Improving the Compliance of Massive Hemorrhage Protocols Through Education Is Associated with Patient Survival

Abstract

Background: In 2015, Spanish scientific societies published a consensus document on managing massive hemorrhage (MH). This study aimed to evaluate the knowledge and application of the Massive Hemorrhage Protocol (MHP) among healthcare professionals and to assess whether an educational intervention could improve compliance and patient outcomes. Methods: A two-phase observational study was conducted in four Spanish university hospitals. In phase one, compliance with MHP recommendations was surveyed. Based on the findings, educational sessions were implemented, focusing on the least known or followed recommendations. Compliance was then reassessed. Primary outcome was adherence to MHP; secondary outcomes included morbidity and 24 h and in-hospital mortality. Results: The MHP was activated in 303 MH episodes, mostly of surgical (42.6%) or traumatic (25%) origin. The most followed recommendation before the intervention was protocol activation (94%), which improved to 98.3% post-intervention (p = 0.049). Lesser-followed recommendations such as requesting a hemorrhage lab panel and correcting hypothermia improved after intervention from 39% to 50.4% (p = 0.05) and 31.3% to 43.8% (p = 0.027), respectively. Overall compliance increased from 68% to 73% (p = 0.05). Mortality remained high in both phases, 24 h (25.4%) and in-hospital (42.2%). Patients who required massive transfusion had higher mortality (53.6%) than those who did not (35.9%, p = 0.03). Survivors had higher protocol compliance (p = 0.003 at 24 h; p = 0.049 in-hospital). Conclusions: Educational intervention modestly improved adherence to MHP recommendations. Higher compliance was associated with better survival outcomes, supporting the need for targeted educational strategies to enhance protocol implementation and improve care in MH cases.

Keywords: education; massive hemorrhage; mortality; protocol compliance.

Figure 1

Flowchart of the study. Abbreviation: MHP: Massive hemorrhage protocol. Intervention: Educational intervention on MHP knowledge and use. * Study criteria for MHP activation: bleeding plus hypotension systolic blood pressure ≤ 80 mmHg or vasopressor requirement in patients receiving at least 6 packed red blood cells in 24 h.

Figure 2

Overall episode degree of compliance before and after an educational intervention for patients receiving massive transfusion. * Data expressed as a median and (interquartile range). Only those patients with complete data of all the evaluated criteria of the massive hemorrhage protocol were included in the analysis. Massive transfusion: transfusion of 10 or more packed red blood cells in 24 h.