Expanding access to prehospital blood products: a narrative review of clinical evidence, systems barriers, and statewide strategies

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 11 450 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.