Process measure aimed at reducing time to haemorrhage control: outcomes associated with Code Crimson activation in exsanguinating truncal trauma

Abstract

BackgroundMajor trauma activation is a process that mobilizes personnel and resources required to care for severely injured patients. Exsanguinating truncal trauma patients require an additional response beyond major trauma activation aimed at expediting haemorrhage control. To address this requirement, ‘Code Crimson’ (CC) activation was developed. Our aim was to examine the performance of CC activation as a process measure in the identification and management of patients with exsanguinating truncal trauma.MethodsRetrospective cohort study (2010–2015) of all adult patients who underwent operative intervention within 6 h of arrival for truncal trauma was performed. Patients were classified into: (i) major haemorrhage (assessment of blood consumption score ≥2, base deficit ≥5 and/or transfusion ≥5 U of red blood cells pre‐/intra‐operatively), or (ii) no major haemorrhage. We evaluated the proportion of patients with/without major haemorrhage in which a CC was activated as well as time to operating theatre across groups.ResultsA total of 210 patients were included with a median Injury Severity Score of 20 (interquartile range (IQR) 9–29) and overall mortality of 13%. Eighty‐nine patients were classified as major haemorrhage and 61 patients underwent CC activation. The majority of CC activations (92%) fulfilled major haemorrhage criteria (sensitivity 63%, specificity 96%). Time to theatre was lower in those with CC activation with median time of 23 min (IQR 15–39.5) versus non‐CC with median of 95 min (IQR 43–180, P < 0.001).ConclusionCC was primarily activated in patients with major haemorrhage and led to a decrease in time to theatre for patients with operative truncal trauma.

The Red Blanket Protocol in a tertiary centre in Aotearoa New Zealand: does this trauma protocol improve time to surgery and clinical outcomes?

“…Code Crimson, for example, is a pre‐hospital and ED protocol used across Australasia, though not in our centre. Based on the haemodynamic parameters of patients, pre‐hospital or the ED team can activate a Code Crimson 11 . Once a Code Crimson is activated, the consultant surgeon and anaesthetist are notified to attend ED.…”

“…Based on the haemodynamic parameters of patients, pre-hospital or the ED team can activate a Code Crimson. 11 Once a Code Crimson is activated, the consultant surgeon and anaesthetist are notified to attend ED. This process allows for senior decision-makers to be present at the assessment and initial management of unstable patients, allowing for optimal planning for definitive management.…”

Haemorrhagic death from severe liver trauma has decreased in the era of haemostatic resuscitation

“…We found that there was no reduction in pre‐hospital time, or time taken from hospital arrival until beginning the haemorrhage control laparotomy. This was despite introducing the ‘code crimson’ call in 2015, which aims hasten decision making and reduce time delays to achieve haemorrhage control, with pre‐hospital identification of critically unstable patients and involving senior staff members early 17 . We believe this reflects minimal delay in the first part of the study as a baseline, which was difficult to improve upon.…”

Activating Code Crimson in the emergency department: Expediting definitive care for trauma patients with severe haemorrhage in Singapore

“…in Australia and New Zealand. [1][2][3] PHIs in Singapore have yet to initiate this form of step-up trauma activation. Code Crimson activation mobilises additional personnel and resources who are specifically required for decision-making, above those that are required for most major trauma activations.…”

“…Moreover, Code Crimson at Westmead Hospital in Sydney, Australia significantly reduced the median time from ED to OT to 23 minutes versus 59 minutes in patients with major haemorrhage in whom the code was not activated. 1 In 2018, Critical Haemorrhage to Operation Room Patient (CHOP) protocol was implemented by the Department of General Surgery at Khoo Teck Puat Hospital in Singapore, with a goal of bringing a severely injured patient rapidly to definitive care within 90 minutes. Analysis of the first 10 cases of CHOP protocol activation reported an average time of 73 minutes from the time of patient's arrival at ED to transfer to OT or IR suite.…”