Elsevier

Injury

Volume 48, Issue 1, January 2017, Pages 41-46
Injury

Experience of implementing a National pre-hospital Code Red bleeding protocol in Scotland

https://doi.org/10.1016/j.injury.2016.09.020Get rights and content

Abstract

Introduction

The Scottish Transfusion and Laboratory Support in Trauma Group (TLSTG) have introduced a unified National pre-hospital Code Red protocol. This paper reports the results of a study aiming to establish whether current pre-hospital Code Red activation criteria for trauma patients successfully predict need for in hospital transfusion or haemorrhagic death, the current admission coagulation profile and Concentrated Red Cell (CRC): Fresh Frozen Plasma (FFP) ratio being used, and whether use of the protocol leads to increased blood component discards?

Methods

Prospective cohort study. Clinical and transfusion leads for each of Scotland’s pre-hospital services and their receiving hospitals agreed to enter data into the study for all trauma patients for whom a pre-hospital Code Red was activated. Outcome data collected included survival 24 h after Code Red activation, survival to hospital discharge, death in the Emergency Department and death in hospital.

Results

Between June 1 st 2013 and October 31 st 2015 there were 53 pre-hospital Code Red activations. Median Injury Severity Score (ISS) was 24 (IQR 14–37) and mortality 38%. 16 patients received pre-hospital blood. The pre-hospital Code Red protocol was sensitive for predicting transfusion or haemorrhagic death (89%). Sensitivity, specificity, positive and negative predictive values of the pre-hospital SBP <90 mmHg component were 63%, 33%, 86% and 12%. 19% had an admission prothrombin time >14 s and 27% had a fibrinogen <1.5 g/L. CRC: FFP ratios did not drop to below 2:1 until 150 min after arrival in the ED. 16 red cell units, 33 FFP and 6 platelets were discarded. This was not significantly increased compared to historical data.

Conclusions

A National pre-hospital Code Red protocol is sensitive for predicting transfusion requirement in bleeding trauma patients and does not lead to increased blood component discards. A significant number of patients are coagulopathic and there is a need to improve CRC: FFP ratios and time to transfusion support especially FFP provision. Training clinicians to activate pre-hospital Code Red earlier during the pre-hospital phase may give blood bank more time to thaw and prepare FFP and may improve FFP administration times and ratios so long as components are used upon their availability.

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.

References (13)

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    The Code Red protocol allows sufficient blood components to be made available to the clinician on arrival of the patient to the ED. An initial review of the implementation of the Code Red protocol between June 1st 2013 and October 31st 2015 (30 months) [1] conducted by the Scottish Transfusion and Laboratory Support in Trauma Group (TLSTG) studied 53 pre-hospital Code Red activations. Median Injury Severity Score (ISS) was 24 (IQR 14–37) and overall mortality 38%.

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    Twenty-three studies investigated the use of vital signs, serum studies, and trauma-related variables, in combination or alone, to predict which patients may need MT. The findings of these studies vary in terms of which variables may be useful in predicting the need for MT. Fifteen studies reported findings regarding the use of vital signs to predict the need for MT. A systolic blood pressure of 90 mm Hg or lower predicted the need for MT in eight studies (Blackmore et al., 2006; Burkhardt et al., 2014; Callcut, Johannigman, Kadon, Hanseman, & Robinson, 2011; Charbit et al., 2013; Dente et al., 2010; Parimi et al., 2016; Reed et al., 2016; Umemura, Nakamura, Nishida, Hoshino & Ishikura, 2016). Six other studies found that blood pressure may also predict MT need and all but one (Tonglet, Minon, Seidel, Poplavsky, & Vergnion, 2014) did not use the 90 mm Hg cutoff point (Fligor et al., 2016; Mina, Winkler & Dente, 2013; Rau et al., 2016; Shackelford et al., 2015; Vandromme, Griffin, Weinberg, Rue & Kerby, 2010).

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