# Toward Standardized Massive Transfusion Protocols: A Multicenter Evaluation of Practice Variability Within a National Trauma System

## TL;DR

This study evaluates how trauma centers use blood transfusion protocols and finds significant differences that could affect patient outcomes.

## Contribution

The study identifies variability and gaps in massive transfusion protocols across trauma centers, advocating for standardized national guidelines.

## Key findings

- All centers can deliver blood products within 15 minutes but differ in activation triggers and transfusion ratios.
- None of the centers had thawed plasma or whole blood ready, and only one had a performance improvement system.
- Tranexamic acid was universally included in protocols, but quality monitoring was lacking.

## Abstract

Background/Objectives: Hemorrhage remains a leading cause of early mortality in trauma patients, and timely transfusion guided by a structured massive transfusion protocol (MTP) is critical for improving outcomes. Although regional trauma centers have been established, standardized MTPs remain insufficiently developed in many settings. This study aimed to evaluate current MTP practices across five major trauma centers within a national trauma care system. Methods: Participating institutions provided written protocols and completed a structured survey addressing key domains, including activation criteria, transfusion strategies, laboratory monitoring, adjunct therapies, termination processes, and performance improvement measures. Findings were analyzed and compared against established international recommendations. Results: All centers had implemented MTPs and were capable of delivering initial blood products within 15 min. However, considerable variation was observed in activation triggers, transfusion ratios, and laboratory monitoring protocols. None of these centers maintained thawed plasma or whole blood in immediate readiness. Only one of five centers had a formal performance improvement monitoring system. Tranexamic acid was included in all institutional protocols. Conclusions: This review highlights significant variability and critical gaps in MTP implementation across trauma centers. Inconsistent activation criteria, the absence of essential components, and limited quality monitoring may compromise the efficacy of current practices. To improve patient outcomes, a standardized, evidence-based MTP framework should be developed and implemented nationwide.