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November 2019

Code Orange: Simulation to Real Life

Authors: D. Neurath, Manager, Transfusion Medicine, EORLA The Ottawa Hospital sites M. Tokessy, Regional Discipline Manager for Transfusion Medicine, Tissue Typing and Molecular Diagnostics On January 11, 2019 in Ottawa, a double decker city bus collided with the shelter of a busy commuter bus station. On impact, the second level of the bus crumpled towards its middle, pinning passengers in their seats. Three passengers were killed, another 23 sustained major blunt force trauma injuries.   In anticipation of the incoming casualties, a Code Orange was declared at the trauma center of The Ottawa Hospital (TOH) Civic Campus.   The Code Orange procedure for Transfusion Medicine (TM) at TOH includes the process of packing 2 validated cold boxes; one box with 10 group O Rh negative red blood cells (RBC) and one with 10 group O Rh positive RBC. Two technologists, wearing red TM vests, bring the two blood boxes to the Emergency Department (ED) and dispense uncrossmatched blood as needed.   Just two months earlier, in November 2018, TM participated in a Code Orange simulation exercise among all other required medical and support services. The scenario simulated casualties of a mass shooting and took place in the ED over a span of three hours. It was the largest simulation ever performed at TOH. Dedicated staff were assigned to observe and evaluate the processes of the exercise. Post-exercise debriefing with the multi-disciplinary team identified gaps in many processes requiring improvements. While the TM support was very effective, there were a few minor changes to be made: identifying a dedicated desk with phone for TM strategically located within the ED, ensuring two technologists to be stationed in the ED (as staffing in the lab permits) and providing a dedicated porter assigned solely to the TM service for transporting additional blood products as needed from the lab. Based on this new information, the Code Orange procedure was revised and signed off by all TM staff within a week of the mock exercise.   Two months later, on that devastating Friday evening, two technologists wearing the red TM vests and equipped with two boxes of RBC set up their station in the ED. It was recognized early on that RBC units weren’t the only urgently needed blood product: and a cold box with thawed group AB plasma was quickly brought to the ED. The two technologists worked tirelessly dispensing RBC and plasma while ordering replacement products from the lab. Most of the female patients were of child-bearing potential (<45-years of age) therefore used many group O Rh negative RBC. Meanwhile in the lab, technologists were performing stat type and screen, thawing plasma, packing blood boxes and ordering additional product from Canadian Blood Services (CBS) to replenish the RBC inventory.   By the end of the evening, 12 patients had been transfused. There were 96 RBC, 58 units of plasma and 10 pools of platelets transfused. Once the Code Orange was over, the TM staff continued support to the OR and ICU patients.   What we learned:   While the Code Orange simulation had provided the team with invaluable improvements to the TM procedure, the real-life casualty response identified additional opportunities for enhancing the process which were included in a newly revised Code Orange procedure:

  1. We recognized the importance of AB plasma being immediately available during the Code Orange process. The procedure has been changed to include a box of 10 thawed AB plasma.
  2. Uncrossmatched group O RBC will continue to be dispensed until the patients’ proper identification is available; only then will group specific blood be issued to avoid any potential errors in wrong blood to patient.
  3. For more timely and effective replacement of the blood inventory during Code Orange, the decision was made to request blood from the General Campus of TOH instead of the local CBS. The transportation time is shorter and the incoming RBC units will already have ABO confirmed in the shared LIS.
  4. Reconciliation is an important aspect of the process to ensure accurate documentation of patient transfusion history.

Our preparedness and past Code Orange exercises aided in developing competency in responding to mass casualties. The simulation exercise was very useful, but nothing can prepare you more than real life situations.   We are fortunate to have dedicated and knowledgeable staff that contributed to the support of the bus crash victims. In the post Code Orange debriefing staff expressed how they felt there is a great sense of pride and accomplishment when you can do what you are trained to do in a manner where it directly impacts the health and survival of another human being.

On the road to a massive hemorrhage protocol (MHP): Updated October, 2019.

Author:Stephanie Cope, Regional Project Coordinator, ORBCoN CE Region

 On September 20, 2019 ORBCoN released Ontario’s first recommendations for massive hemorrhage.  A modified Delphi technique was used by a multi-disciplinary panel of experts to reach consensus. For additional information regarding background, methods and results, refer to the article just published in CMAJ Open.   This unique approach resulted in 42 recommendation statements and 8 quality indicators which will form the basis of one provincial standardized protocol for all Ontario hospitals to follow, a process that has not been done before.   Currently we are in the process of developing the toolkit – which will aid hospitals in the implementation of these recommendations and quality metrics. We have twelve different working groups and one Steering Committee hard at work on this initiative. Resources to include: pretransport care, facilitation of early transfer, activation/termination criteria, determination of team, communication, lab testing, temperature requirements, blood and blood products, training materials, pediatrics, patient/family support and quality reporting. The toolkit will also address obstetrical patients, various hospital sizes and hospitals with limited resources.   The target completion date for the MHP toolkit is spring 2020. ORBCoN’s bi-annual Transfusion Committee Forum (2020) will be dedicated to the release of the MHP toolkit. Stay tuned for more information coming soon.   Have you been busy with massive hemorrhage activities at your hospital? We would love to hear from you and even feature your hospital work in our newsletter! Suggestions for the provincial toolkit are welcome and can be directed to Stephanie.cope@sunnybrook.ca

  Question – Cryo and Fibrinogen Dosing in MHP for Adult vs Pediatric We are trying to implement our MHP protocol and some questions have arisen regarding our proposed procedure. Regarding a pediatric MHP, should platelets and cryoprecipitate be included in the “pack”? Is fibrinogen concentrate an acceptable substitute for cryoprecipitate in an MHP situation?   Answer:   The final Ontario Massive Hemorrhage Protocol (MHP) Toolkit is currently in development and is expected to be available in the Spring of 2020.  It will contain recommendations for both large and small hospitals as well a special section addressing management of pediatric patients.   This toolkit will have guidance on the use of blood components and products as well as tranexamic acid, maintaining temperature (keep patient warm), Ca, minimizing blood loss from hemorrhaging sites, etc.   Here’s some information and references that may help you in the meantime:   Cryoprecipitate and fibrinogen concentrate dosing for MHP   For recommendations on the use and dosing of cryoprecipitate and fibrinogen concentrate for replacement of fibrinogen refer to the most recent statement released by the National Advisory Committee on Blood and Blood Products   Is there a need for a standardized protocol which can help in the management of patients who are massively bleeding?   To find out, watch this U of T rounds presentation by Drs. Jeannie Callum and Katerina Pavenski, posted on ORBCoN’s website.   For expert recommendations on what should be included in a Massive Hemorrhage Protocol go to: https://transfusionontario.org/documents/?cat=massive-hemorrhage-protocol