Timeliness, Appropriateness, and Safety of Blood Transfusion in the Emergency Department: A Prospective Observational Study

Aim and background: Timely and appropriate blood transfusion is critical for resuscitation in the emergency department (ED); yet delays, inappropriate utilization, and safety concerns, particularly during emergency-release transfusion, remain important challenges.We evaluated the timeliness, appropriateness, and safety of blood transfusion practices in the ED using a time-stamped, end-to-end workflow analysis.Materials and methods: This prospective observational study was conducted over 2 years in the ED and blood center of a tertiary care teaching hospital.All patients aged ≥16 years receiving emergency blood transfusions were included.Time-stamped data were collected for predefined transfusion workflow steps.Transfusion appropriateness was assessed by indication-specific component utilization and massive transfusion protocol (MTP) activation.Safety was evaluated through emergency-release practices, including uncrossmatched and O Rh(D)-negative transfusion.Results: A total of 1,152 patients received emergency transfusions.Trauma and hemorrhagic shock were the most common indications (39.6%).Over half of the patients required intensive care unit (ICU) admission (51.3%), and MTP was activated in 13.7%.Uncrossmatched blood and O Rh(D)-negative red cells were used in 8.4 and 4.8% of patients, respectively.After normalization of platelet dosing, MTP-activated patients demonstrated near-balanced red cell, plasma, and platelet utilization.The median decision-to-transfusion time for emergency lifesaving transfusion was 59 minutes, compared with 105 minutes for routine transfusions.Pre-analytical processes accounted for the largest proportion of transfusion delay.Conclusion: Emergency blood transfusion in the ED was timely, indication-appropriate, and safe, with selective use of emergency-release strategies and balanced component therapy during massive transfusion.System-level improvements targeting pre-analytical delays may further enhance transfusion efficiency in emergency care. Clinical significance:This study provides real-world evidence on the timeliness, appropriateness, and safety of emergency blood transfusion workflows, highlighting critical pre-analytical delays and supporting structured transfusion governance in high-acuity settings.