{"status":"ok","message-type":"work","message-version":"1.0.0","message":{"indexed":{"date-parts":[[2025,10,10]],"date-time":"2025-10-10T01:27:13Z","timestamp":1760059633186,"version":"build-2065373602"},"reference-count":39,"publisher":"MDPI AG","issue":"13","license":[{"start":{"date-parts":[[2025,6,30]],"date-time":"2025-06-30T00:00:00Z","timestamp":1751241600000},"content-version":"vor","delay-in-days":0,"URL":"https:\/\/creativecommons.org\/licenses\/by\/4.0\/"}],"funder":[{"name":"\u201cInstituto de Salut Carlos III\u201d 2016","award":["PI16\/01134"],"award-info":[{"award-number":["PI16\/01134"]}]}],"content-domain":{"domain":[],"crossmark-restriction":false},"short-container-title":["JCM"],"abstract":"<jats:p>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.<\/jats:p>","DOI":"10.3390\/jcm14134632","type":"journal-article","created":{"date-parts":[[2025,6,30]],"date-time":"2025-06-30T13:06:17Z","timestamp":1751288777000},"page":"4632","update-policy":"https:\/\/doi.org\/10.3390\/mdpi_crossmark_policy","source":"Crossref","is-referenced-by-count":0,"title":["Improving the Compliance of Massive Hemorrhage Protocols Through Education Is Associated with Patient Survival"],"prefix":"10.3390","volume":"14","author":[{"ORCID":"https:\/\/orcid.org\/0000-0002-0215-1561","authenticated-orcid":false,"given":"Pilar","family":"Paniagua-Iglesias","sequence":"first","affiliation":[{"name":"Anaesthesiology Department, University Hospital Santa Creu i Sant Pau, 08041 Barcelona, Spain"},{"name":"Institut d\u2019Investigaci\u00f3 Biom\u00e8dica Sant Pau (IIB SANT PAU), 08041 Barcelona, Spain"}],"role":[{"role":"author","vocabulary":"crossref"}]},{"ORCID":"https:\/\/orcid.org\/0000-0003-4167-8638","authenticated-orcid":false,"given":"Maria Dolores","family":"Rinc\u00f3n-Ferrari","sequence":"additional","affiliation":[{"name":"Intensive Care Units Department, University Hospital Virgen del Roc\u00edo, 41013 Sevilla, Spain"}],"role":[{"role":"author","vocabulary":"crossref"}]},{"given":"Angel","family":"Candela-Toha","sequence":"additional","affiliation":[{"name":"Anaesthesiology Department, Hospital Ram\u00f3n y Cajal & IRy CIS, 28034 Madrid, Spain"}],"role":[{"role":"author","vocabulary":"crossref"}]},{"ORCID":"https:\/\/orcid.org\/0000-0001-8038-972X","authenticated-orcid":false,"given":"Maria","family":"Marcos-Jubilar","sequence":"additional","affiliation":[{"name":"Haematology Department, University Clinic of Navarra, 31008 Pamplona, Spain"}],"role":[{"role":"author","vocabulary":"crossref"}]},{"given":"Marta","family":"Barquero-Lopez","sequence":"additional","affiliation":[{"name":"Anaesthesiology Department, University Hospital Germans Trias I Pujol, 08916 Barcelona, Spain"}],"role":[{"role":"author","vocabulary":"crossref"}]},{"ORCID":"https:\/\/orcid.org\/0000-0003-3975-6588","authenticated-orcid":false,"given":"Ignasi","family":"Gich-Saladich","sequence":"additional","affiliation":[{"name":"Institut d\u2019Investigaci\u00f3 Biom\u00e8dica Sant Pau (IIB SANT PAU), 08041 Barcelona, Spain"},{"name":"Department of Clinical Epidemiology and Public Health, University Hospital Santa Creu i Sant Pau, 08041 Barcelona, Spain"},{"name":"CIBER of Epidemiology and Public Health (CIBERESP), 28029 Madrid, Spain"}],"role":[{"role":"author","vocabulary":"crossref"}]},{"given":"Laura","family":"Medina-Marrero","sequence":"additional","affiliation":[{"name":"Blood & Tissue Bank, Hospital de la Santa Creu i Sant Pau, 