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

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.

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.

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.

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.

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.

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.

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.

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.