title: The effectiveness of a 'Code Red' transfusion request policy initiated by pre-hospital physicians.
abstract: BACKGROUND
  Major trauma is a leading cause of mortality and serious morbidity. Recent approaches to life-threatening traumatic haemorrhage have emphasized the importance of early blood product transfusion. We have implemented a pre-hospital transfusion request policy where a pre-hospital physician can request the presence of a major transfusion pack on arrival at the destination trauma centre.
  
  
  OBJECTIVE
  This study was performed to establish whether three simple criteria (1) suspicion or evidence of active haemorrhage (2) systolic BP<90 mmHg (3) failure of blood pressure to respond to an intravenous fluid bolus) which were used to activate a pre-hospital 'Code Red' transfusion request accurately identified seriously injured patients who required transfusion on arrival at hospital.
  
  
  METHODS
  Prospective evaluation of all pre-hospital 'Code Red' requests over a 30-month period (August 2008-May 2011) was performed for patients transported to a major trauma centre. Mechanism of injury, Injury Severity Score, hospital mortality, and use of blood products were recorded. Patients were followed up to hospital discharge.
  
  
  RESULTS
  176 'Code Red' activations were made in the study period. 129 patients were transported to the Trauma Centre. Mechanism of injury was penetrating trauma in 39 (30%) cases, road traffic collision in 58 (45%), falls in 18 (14%) and 'other' in 14 (10.8%). Complete data was available for 126 patients. Of the patients reaching hospital, 20 died in the emergency department or operating theatre, 22 died following admission and 84 survived to hospital discharge. Mean Injury Severity Score (ISS) was 29.1. (range 0-66). Overall, 115 (91%) of the patients declared 'Code Red' pre-hospital received blood product transfusion after arrival in hospital. Eleven patients did not receive any blood products following hospital admission. In patients declared 'Code Red' pre-hospital, mean packed red blood cell transfusion in the first 24-h was 10.4 unit (95% CI 8.4-12.3 unit).
  
  
  CONCLUSIONS
  The use of simple pre-hospital criteria allowed physicians to successfully identify trauma patients with severe injury and a requirement for blood product transfusion. This allowed blood products to be ready on the patient's arrival in a major trauma centre with the potential for earlier transfusion.
authors.affiliation: Emergency Medicine & Pre-hospital Care, London's Air Ambulance, The Royal London Hospital, Whitechapel Road, London E1 1BB, United Kingdom. Electronic address: anne.weaver@bartshealth.nhs.uk.
authors.forename: Anne E
authors.initials: AE
authors.lastname: Weaver
authors.affiliation: Emergency Medicine, London's Air Ambulance, The Royal London Hospital, Whitechapel Road, London E1 1BB, United Kingdom. Electronic address: cshdunn@gmail.com.
authors.forename: Ceri
authors.initials: C
authors.lastname: Hunter-Dunn
authors.affiliation: Emergency Medicine & Pre-hospital Care, London's Air Ambulance, The Royal London Hospital, Whitechapel Road, London E1 1BB, United Kingdom. Electronic address: Richard.lyon@doctors.org.uk.
authors.forename: Richard M
authors.initials: RM
authors.lastname: Lyon
authors.affiliation: North Bristol NHS Trust, Bristol, United Kingdom; School of Clinical Sciences, University of Bristol, Bristol, United Kingdom; London's Air Ambulance, The Royal London Hospital, Whitechapel Road, London E1 1BB, United Kingdom. Electronic address: djlockey@hotmail.com.
authors.forename: David
authors.initials: D
authors.lastname: Lockey
authors.affiliation: London's Air Ambulance, The Royal London Hospital, Whitechapel Road, London E1 1BB, United Kingdom. Electronic address: Charlotteloumann@gmail.com.
authors.forename: Charlotte L
authors.initials: CL
authors.lastname: Krogh
mesh_terms: D001291:Attitude of Health Personnel; D001778:Blood Coagulation Disorders / Q000175:diagnosis / Q000401:mortality / Q000628:therapy*; D016913:Blood Component Transfusion / Q000706:statistics & numerical data; D042241:Early Diagnosis; D004632:Emergency Medical Services / Q000639:trends; D006801:Humans; D009104:Multiple Trauma / Q000401:mortality / Q000628:therapy*; D017410:Practice Guidelines as Topic; D011446:Prospective Studies; D016019:Survival Analysis; D014193:Trauma Centers; D015599:Trauma Severity Indices; D016896:Treatment Outcome; D006113:United Kingdom / Q000453:epidemiology
keywords: Haemorrhage; Massive transfusion; Pre-hospital care; Trauma