Experience of implementing a National pre-hospital Code Red bleeding protocol in Scotland
Introduction
Despite improvements in trauma care over the last 20 years major haemorrhage is still a significant cause of death in trauma patients, with up to 40% dying of acute haemorrhage [1]. The Scottish Transfusion and Laboratory Support in Trauma Group (TLSTG) were therefore established in March 2014 to provide a forum focused upon optimising the transfusion support given to patients following major trauma in Scotland. Over the last couple of years, three of Scotland’s four pre-hospital services, Emergency Medical Retrieval Service (EMRS) based in the West of Scotland, Tayside Trauma Team (TTT) based in the East and Medic 1 based in the South East, have worked together through the TLSTG to introduce a unified national pre-hospital Code Red protocol. This is activated prior to a patient with major or massive haemorrhage arriving in the Emergency Department (ED), allowing time for blood components such as Fresh Frozen Plasma (FFP) to be thawed.
It is recognised that it is difficult in the pre-hospital setting to accurately predict trauma patients who are at risk of massive haemorrhage. These patients are at risk of Acute Traumatic Coagulopthy (ATC) and require treatment with appropriate blood components as early as possible. It is therefore important that any criteria selected to identify these patients is accurate and able to identify those most at risk of developing coagulopathy to enable early treatment. Blood components are equally a precious commodity and care must be taken not to waste them.
The aims of this study are:
- (1)
To establish whether current pre-hospital Code Red activation criteria successfully predict need for in hospital transfusion or haemorrhagic death?
- (2)
To establish what is the current admission coagulation profile of pre-hospital Code Red trauma patients in Scotland and whether they are receiving appropriate treatment of any coagulation derangement?
- (3)
To establish the current Concentrated Red Cell (CRC): Fresh Frozen Plasma (FFP) ratio being used in pre-hospital Code Red trauma patients in Scotland?
- (4)
To see whether use of a pre-hospital Code Red protocol leads to increased FFP and CRC discards?
Section snippets
Patients and methods
Patients likely to require Massive Transfusion (MT; defined here as 10 or more CRCs in 24 h) with life threatening haemorrhage can be difficult to diagnose and there is no reliable pre defined criteria that can be used to identify them. As a guide and based on other pre hospital services’ practice [2] it was decided that the pre-hospital physician should be asked to consider the following factors in order to decide whether to activate the National pre-hospital Code Red protocol:
- 1.
Suspected or
Results
During the 30-month study period between June 1 st 2013 and October 31 st 2015 there were 53 pre-hospital Code Red activations for trauma. 23 activations were to Royal Infirmary Edinburgh (South-East), 18 to Queen Elizabeth University Hospital (West), 10 to Ninewells Hospital (East), 1 to Victoria Infirmary (West) and 1 to Glasgow Royal Infirmary (West).
The mean age of pre-hospital Code Red patients was 42 (SD 19) years and 75% patients were male. Overall median ISS was 24 (IQR 14–37) and 68% of
Discussion
It is evident that activation of our pre-hospital Code Red policy is sensitive (89%) for predicting a trauma patient’s need for blood component transfusion. The criteria of pre-hospital SBP < 90 mmHg was less sensitive (63%) and although it had good predictive value for blood component requirement if present, a third of patients who received blood components did not meet the pre-hospital Code Red criteria of SBP < 90 mmHg. This suggests that pre-hospital teams are using the Code Red criteria as a
Conclusions
A National pre-hospital Code Red protocol is sensitive for predicting transfusion requirement in bleeding patients. 19% of our pre-hospital Code Red population was coagulopathic and 27% hypofibrinogenaemic. CRC: FFP ratio approached 2:1 at 2 h. Use of the pre-hospital Code Red protocol did not seem to increase blood component discards.
This study highlights the need to improve time to transfusion support especially provision of FFP. This should improve both the time to administration of FFP and
Contributions
All authors have made substantial contributions to all of the following (except author 12 who was involved in the conception and design of the study only):
- (1)
the conception and design of the study, or acquisition of data, or analysis and interpretation of data
- (2)
drafting the article or revising it critically for important intellectual content and
- (3)
final approval of the version to be submitted.
No writing assistance was required.
Acknowledgements
This study was only possible due to the support of the Scottish National Blood Transfusion Service (SNBTS) and the regional transfusion practitioners and clinicians who collated transfusion data. MR was supported by an NHS Research Scotland Career Researcher Clinician award.
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