08041 Barcelona, Spain"}],"role":[{"role":"author","vocabulary":"crossref"}]},{"given":"Alba","family":"Bosch-Llobet","sequence":"additional","affiliation":[{"name":"Blood and Tissue Bank of Catalonia, 08005 Barcelona, Spain"}],"role":[{"role":"author","vocabulary":"crossref"}]},{"given":"Daniela","family":"Garrido-Fleischmann","sequence":"additional","affiliation":[{"name":"Hospital Clinic de Barcelona, 08036 Barcelona, Spain"}],"role":[{"role":"author","vocabulary":"crossref"}]},{"ORCID":"https:\/\/orcid.org\/0000-0003-4896-5832","authenticated-orcid":false,"given":"Jordi","family":"Ordo\u00f1ez-Llanos","sequence":"additional","affiliation":[{"name":"Department of Biochemistry, Hospital de la Santa Creu i Sant Pau, 08025 Barcelona, Spain"},{"name":"Foundation for Clinical Biochemistry & Molecular Pathology, 08007 Barcelona, Spain"}],"role":[{"role":"author","vocabulary":"crossref"}]},{"given":"Gerard","family":"Urrutia-Cuch\u00ed","sequence":"additional","affiliation":[{"name":"Department of Clinical Epidemiology and Public Health, University Hospital Santa Creu i Sant Pau, 08041 Barcelona, Spain"},{"name":"CIBER of Epidemiology and Public Health (CIBERESP), 28029 Madrid, Spain"}],"role":[{"role":"author","vocabulary":"crossref"}]}],"member":"1968","published-online":{"date-parts":[[2025,6,30]]},"reference":[{"key":"ref_1","doi-asserted-by":"crossref","first-page":"2478","DOI":"10.1111\/trf.13755","article-title":"The confusion continues: Results from an American Association for the Surgery of Trauma survey on massive transfusion practices among United States trauma centers","volume":"56","author":"Etchill","year":"2016","journal-title":"Transfusion"},{"key":"ref_2","doi-asserted-by":"crossref","first-page":"1654","DOI":"10.1378\/chest.09-0251","article-title":"Massive transfusion: New insights","volume":"136","author":"Sihler","year":"2009","journal-title":"Chest"},{"key":"ref_3","doi-asserted-by":"crossref","first-page":"41","DOI":"10.1097\/TA.0b013e31819313bb","article-title":"Predefined Massive Transfusion Protocols are Associated With a Reduction in Organ Failure and Postinjury Complications","volume":"66","author":"Cotton","year":"2009","journal-title":"J. Trauma Acute Care Surg."},{"key":"ref_4","doi-asserted-by":"crossref","first-page":"1719","DOI":"10.1177\/00031348221075752","article-title":"Massive Transfusion Activations in Non-Trauma Patients","volume":"89","author":"Dhillon","year":"2023","journal-title":"Am. Surg."},{"key":"ref_5","doi-asserted-by":"crossref","first-page":"986","DOI":"10.1097\/01.sla.0000259433.03754.98","article-title":"Causes of death in U.S. special operations forces in the global war on terrorism: 2001\u20132004","volume":"245","author":"Holcomb","year":"2007","journal-title":"Ann. Surg."},{"key":"ref_6","first-page":"1498","article-title":"Creation, Implementation, and Maturation of a Massive Transfusion Protocol for the Exsanguinating Trauma Patient","volume":"68","author":"Nunez","year":"2010","journal-title":"J. Trauma Inj. Infect. Crit. Care"},{"key":"ref_7","doi-asserted-by":"crossref","first-page":"1616","DOI":"10.1097\/TA.0b013e3181a59ad5","article-title":"Improvements in Early Mortality and Coagulopathy are Sustained Better in Patients With Blunt Trauma After Institution of a Massive Transfusion Protocol in a Civilian Level I Trauma Center","volume":"66","author":"Dente","year":"2009","journal-title":"J. Trauma Acute Care Surg."