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

Abstract 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.