The simplest solution may be good, but is it good enough? Evaluating the effect of a nudge to administer calcium during blood product resuscitation for traumatic injuries

Background: Hypocalcemia following severe injury is common. Current institution-specific guidelines recommend calcium (Ca⁺⁺) supplementation during blood product resuscitation. We hypothesize that a nudge intervention would improve clinician adherence to Ca⁺⁺-specific guidelines. Methods: This study at an urban Level I trauma center evaluated compliance with Ca⁺⁺-specific guidelines during trauma resuscitations. A baseline assessment of guideline awareness preceded four-month pre-intervention and four-month post-intervention periods from July 2021 to February 2022. Nudge signs prompting clinicians to administer Ca⁺⁺ were placed throughout all phases of care. Administration of ≥1 dose of Ca⁺⁺ after four blood products was the primary endpoint. Aggregate ionized calcium (iCa⁺⁺) levels and percent time within a normal iCa⁺⁺ range were secondary outcomes. Results: Baseline assessment of n = 41 trauma team members indicated 83% were uncertain or unaware of current Ca⁺⁺ recommendations. Of 86 screened patients, 25 met inclusion criteria. These were median ([IQR] 34 [25–43]) years old with an Injury Severity Score of 18 [14-26] and 84% penetrating injuries with n = 11 pre-intervention and n = 14 post-intervention. The absolute difference (95% CI) in Ca⁺⁺ guideline adherence post-intervention compared to pre-intervention was 6.5% (−11.9% to 24.9%, p = 0.755). In aggregate, iCa⁺⁺ levels were no different between groups, although the distribution of levels post-intervention trended toward the normal range with less extreme hypocalcemia. Conclusions: Signs prompting clinicians to give Ca⁺⁺ were associated with a modest, non-statistically significant increase in adherence to institution-specific guidelines and a slight shift in the distribution of iCa⁺⁺ values toward normal. Future work to optimize resuscitation should evaluate larger cohorts of acutely injured patients and more potent nudges.