},{"key":"ref_8","doi-asserted-by":"crossref","first-page":"198","DOI":"10.1016\/j.jamcollsurg.2009.04.016","article-title":"Massive Transfusion Protocols: The Role of Aggressive Resuscitation Versus Product Ratio in Mortality Reduction","volume":"209","author":"Riskin","year":"2009","journal-title":"J. Am. Coll. Surg."},{"key":"ref_9","first-page":"434","article-title":"The effect of massive transfusion protocol implementation on the survival of trauma patients: A systematic review and meta-analysis","volume":"18","author":"Consunji","year":"2020","journal-title":"Blood Transfus."},{"key":"ref_10","doi-asserted-by":"crossref","first-page":"1177","DOI":"10.1097\/TA.0b013e31816c5c80","article-title":"Damage control hematology: The impact of a trauma exsanguination protocol on survival and blood product utilization","volume":"64","author":"Cotton","year":"2008","journal-title":"J. Trauma Acute Care Surg."},{"key":"ref_11","doi-asserted-by":"crossref","first-page":"S91","DOI":"10.1097\/01.ta.0000199549.80731.e6","article-title":"Massive transfusion practices around the globe and a suggestion for a common massive transfusion protocol","volume":"60","author":"Malone","year":"2006","journal-title":"J. Trauma Acute Care Surg."},{"key":"ref_12","doi-asserted-by":"crossref","first-page":"630","DOI":"10.1097\/ACO.0000000000000131","article-title":"The helsinki declaration on patient safety in anaesthesiology","volume":"27","author":"Staender","year":"2014","journal-title":"Curr. Opin. Anaesthesiol."},{"key":"ref_13","doi-asserted-by":"crossref","first-page":"238","DOI":"10.11622\/smedj.2016088","article-title":"The use of massive transfusion protocol for trauma and non-trauma patients in a civilian setting: What can be done better?","volume":"57","author":"Wijaya","year":"2016","journal-title":"Singapore Med. J."},{"key":"ref_14","doi-asserted-by":"crossref","first-page":"21","DOI":"10.1016\/j.injury.2014.09.020","article-title":"Compliance with a massive transfusion protocol (MTP) impacts patient outcome","volume":"46","author":"Bawazeer","year":"2015","journal-title":"Injury"},{"key":"ref_15","doi-asserted-by":"crossref","first-page":"1004","DOI":"10.1097\/TA.0b013e3181bcb2a8","article-title":"Room for (Performance) improvement: Provider-related factors associated with poor outcomes in massive transfusion","volume":"67","author":"Cotton","year":"2009","journal-title":"J. Trauma Acute Care Surg."},{"key":"ref_16","doi-asserted-by":"crossref","first-page":"483","DOI":"10.1016\/j.medin.2015.05.002","article-title":"Documento multidisciplinar de consenso sobre el manejo de la hemorragia masiva (documento HEMOMAS)","volume":"39","author":"Llau","year":"2015","journal-title":"Med. Intensiv."},{"key":"ref_17","first-page":"312","article-title":"Assessment of the degree of knowledge of the massive transfusion protocol in four Spanish hospitals","volume":"161","year":"2023","journal-title":"Med. Clin."},{"key":"ref_18","doi-asserted-by":"crossref","first-page":"454","DOI":"10.1016\/j.medin.2023.03.007","article-title":"Multidisciplinary consensus document on the management of massive haemorrhage. First update 2023 (document HEMOMAS-II)","volume":"47","author":"Llau","year":"2023","journal-title":"Med. Intensiv."},{"key":"ref_19","first-page":"423","article-title":"How well does your massive transfusion protocol perform? A scoping review of quality indicators","volume":"18","author":"Sanderson","year":"2020","journal-title":"Blood Transfus."