title: Experience of implementing a National pre-hospital Code Red bleeding protocol in Scotland.
abstract: BACKGROUND
  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 24h after Code Red activation, survival to hospital discharge, death in the Emergency Department and death in hospital.
  
  
  RESULTS
  Between June 1st 2013 and October 31st 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 <90mmHg component were 63%, 33%, 86% and 12%. 19% had an admission prothrombin time >14s and 27% had a fibrinogen <1.5g/L. CRC: FFP ratios did not drop to below 2:1 until 150min 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.
authors.affiliation: Department of Emergency Medicine, Royal Infirmary of Edinburgh, NHS Lothian, 51 Little France Crescent, Edinburgh EH16 4SA, UK; Emergency Medicine Research Group Edinburgh (EMERGE), Royal Infirmary of Edinburgh, 51 Little France Crescent, Edinburgh EH16 4SA, UK; College of Medicine and Veterinary Medicine, University of Edinburgh, The Chancellor's Building, 49 Little France Crescent, Edinburgh EH16 4SB, UK. Electronic address: mattreed1@hotmail.com.
authors.forename: Matthew J
authors.initials: MJ
authors.lastname: Reed
authors.affiliation: Emergency Medicine Research Group Edinburgh (EMERGE), Royal Infirmary of Edinburgh, 51 Little France Crescent, Edinburgh EH16 4SA, UK; Scottish National Blood Transfusion Service, 21 Ellen's Glen Rd, Edinburgh EH17 7QT, UK.
authors.forename: Alison
authors.initials: A
authors.lastname: Glover
authors.affiliation: College of Medicine and Veterinary Medicine, University of Edinburgh, The Chancellor's Building, 49 Little France Crescent, Edinburgh EH16 4SB, UK.
authors.forename: Lauren
authors.initials: L
authors.lastname: Byrne
authors.affiliation: Department of Emergency Medicine, Ninewells Hospital, Dundee DD2 1UB, UK; EMRS, Emergency Medical Retrieval Service, ScotSTAR, Hangar B, 180 Abbotsinch Road, Paisley PA3 2RY, UK.
authors.forename: Michael
authors.initials: M
authors.lastname: Donald
authors.affiliation: EMRS, Emergency Medical Retrieval Service, ScotSTAR, Hangar B, 180 Abbotsinch Road, Paisley PA3 2RY, UK; Department of Emergency Medicine, Royal Alexandra Hospital, NHS Greater Glasgow and Clyde, Corsebar Rd, Paisley PA2 9PN, UK.
authors.forename: Niall
authors.initials: N
authors.lastname: McMahon
authors.affiliation: EMRS, Emergency Medical Retrieval Service, ScotSTAR, Hangar B, 180 Abbotsinch Road, Paisley PA3 2RY, UK; Department of Emergency Medicine, Monklands Hospital, NHS Lanarkshire, Monkscourt Ave, Airdrie ML6 0JS, UK.
authors.forename: Neil
authors.initials: N
authors.lastname: Hughes
authors.affiliation: EMRS, Emergency Medical Retrieval Service, ScotSTAR, Hangar B, 180 Abbotsinch Road, Paisley PA3 2RY, UK; Department of Emergency Medicine, Queen Elizabeth University Hospital, NHS Greater Glasgow and Clyde, 1345 Govan Rd, Glasgow G51 4TF, UK.
authors.forename: Nicola K
authors.initials: NK
authors.lastname: Littlewood
authors.affiliation: Department of Emergency Medicine, Ninewells Hospital, Dundee DD2 1UB, UK.
authors.forename: Justin
authors.initials: J
authors.lastname: Garrett
authors.affiliation: Department of Transfusion Medicine, Royal Infirmary of Edinburgh, NHS Lothian, 51 Little France Crescent, Edinburgh EH16 4SA, UK.
authors.forename: Catherine
authors.initials: C
authors.lastname: Innes
authors.affiliation: Department of Transfusion Medicine, Queen Elizabeth University Hospital, NHS Greater Glasgow and Clyde, 1345 Govan Rd, Glasgow G51 4TF, UK.
authors.forename: Margaret
authors.initials: M
authors.lastname: McGarvey
authors.affiliation: Department of Transfusion Medicine, Ninewells Hospital, Dundee DD2 1UB, UK.
authors.forename: Eleanor
authors.initials: E
authors.lastname: Hazra
authors.affiliation: Scottish National Blood Transfusion Service, 21 Ellen's Glen Rd, Edinburgh EH17 7QT, UK; Department of Transfusion Medicine, Ninewells Hospital, Dundee DD2 1UB, UK.
authors.forename: P Sam M
authors.initials: PS
authors.lastname: Rawlinson
mesh_terms: D000328:Adult; D001778:Blood Coagulation Disorders / Q000401:mortality / Q000628:therapy*; D016913:Blood Component Transfusion / Q000706:statistics & numerical data*; D001803:Blood Transfusion / Q000379:methods*; D059019:Clinical Coding / Q000379:methods*; D002985:Clinical Protocols; D004632:Emergency Medical Services / Q000379:methods* / Q000458:organization & administration; D005260:Female; D006284:Health Plan Implementation; D006801:Humans; D015601:Injury Severity Score; D008297:Male; D017410:Practice Guidelines as Topic; D011446:Prospective Studies; D012606:Scotland / Q000453:epidemiology; D016019:Survival Analysis; D014193:Trauma Centers; D015599:Trauma Severity Indices; D016896:Treatment Outcome; D014947:Wounds and Injuries / Q000401:mortality / Q000628:therapy*
keywords: Haemorrhage; Massive transfusion; Pre-hospital care; Trauma