PHBTIC Kick-Off Meeting Highlights Goal of Increased Pre-Hospital Blood Transfusions

The Prehospital Blood Transfusion Initiative Coalition (PHBTIC) recently held its kick-off meeting via Zoom to start moving the needle forward on its national effort to advance the ability to administer blood in the field given its potential for a significant impact in treating patients.

“The coalition is designed to be an avenue to bring folks together to learn and share experiences and best practices, to help folks collaborate and cooperate, and to help us all collectively get things done,” says Coalition chairman Jon Krohmer, M.D.

Krohmer is the former director of the National Highway Traffic Safety Administration’s Office of EMS and is an EMS physician and EMS SME consultant for Velico Medical.

Krohmer pointed out research shows exsanguination remains the leading cause of preventable deaths among trauma victims with nearly half of these patients dying in the prehospital setting.

“We also want to be cognizant of the fact there are medical conditions or other conditions in which the administration of blood components in the field will be very beneficial to those patients,” he added.

For example, prehospital blood resuscitation also is clinically indicated for selected patients who hemorrhage from medical conditions such as post-partum hemorrhage and abdominal bleeds, potentially doubling the number of patients who would benefit from field transfusions.

Limited Access to Pre-Hospital Blood Transfusions

Individuals requiring blood transfusions in the field in most U.S. locations do not have access to pre-hospital blood transfusions due to inadequate reimbursement policies and state-by-state scope of practice limitations.

The PHBTIC seeks to change that and has broad support from others.

Krohmer cited a Journal of Trauma and Acute Care Surgery study indicating every minute the pre-hospital resuscitation is delayed demonstrates a two percent increase in the odds of 30-day mortality.

Krohmer pointed out support from the American College of Surgeons Committee on Trauma, the American College of Emergency Physicians, and the National Association of EMS Physicians for the idea that patients with signs of hemorrhagic shock should receive prehospital blood products whenever available.

Other position statements have been put out by the International Association of Emergency Medical Services Chiefs and the National Association of Emergency Medical Technicians.

A PHBTIC steering committee has developed a vision and mission statement highlighting two major issues: the broad availability of blood products and the ability to administer them in the field, Krohmer says.

That includes not only the scope of practice issue which varies by state, but the accessibility of blood products for EMS agencies when they want to establish these programs, and then appropriate reimbursement for it from all reimbursement sources, he adds.

“We also want to reinforce that this initiative is agnostic to the type of blood component,” Krohmer says.

PHBTIC's Key Areas of Focus

Those two issues are part of five areas of focus that also include education and an outreach program not only for payers, but for the EMS community, as there are still many questions that exist not just for them, but also for the community at large, Krohmer says.

Another area is research that supports the mission and identifies areas that still need to be addressed as well as strategic preparedness issues.

The PHBTIC strategy includes:

• Building an industry-wide, collaborative initiative including medical groups, EMS trade associations, blood collectors, advocacy groups, and commercial companies.
• Elevating federal awareness of the importance of prehospital transfusion.
• Promoting policies that support access to prehospital transfusions, including reimbursement and scope of practice.
• Encouraging targeted research, dissemination of use cases, and maintaining a publications database.
• Building nationwide awareness of the critical importance of blood on emergency medical vehicles.

PBHTIC seeks to form a corporate advisory board consisting primarily of industry partners who support the initiative from a financial perspective, Krohmer said. The coalition also is seeking to engage a Washington D.C.-based consultant to work on issues as they relate to Congress and executive branch agencies.

PBHTIC has established five pillars: scope of practice, education, outreach, strategic preparedness, and research.

Eric Bank, LP, NRP, assistant chief of EMS in Harris County, Texas, made the case for pre-hospital blood products by noting the approach has been long used by the military during wartime.

“We know that this is an important medical intervention,” he says.

Barriers to Access

Bank noted that Tactical Combat Casualty Care guidelines state that the preferred fluids for resuscitation of casualties in hemorrhagic shock in descending order of preference are low titer or positive whole blood; 1:1:1 plasma, packed red blood cells (PRBCs), and platelets; 1:1 plasma and RBCs; reconstituted dry plasma, liquid plasma, or thawed plasma alone or PRBCs alone.

