Balanced Component and Whole-Blood Transfusion Practices in US Trauma Centers

Importance Balanced transfusion is a cornerstone of modern hemorrhage resuscitation, yet national adoption patterns and hospital practice variation remain poorly characterized, particularly following increasing use of whole blood (WB). Objective To evaluate trends, between-hospital variation, and patient and institutional factors associated with balanced component and WB transfusion in US trauma centers. Design, Setting, and Participants This retrospective cohort study of adult trauma patients in hemorrhagic shock receiving blood transfusion within 4 hours of hospital arrival used data from the Trauma Quality Improvement Program (2018-2024). Multilevel mixed-effects logistic regression was used to evaluate patient and hospital characteristics associated with balanced component and WB use and quantify hospital-level variation. Exposure Patient demographic and injury characteristics, hospital structural characteristics, and calendar year. Main Outcomes and Measures The primary outcome was balanced component and WB use within 4 hours of arrival, defined by standardized ratios of plasma to red blood cells and platelet to red blood cells or receipt of WB. Temporal trends and facility variation were assessed using adjusted odds ratios (ORs), intraclass correlation coefficients, and median ORs. Results The study included 71 997 patients treated at 650 trauma centers (197 [30.3%] American College of Surgeons–verified level I). The median (IQR) age was 36.0 (26.0-52.0) years, 54 889 patients (76.2%) were male, and 45 185 patients (62.8%) sustained blunt injury. Balanced component and WB transfusion increased from 12.4% (918 transfusions) in 2018 to 37.6% (4244 transfusions) in 2024 (adjusted OR, 5.33; 95% CI, 4.88-5.81), largely corresponding to increasing WB adoption after 2020, whereas component-based balanced transfusion remained relatively stable. Significant between-hospital variation persisted after adjustment. Hospital-level differences accounted for 24% of variation in balanced component and WB use (intraclass correlation coefficient, 0.24; 95% CI, 0.21-0.26). Male sex, helicopter transport, and treatment at larger hospitals were associated with higher odds of balanced component and WB use, whereas major hemorrhage control surgery and severe torso injuries were negatively associated, despite higher total transfusion volumes. Conclusions and Relevance In this retrospective cohort study of trauma patients at risk of hemorrhagic shock, the use of balanced component and WB use increased from 2018 to 2024, reflecting increasing WB adoption. Substantial between-hospital variation persisted. These findings can inform evaluation of hospital-level variation and future implementation of balanced transfusion practices across trauma centers.