{"status":"ok","message-type":"work","message-version":"1.0.0","message":{"indexed":{"date-parts":[[2026,11,6]],"date-time":"2026-11-06T19:19:30Z","timestamp":1793992770367,"version":"4.8.0"},"reference-count":55,"publisher":"BMJ","issue":"2","license":[{"start":{"date-parts":[[2026,6,26]],"date-time":"2026-06-26T00:00:00Z","timestamp":1782432000000},"content-version":"unspecified","delay-in-days":86,"URL":"https:\/\/creativecommons.org\/licenses\/by-nc\/4.0\/"}],"content-domain":{"domain":["bmj.com"],"crossmark-restriction":true},"short-container-title":["Trauma Surg Acute Care Open"],"accepted":{"date-parts":[[2026,6,14]]},"published-print":{"date-parts":[[2026,4]]},"abstract":"<jats:p>Traumatic hemorrhage remains a leading cause of preventable death in the USA, and early administration of blood products improves outcomes in hemorrhagic shock. However, access to prehospital transfusion on ground ambulances remains limited and uneven. This narrative review synthesizes current clinical evidence, implementation barriers, and emerging models for prehospital blood use in the USA, with a focus on the potential role of statewide coordination within trauma systems. A targeted review of peer-reviewed literature, consensus guidelines, and system implementation reports was conducted, examining clinical efficacy, trauma system integration, regulatory frameworks, logistical considerations, reimbursement challenges, and statewide strategies. Approximately 3% of the 11\u2009450 eligible US 9-1-1 ground emergency medical service (EMS) units currently provide prehospital blood transfusion, with access largely determined by local resources rather than patient need. Major barriers include logistical and stewardship challenges, lack of sustainable reimbursement pathways, absence of centralized data infrastructure, and the decentralized nature of the US blood supply. Clinical evidence supports the use of blood products for both traumatic and non-traumatic hemorrhage, demonstrating improvements in early hemodynamics and survival. Emerging efforts, including those led by the Prehospital Blood Transfusion Coalition and coordinated initiatives in states such as Texas, West Virginia, Florida, Delaware, and Colorado, highlight the feasibility of state-level implementation through shared governance, blood rotation strategies, and public investment. Overall, evidence supports the use of prehospital blood in selected populations, yet access remains limited and uneven. State-directed coordination represents a pragmatic framework to align existing blood centers, hospitals, and EMS agencies, although additional research, data integration, and national policy development are needed to guide broader implementation.<\/jats:p>","DOI":"10.1136\/tsaco-2026-002321","type":"journal-article","created":{"date-parts":[[2026,6,26]],"date-time":"2026-06-26T13:15:27Z","timestamp":1782479727000},"page":"e002321","update-policy":"https:\/\/doi.org\/10.1136\/crossmarkpolicy","source":"Crossref","is-referenced-by-count":3,"title":["Expanding access to prehospital blood products: a narrative review of clinical evidence, systems barriers, and statewide strategies"],"prefix":"10.1136","volume":"11","author":[{"ORCID":"https:\/\/orcid.org\/0009-0007-1728-4643","authenticated-orcid":false,"given":"Jamison P","family":"Geracci","sequence":"first","affiliation":[{"name":"West Virginia University School of Medicine, Morgantown, West Virginia, USA"},{"name":"Division of Trauma and Emergency Surgery, The University of Texas at San Antonio, San Antonio, Texas, USA"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Spencer M","family":"Knierim","sequence":"additional","affiliation":[{"name":"Department of Emergency Health Sciences, The University of Texas at San Antonio, San Antonio, Texas, USA"},{"name":"College of Public Health, University of South Florida, Tampa, Florida, USA"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Alexander F","family":"Bowers","sequence":"additional","affiliation":[{"name":"Division of Trauma and Emergency Surgery, The University of Texas at San Antonio, San Antonio, Texas, USA"},{"name":"Department of Surgery, The University of Texas Health Science Center at San Antonio, San Antonio, Texas, USA"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Hannah L","family":"Borland","sequence":"additional","affiliation":[{"name":"Division of Trauma and Emergency Surgery, The University of Texas at San Antonio, San Antonio, Texas, USA"},{"name":"Department of Surgery, The University of Texas Health Science Center at San Antonio, San Antonio, Texas, USA"},{"name":"Long School of Medicine, The University of Texas Health Science Center at San Antonio Joe R and Teresa Lozano Long School of Medicine, San Antonio, Texas, USA"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Evan","family":"Baines","sequence":"additional","affiliation":[{"name":"The University of Texas at San Antonio, San Antonio, Texas, USA"},{"name":"Texas A&M University System, College Station, Texas, USA"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Cory","family":"Lacek","sequence":"additional","affiliation":[{"name":"The University of Texas Southwestern Medical Center Medical School, Dallas, Texas, USA"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Peter","family":"Antevy","sequence":"additional","affiliation":[{"name":"Palm Beach County Fire Rescue, West Palm Beach, Florida, USA"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"ORCID":"https:\/\/orcid.org\/0000-0002-3943-5330","authenticated-orcid":false,"given":"Jennifer A","family":"Shuford","sequence":"additional","affiliation":[{"name":"Commissioner, Texas Department of State Health Services, Austin, Texas, USA"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Kenneth A","family":"Scheppke","sequence":"additional","affiliation":[{"name":"Deputy Secretary for Health, Florida Department of Health, Tallahassee, Florida, USA"},{"name":"Palm Beach Fire Rescue Department, Palm Beach, Florida, USA"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"ORCID":"https:\/\/orcid.org\/0009-0009-4514-3690","authenticated-orcid":false,"given":"Traceee","family":"Rose","sequence":"additional","affiliation":[{"name":"Southwest Texas Regional Advisory Council, San Antonio, Texas, USA"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Eric","family":"Epley","sequence":"additional","affiliation":[{"name":"Southwest Texas Regional Advisory Council, San Antonio, Texas, USA"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"ORCID":"https:\/\/orcid.org\/0000-0001-8312-9157","authenticated-orcid":false,"given":"John B","family":"Holcomb","sequence":"additional","affiliation":[{"name":"Department of Surgery, University of Alabama at Birmingham Health System, Birmingham, Alabama, USA"},{"name":"Associate EMS Medical Director, Washington County EMS, Washington County, Texas, USA"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Randall","family":"Schaefer","sequence":"additional","affiliation":[{"name":"Schaefer Consulting, LLC, New Braunfels, Texas, USA"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Donald H","family":"Jenkins","sequence":"additional","affiliation":[{"name":"Division of Trauma and Emergency Surgery, 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First responders start delivering life-saving whole blood. UCHealth Northern Colorado Foundation. 2024. Available: https:\/\/www.uchealthnocofoundation.org\/stories\/2024\/first-responders-life-saving-whole-blood\/ [Accessed 27 Dec 2025]."},{"key":"2026062606151691000_11.2.e002321.48","unstructured":"FEMS . Whole blood. 2026. Available: https:\/\/fems.dc.gov\/page\/whole-blood"},{"key":"2026062606151691000_11.2.e002321.49","unstructured":"Tidewater EMS . 2026. Available: https:\/\/www.tidewaterems.org\/news\/whole-blood-initiative."},{"key":"2026062606151691000_11.2.e002321.50","unstructured":"CMS . Ambulance fee schedule & zip code files. 2026. 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