Retired Army Lieutenant Colonel Randall Schaefer, DNP, RN, ACNS-BC, CEN noted cost as a barrier to starting a new program “is a symptom of larger reimbursement issues going on in EMS.”

A PBHTIC working group focusing on reimbursement seeks to identify current reimbursement limitations caused by air and ground programs and all delivery models: private, hospital, government–fire, third service – and volunteer, among others. The group also seeks to identify potential reimbursement mechanisms and approaches at federal, and state governmental levels and develop strategy and plans -- including rationale and supporting data – to facilitate  EMS agency discussions with potential funding sources.  

The scope of practice working group addresses state scope of practice models. variations and will work to promote consistency across the U.S.

"A survey is being developed in conjunction with the National Association of State EMS officials to get background information on the current environment of blood therapy in various states," Krohmer says.

"The ability of paramedics to initiate blood therapy needs to be addressed," he adds.

Survey components will be shared with the National Association of State EMS Officials to get background information on the current bloody therapy environment in various states, says Krohmer.

PBHTC also will work with the National Emergency Medical Services Information System to ensure appropriate data elements are included in ePCR records being recorded to help support a program database.

PBHTIC will work in concert with Tulane University – which has started a pre-hospital blood registry – to ensure blood components therapy and the clinical outcome that is being achieved by that is appropriately documented and cataloged.

Ciaran Flanagan, Velico Medical's chief commercial officer, notes that PBHTC is developing educational outreach initiatives customized for all stakeholder communities including the general population.

“Identifying best practices is very important to us in terms of evolving agency protocols, policies, procedures, and financial considerations,” Flanagan notes.

PBHTIC continues to add materials to its website at www.prehospitaltransfusion.org and welcomes input from all stakeholders.

PBHTIC's Pillars to Action

The PBHTIC strategic preparedness pillar aims to develop concepts and implementation for establishing readiness for major mass casualty incidents, military blood product needs more than internal production capability, and other national emergencies.

“From a strategic and a preparedness standpoint, the US Department of Health and Human Services, Biomedical Advanced Research and Development Authority (HHS, BARDA) is very active in that and is leading many of those activities,” says Krohmer.

The PBHTC research pillar will log all prehospital transfusion references currently available, making them available to interested communities.

“We'll make sure we include academic communities and organizations involved in looking both at pre-hospital and hospital research – we can’t separate those because the pre-hospital activities are going to affect hospital outcomes hopefully in a very positive way,” Krohmer says.

Leah Mendelsohn Stone, vice president of public policy and advocacy at the Association for the Advancement of Blood & Biotherapies, notes the organization worked with the EMS community to explore different options for payer coverage and reimbursement of pre-hospital blood transfusions, and draft language for Congressional bills in 2020.

“There was no movement on the bill language for a variety of reasons,” she adds. “In 2021, we approached the Center for Medicare and Medicaid Innovation at the Centers for Medicare & Medicaid Services and requested that they incorporate pre-hospital blood transfusion into existing service delivery and payment policies.

“While CMMI understood the need, it wasn't something they were willing to incorporate at the time. Since then, we’ve been continuing to have discussions about the importance of pre-hospital transfusions.”

Betzy Gonzalez, MS, BB (ASCP) Director, Scientific and Technical Operations from America's Blood Centers notes the organization is addressing the scope of practice and reimbursement barriers that limit the widespread availability of pre-hospital blood.

Schaefer notes, “We have been able to identify 121 ground agencies to date that are doing pre-hospital blood with a nice split between fire-based EMS and third service doing it.”  

Bill Salmeron, EMS chief of New Orleans, spoke of the city’s pre-hospital blood program, established on October 2. At least 213 patients ages five and older have been treated – 83 percent for penetrating trauma; 13 percent for blunt trauma, and 4 percent for off-protocol use such as OB-GYN and GI bleeds for which medical control orders are needed.

“We now consider prehospital blood to be an essential standard of care in our department,” he says.