulances don’t carry blood,” said Dr. Kerby. To implement blood use on ambulances, replacing the crystalloid solutions now in use in many paramedic units requires changes to institutional policy, training, and infrastructure.

Implementing a whole blood program on ambulances would entail revising regulations and laws on EMS scope of practice to permit paramedics to use blood, a step that must be taken in individual US states.

In 2021, the National Highway Traffic Safety Administration released a National EMS Scope of Practice Model to guide state-level scope-of-practice legislation and regulations. The model included an “interpretive guideline” suggesting that paramedics may “maintain infusion of blood or blood products” with case-by-case medical director approval;¹⁰ however, it did not include any mention of initiating blood transfusion for exsanguinating patients on scene or enroute to hospital care.

Nonetheless, by fall 2024, 38 US states began permitting EMS units to initiate blood use in the field. The change is likely attributable, at least in part, to advocacy by the Prehospital Blood Transfusion Initiative Coalition. This group brings together representatives from organizations focused on trauma care, surgical care, emergency medicine, EMS, blood banking, and other aspects of this issue, including the ACS COT, to advance research, policy, and implementation of prehospital blood protocols.

“I think the coalition has done an excellent job regarding raising awareness of this issue in individual states and pushing the advocacy efforts necessary to effect change,” Dr. Kerby said.

Updating regulations to permit usage is only half the battle, however. Despite scopes of practice that include blood use, only about 1% of all EMS units carry blood at present. The reason is simple: there is a strong, unmet need for EMS agencies to receive reimbursement for blood use.

The payment structure for ambulance services currently is based on transportation, not the services provided while enroute to the hospital, “no matter what they do for that patient,” Dr. Kerby noted.

This revenue model means that there is often no option to add blood to ambulances, no matter how lifesaving such a step may be for the populations served.

The solution to this issue is two-fold, according to Dr. Kerby. First, funding for individual EMS agencies via city and state governments and philanthropic funding sources may ease the financial burden of blood implementation for individual EMS agencies. Second, the US Centers for Medicaid & Medicare Services can definitively update federal regulations to include reimbursement for blood usage on ambulances, a solution that would extend to all EMS agencies nationwide.

The need is particularly acute in underserved areas. Notably, about half of all automobile accidents occur in rural areas, where only about 20% of the US population resides. As a result of this high vulnerability and long travel times, those in rural areas have particularly strong needs for EMS units to include the capacity for blood in resuscitation. Yet rurality also often constrains EMS agency funding, making the need for assistance particularly acute—and unlikely to be fully solved without change in reimbursement models nationwide.

Here, too, the ACS is engaged in legislative and regulatory advocacy, partnered with “a long and very inclusive list of representatives who are all banding together to develop some uniform talking points and a targeted strategy for what the ask is,” said Dr. Kerby.

The presence of a strong coalition, along with early successes, may bode well for the advancement of a reimbursement model that makes prehospital transfusions, particularly with whole blood, accessible to all patients.

What Universal Access Might Achieve

If universal access to prehospital blood were implemented in the US, how many lives might be saved? At the ACS news conference, Dr. Holcomb said 10,000 lives per year.

“I wholeheartedly agree with the statement,” Dr. Kerby said, explaining how multiple statistical analyses had generated that number of prospective rescues.

He pointed out that this number of lives shows the effort to deliver universal prehospital access to blood may be a uniquely potent way to help patients in need: “There are not a lot of interventions that we can do that save 10,000 patients a year.” 

Sophia Newman is the Medical Writer and Speechwriter in the ACS Division of Integrated Communications in Chicago, IL.

References

1. Association for the Advancement of Blood and Biotherapies. Highlights of transfusion medicine history. Accessed February 4, 2025. https://www.aabb.org/news-resources/resources/transfusion-medicine/highlights-of-transfusion-medicine-history.
2. Gurney JM, Staudt AM, del Junco DJ, et al. Whole blood at the tip of the spear: A retrospective cohort analysis of warm fresh whole blood resuscitation versus component therapy in severely injured combat casualties. Surgery. 2022;171(2):518-525.
3. Spinella PC, Perkins JG, Grathwohl KW, Beekley AC, Holcomb JB. Warm fresh whole blood is independently associated with improved survival for patients with combat-related traumatic injuries. J Trauma. 2009;66(4 Suppl):S69–S76.
4. Dorken-Gallastegi A, Spinella PC, Neal MD, et al. Whole blood and blood component resuscitation in trauma: Interaction and association with mortality. Ann Surg. 2024;280(6):1014-1020.
5. Torres CM, Kent A, Scantling D, et al. Association of whole blood with survival among patients presenting with severe hemorrhage in US and Canadian adult civilian trauma centers. JAMA Surg. 2023;158(5):532-540.
6. Torres CM, Kenzik KM, Saillant NN, et al. Timing to first whole blood transfusion and survival following severe hemorrhage in trauma patients. JAMA Surg. 2024;159(4):374-381.
7. Braverman MA, Smith A, Pokorny D, et al. Prehospital whole blood reduces early mortality in patients with hemorrhagic shock. Transfusion. 2021;61 Suppl 1:S15-S21.
8. Sherwood MR, Clayton S, Leeper CM, et al. Receipt of RhD-positive whole blood for life-threatening bleeding in female children: A survey in alloimmunized mothers regarding minimum acceptable survival benefit relative to risk of maternal alloimmunization to anti-D. Transfusion. 2024;64 Suppl 2:S100-S110.
9. Clements TW, Van Gent J-M, Menon N, et al. Use of low-titer O-positive whole blood in female trauma patients: A literature review, qualitative multidisciplinary analysis of risk/benefit, and guidelines for its use as a universal product in hemorrhagic shock. J Am Coll Surg. 2024;238(3):347-357.
10. National Association of State EMS Officials; National Highway Traffic Safety Administration. National EMS scope of practice model 2019: Including change notices 1.0 and 2.0 (Report No. DOT HS 813 151). Published August 2021. Accessed February 4, 2025. https://www.ems.gov/national-ems-scope-of-practice-model/.