},{"key":"ref_20","doi-asserted-by":"crossref","first-page":"37","DOI":"10.1016\/j.ijoa.2018.10.004","article-title":"Massive hemorrhage protocol activation in obstetrics: A 5-year quality performance review","volume":"38","author":"Margarido","year":"2019","journal-title":"Int. J. Obstet. Anesthesia"},{"key":"ref_21","doi-asserted-by":"crossref","first-page":"1074","DOI":"10.1016\/j.injury.2016.11.021","article-title":"Fibrinogen is an independent predictor of mortality in major trauma patients: A five-year statewide cohort study","volume":"48","author":"McQuilten","year":"2017","journal-title":"Injury"},{"key":"ref_22","doi-asserted-by":"crossref","first-page":"e33","DOI":"10.1053\/j.jvca.2016.11.019","article-title":"Efficacy and Safety of Fibrinogen Concentrate in Surgical Patients: A Meta-Analysis of Randomized Controlled Trials","volume":"31","author":"Fominskiy","year":"2017","journal-title":"J. Cardiothorac. Vasc. Anesth."},{"key":"ref_23","doi-asserted-by":"crossref","first-page":"98","DOI":"10.1186\/s13054-023-04327-7","article-title":"The European guideline on management of major bleeding and coagulopathy following trauma: Sixth edition","volume":"27","author":"Rossaint","year":"2023","journal-title":"Crit. Care"},{"key":"ref_24","doi-asserted-by":"crossref","first-page":"447","DOI":"10.1097\/SLA.0b013e318185a9ad","article-title":"Increased Plasma and Platelet to Red Blood Cell Ratios Improves Outcome in 466 Massively Transfused Civilian Trauma Patients","volume":"248","author":"Holcomb","year":"2008","journal-title":"Ann. Surg."},{"key":"ref_25","doi-asserted-by":"crossref","first-page":"471","DOI":"10.1001\/jama.2015.12","article-title":"Transfusion of Plasma, Platelets, and Red Blood Cells in a 1:1:1 vs a 1:1:2 Ratio and Mortality in Patients With Severe Trauma","volume":"313","author":"Holcomb","year":"2015","journal-title":"JAMA"},{"key":"ref_26","doi-asserted-by":"crossref","first-page":"342","DOI":"10.1016\/j.amjsurg.2017.08.045","article-title":"Does a balanced transfusion ratio of plasma to packed red blood cells improve outcomes in both trauma and surgical patients? A meta-analysis of randomized controlled trials and observational studies","volume":"216","author":"Rahouma","year":"2018","journal-title":"Am. J. Surg."},{"key":"ref_27","doi-asserted-by":"crossref","first-page":"108","DOI":"10.1111\/tme.12022","article-title":"Experience with a massive transfusion protocol in the management of massive haemorrhage","volume":"23","author":"Sinha","year":"2013","journal-title":"Transfus. Med."},{"key":"ref_28","doi-asserted-by":"crossref","first-page":"127","DOI":"10.1001\/2013.jamasurg.387","article-title":"The Prospective, Observational, Multicenter, Major Trauma Transfusion (PROMMTT) Study","volume":"148","author":"Holcomb","year":"2013","journal-title":"JAMA Surg."},{"key":"ref_29","doi-asserted-by":"crossref","first-page":"2045","DOI":"10.1213\/ANE.0000000000002436","article-title":"Initiation and termination of massive transfusion protocols: Current strategies and future prospects","volume":"125","author":"Foster","year":"2017","journal-title":"Anesth. Analg."},{"key":"ref_30","doi-asserted-by":"crossref","first-page":"746","DOI":"10.1111\/vox.13244","article-title":"International Forum on the Management of Major Haemorrhage: Summary","volume":"117","author":"Green","year":"2022","journal-title":"Vox Sang."