Whole Blood Drives Increasing Use of Balanced Transfusion in US Trauma Centers, but Adoption Varies Widely

The use of balanced transfusion in U.S. trauma centers roughly tripled between 2018 and 2024, driven largely by increased use of whole blood, according to a national cohort study published in JAMA Network Open. However, substantial variation in practice persisted between hospitals.

Researchers from the University of Alabama at Birmingham analyzed data from the American College of Surgeons Trauma Quality Improvement Program (TQIP) on 71,997 trauma patients in hemorrhagic shock who received at least 1,000 mL of blood products within four hours of arrival at 650 trauma centers. The primary outcome was receipt of balanced component or whole blood transfusion within four hours.

The percentage of patients receiving balanced components or whole blood transfusion increased from 12.4% in 2018 to 37.6% in 2024 (adjusted odds ratio, 5.33; 95% CI, 4.88-5.81). The increase was largely driven by whole blood, which rose from 8.1% in 2020, the first year TQIP captured whole blood use, to 25.1% in 2024. Component-based balanced transfusion remained relatively stable at approximately 12% to 16%.

Hospital adoption of whole blood also increased, from 33% of centers in 2020 to 65.6% in 2024, with the highest uptake among level I trauma centers.

Despite the overall increase, researchers found substantial variation between hospitals. Hospital-level differences accounted for 24% of the variation in balanced component and whole blood use, with the intraclass correlation coefficient increasing from 0.22 in 2018 to 0.35 in 2024. By 2024, two otherwise similar patients could have more than a threefold difference in their likelihood of receiving balanced transfusion based on the treating facility.

The authors suggested that the variation may reflect differences in institutional protocols, product availability, prehospital transfusion practices, infrastructure and registry reporting. The study characterized adoption patterns rather than clinical outcomes, and the observational design limits conclusions about whether increased use of balanced transfusion improves patient outcomes.