Ontario’s first Massive Hemorrhage Protocol will enable rapid and coordinated delivery of blood products to patients province-wide

September 4, 2019

A groundbreaking study in CMAJ Open outlines the design of Ontario’s first Massive Hemorrhage Protocol (MHP), a set of recommendations for hospitals that will enable rapid and coordinated delivery of blood products in a patient who is hemorrhaging.

“Every day hospitals treat massively bleeding patients – whether the bleeding is caused by car crash, penetrating trauma, or post-partum hemorrhage; however, there hasn’t been one standard protocol for all hospitals to follow.” says Dr. Jeannie Callum, lead author and transfusion medicine specialist at Sunnybrook Health Sciences Centre. “Internationally, no one has come to this type of consensus on how to go about managing massive bleeding in-hospital over a geographical area of this size. We have seen an incredibly positive response to the standardization process.”

Centres that rarely see severely bleeding patients have a wide variety of methods to care for these patients. Many hospitals, especially smaller ones, have no formal policy. The MHP will provide clear process and coordination to save valuable seconds. Several of the paper’s 42 recommendations include:

  1. All hospitals have a team that is trained and prepared to execute the protocol
  2. Early transport out to a tertiary care hospital for definitive bleeding control, and
  3. Identify a designated clinical lead for the protocol.

“Massive hemorrhage protocol brings together the right health care team to the right patient with the right resources. Having a MHP and following it has been linked to better patient outcomes,” said Dr. Katerina Pavenski, study co-lead, and transfusion medicine physician at St. Michael’s Hospital.

The study team, which was comprised of transfusion medicine specialists and technologists, anesthesiologists, critical care physicians, and trauma physicians looked at the issue and came up with 42 statements and 8 quality indicators to form the basis of a province-wide protocol. These were evaluated using a modified Delphi technique, which allows panelists to review and rate the proposed statements. The panelists were 36 experts from across Ontario with diverse clinical backgrounds. Three rounds of reviews were held to reach consensus. Additional changes from external stakeholders were incorporated to form the proposed MHP.

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Ontario’s Top 10 Recommendations for Massive Hemorrhage Protocol

  1. All hospitals shall have a protocol to guide the management of a massively bleeding patient
  2. The protocol shall be called “The Massive Hemorrhage Protocol”
  3. Participating team members should have access to formal training and drills
  4. The protocol should specify how the lead clinician at the bedside is designated
  5. Tranexamic acid (TXA) should be administered as soon as possible
  6. All patients should receive interventions to prevent hypothermia
  7. The protocol shall state the reversal strategy for commonly used oral anticoagulants
  8. The transport service(s) should be promptly notified if the decision is made to transfer the patient to another hospital for definitive hemorrhage control
  9. Laboratory testing should be done at baseline and at a minimum hourly until the protocol is terminated
  10. The protocol shall consider the available resources at the institution

This achieves standardization and better outcomes for patients

For more information on the provincial MHP visit www.transfusionontario.org

On average, there is one Massive Hemorrhage Protocol enacted every three days in hospitals like St. Michael’s and Sunnybrook. Given that this protocol will be the standard at all hospitals in Ontario it has the ability to reach and benefit hundreds of patients every year.

The next phase of this work will be the creation of a MHP toolkit by the Ontario Regional Blood Coordinating Network (ORBCoN) funded by the Ontario Ministry of Health and Long-Term Care, including specific recommendations for pediatric and obstetrical patients, and for hospitals with limited availability of blood components or means to achieve bleeding control.

“Massive bleeding is a leading preventable cause of death following trauma, childbirth, and surgery,” says Dr. Callum. “Our study team believes that the standardization of a massive hemorrhage protocol in Ontario will simplify training, enhance communication and the use of evidence-based techniques, and most importantly improve patient comfort, safety and outcomes.”

Q&A: Ontario’s first Massive Hemorrhage Protocol

What is a massive hemorrhage?

A massive hemorrhage is large volume and rapid bleed that needs immediate stabilization through the transfusion of blood products and fast identification and treatment of the source of bleeding.

How serious is a massive hemorrhage?

Massive bleeding is a leading preventable cause of death following trauma, childbirth, and surgery. There were 5.1 million deaths after traumatic injury worldwide in 2010, mostly affecting young people, accounting for nearly 10% of all deaths. In the United States, it is estimated that up to 20% of such deaths are the direct result of preventable hemorrhage.

What is Ontario’s Massive Hemorrhage Protocol (MHP)?

It is a clinical workflow for managing massive hemorrhage. Design of this workflow was based on the 42 recommendations and 8 quality indicators. These in turn were developed through consensus of local experts including transfusion medicine specialists, surgeons, emergency physicians, nurses and laboratory technologists. MHP will standardize the approach to massive hemorrhage for all hospitals that supply blood in the province.

How was the MHP developed?

Not all MHP interventions are based on good quality studies. Therefore, we decided to use a Delphi method to reach consensus about what should be in our provincial plan. Delphi allows panelists to review and rate the proposed recommendations. The panelists were 36 experts from across Ontario and from diverse clinical backgrounds. Three rounds of review were held to reach agreement on the recommendations and indicators which formed the basis of the MHP.

Why don’t hospitals already have an MHP?

Developing a plan requires resources. Also, many smaller places encounter massive hemorrhage very rarely. Thus it is not surprising that many centres, especially smaller ones, have no formal policy to care for severely bleeding patients. This standardized approach will ensure hospitals all follow the same policy and care plan.

Has an MHP ever been developed in another province or country?

A few other provinces have developed provincial MHPs, also a few countries have country-wide MHPs. What is unique about this endeavor is that it was developed by a rigorous consensus-building method and took into account special populations (ex. pediatrics, postpartum) and circumstances (ex. small hospital with limited blood product availability) rather than the one size fits all approach.

How many patients will potentially be affected by the MHP on a yearly basis?

We know that there is, on average, one Massive Hemorrhage Protocol enacted every three days in hospitals like St. Michael’s and Sunnybrook. Given that this protocol will be the standard at all hospitals in Ontario it has the ability to reach and benefit hundreds of patients.

What is the next step in the process for rolling-out the MHP to all Ontario hospitals?

The next phase of this work will be the creation of an actual template plan and MHP toolkit by the Ontario Regional Blood Coordinating Program which is funded by the Ministry of Health and Long-term Care Ontario. The toolkit will include specific recommendations for pediatric and obstetrical patients, and for hospitals with limited availability of blood components or means to achieve bleeding control. It will also provide suggestions on how to implement the plan, train staff and monitor quality indicators. This will give hospitals a sound launching off point to develop their own local policies and procedures.

For media inquiries:

Laura Bristow
Communications Advisor
Sunnybrook Health Sciences Centre
416-480-4040, laura.bristow@sunnybrook.ca