},{"key":"ref_31","doi-asserted-by":"crossref","first-page":"65","DOI":"10.1136\/emermed-2019-208665","article-title":"Massive transfusion in The Netherlands","volume":"37","author":"Rijnhout","year":"2020","journal-title":"Emerg. Med. J."},{"key":"ref_32","doi-asserted-by":"crossref","first-page":"103297","DOI":"10.1016\/j.transci.2021.103297","article-title":"Blood shortages and changes to massive transfusion protocols: Survey of hospital practices during the COVID-19 pandemic","volume":"61","author":"Jacobs","year":"2022","journal-title":"Transfus. Apher. Sci."},{"key":"ref_33","doi-asserted-by":"crossref","unstructured":"Paganini, M., Abowali, H., Bosco, G., Balouch, M., Enten, G., Deng, J., Shander, A., Ciesla, D., Wilson, J., and Camporesi, E. (2021). Quality Improvement Project of a Massive Transfusion Protocol (MTP) to Reduce Wastage of Blood Components. Int. J. Environ. Res. Public Health, 18.","DOI":"10.3390\/ijerph18010274"},{"key":"ref_34","doi-asserted-by":"crossref","first-page":"1408","DOI":"10.1111\/trf.14571","article-title":"Blood product transfusion and wastage rates in obstetric hemorrhage","volume":"58","author":"Yazer","year":"2018","journal-title":"Transfusion"},{"key":"ref_35","doi-asserted-by":"crossref","first-page":"45","DOI":"10.1111\/trf.13880","article-title":"Blood component transfusion and wastage rates in the setting of massive transfusion in three regional trauma centers","volume":"57","author":"Dunbar","year":"2017","journal-title":"Transfusion"},{"key":"ref_36","doi-asserted-by":"crossref","first-page":"162","DOI":"10.1111\/tme.12096","article-title":"Not only in trauma patients: Hospital-wide implementation of a massive transfusion protocol","volume":"24","author":"Morton","year":"2014","journal-title":"Transfus. Med."},{"key":"ref_37","doi-asserted-by":"crossref","first-page":"145","DOI":"10.1016\/j.medin.2015.03.005","article-title":"Escalas pron\u00f3sticas en la disfunci\u00f3n multiorg\u00e1nica: Estudio de cohortes","volume":"40","author":"Labajo","year":"2016","journal-title":"Med. Intensiv."},{"key":"ref_38","doi-asserted-by":"crossref","first-page":"527","DOI":"10.1097\/TA.0b013e3181826ddf","article-title":"Optimizing outcomes in damage control resuscitation: Identifying blood product ratios associated with improved survival","volume":"65","author":"Gunter","year":"2008","journal-title":"J. Trauma Acute Care Surg."},{"key":"ref_39","doi-asserted-by":"crossref","first-page":"31","DOI":"10.1111\/medu.13122","article-title":"Beyond a good story: From Hawthorne Effect to reactivity in health professions education research","volume":"51","author":"Paradis","year":"2017","journal-title":"Med. Educ."}],"container-title":["Journal of Clinical Medicine"],"original-title":[],"language":"en","link":[{"URL":"https:\/\/www.mdpi.com\/2077-0383\/14\/13\/4632\/pdf","content-type":"unspecified","content-version":"vor","intended-application":"similarity-checking"}],"deposited":{"date-parts":[[2025,10,9]],"date-time":"2025-10-09T18:02:05Z","timestamp":1760032925000},"score":1,"resource":{"primary":{"URL":"https:\/\/www.mdpi.com\/2077-0383\/14\/13\/4632"}},"subtitle":[],"short-title":[],"issued":{"date-parts":[[2025,6,30]]},"references-count":39,"journal-issue":{"issue":"13","published-online":{"date-parts":[[2025,7]]}},"alternative-id":["jcm14134632"],"URL":"https:\/\/doi.org\/10.3390\/jcm14134632","relation":{},"ISSN":["2077-0383"],"issn-type":[{"type":"electronic","value":"2077-0383"}],"subject":[],"published":{"date-parts":[[2025,6,30]]}}}