Massive blood loss protocol 'Code Red' at Papworth Hospital: A closed loop audit.

M Tennyson,G Biosse-Duplan,H Layard Horsfall,J Redlaff,N Jones,M Lewin

doi:10.1177/1750458920943361

Abstract

AimTo investigate if the massive blood loss protocol ‘Code Red’ at a specialist cardiothoracic hospital was activated according to local and national guidelines by a closed loop audit.MethodsElectronic and paper patient care systems were searched in 2015 and 2018 to access records for the ‘Code Red’ activations. Activation of the massive blood loss protocol was compared against the national standards set by The British Committee for Standards in Haematology. The percentage of cases meeting each of the ten standards in the specialist cardiac unit’s Protocol for the Management of Massive Blood Loss in Adults (adapted from the national standards) were evaluated.Results‘Code Red’ protocol was activated on 18 occasions in 2015 and nine occasions in 2018, representing just 0.83 and 0.26% of emergency surgeries, respectively. Between 2015 and 2018, there was a 6% increase of ‘Code Red’ cases being appropriately activated, a 26% increase in the prompt notification of the haematology department upon activation, alongside a 30% increase in the timely delivery of blood products, and a 25% decrease in the average amount of blood transferred prior to ‘Code Red’ activation.ConclusionThere has been an improvement in the standards of care and management of massive blood loss this specialist cardiac centre despite the target timeframe being reduced from 30 to 15min between 2015 and 2018. Preparation for and anticipation of massive blood loss has likely decreased the number of incidences requiring ‘Code Red’ activation, permitting delivery of safe patient care.

Highlights

Our institution is an international centre of excellence in cardiothoracic surgery, reparative and transplant, and intensive care
A closed loop audit cycle was performed on the appropriateness of 'Code Red' activation according to hospital guidelines at the specialist cardiac unit, to assess changes made since the initial audit in 2015
We noticed an increase of 26% in the proportion of cases in which haematology consultants were informed of the 'Code Red' activation, and a 30% increase in the timely receipt of blood products after 'Code Red' activation

Summary

Introduction

Our institution is an international centre of excellence in cardiothoracic surgery, reparative and transplant, and intensive care. The need for prophylactic high-dose anticoagulation increases the risk of massive blood loss. Massive blood loss is a serious clinical situation associated with worse patient outcomes, including a higher mortality (Stainsby et al 2006b). Guidelines from the British Committee for Standards in Haematology (BCSH) (Hunt et al 2015, Stainsby et al 2006b) and the Association of Anaesthetists of Great. Britain and Ireland (Thomas et al 2010) stress the need for effective recognition of haemorrhage and an effective protocol. Designing a protocol requires a definition of severe haemorrhage based on parameters monitored in surgery as opposed to using retrospective measures. The BCSH guidelines define massive blood loss as a bleed that leads to a heart rate of more than 110beats/

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