Regional
The evolution of Ontario’s massive hemorrhage protocol
Stephanie Cope
Ontario Regional Blood Coordinating Network, Ontario, Canada
Katerina Pavenski
St. Michael’s Hospital – Unity Health Toronto Ontario, Canada
Andrew Petrosoniak
St. Michael’s Hospital – Unity Health Toronto Ontario, Canada
In 2018, a province wide survey of Ontario hospitals found that 33% of hospitals did not have an established massive hemorrhage protocol (MHP)1. Our results also demonstrated marked variability in the delivery of care for bleeding patients including MHP activation criteria, temperature monitoring, testing and transfusion support. The survey identified an opportunity for improvement at a provincial level. With our data as the impetus, a multi-disciplinary panel was established with the goal of creating Ontario’s first recommendations for a massive hemorrhage protocol using a consensus process. This led to 42 key evidence-based statements to aid in the standardization and management of massive hemorrhage2.
Figure 1. Timeline
Closing the Gap: MHP 1.0
The potential impact of this project was clear with Ontario being the largest population of all Canadian provinces transfusing more than 345,000 red blood cells (RBC) in 2023-24.
We applied a guiding principle during this project that "All Hospitals shall have a protocol to guide the management of a massively bleeding patient”. We acknowledged that medical resources differed across Ontario’s 158 hospitals (with a transfusion service) leading to variability and availability of services (e.g. access to blood and blood products, testing and medical expertise). To mitigate this gap in patient care and recognizing that a ‘one size fits all’ model would not be appropriate, we created a comprehensive toolkit in 2021.
The toolkit is comprised of 12 key areas; pre-hospital & transport, damage control resuscitation, teams, communication, laboratory tests, temperature, transfusion medicine & coagulation, education, pediatrics, patient & family support, quality and research. It provides guidance to select patient populations and systematic details to support hospitals of all sizes. Using a set of evidence-based recommendations customized for the local setting, we were able to reduce implementation challenges and were able to gain substantial uptake and support from Ontario hospitals.
Figure 2. Picture of toolkit
This initiative highlights that successful care of bleeding patients requires end-to-end care from bleeding identification, administration of blood products and ultimately definitive hemostasis. The 7T’s below constituted the framework of the provincial toolkit and illustrates that ‘transfusion’ is just one element in an MHP. 1. Triggering 2. Teams 3. Tranexamic acid (TXA) 4. Temperature 5. Testing 6. Transfusion 7. Termination (and tracking performance)
Measurable improvements In order to assess uptake and to measure barriers to success we conducted a follow-up survey in 2023 that mirrored our original research, allowing for direct comparison. The results are impressive. Ninety-five percent of Ontario hospitals responded they had an MHP, were working on alignment with the Ontario MHP, or in process of implementing the Ontario MHP.
We demonstrated an increase in the number of hospitals who have a MHP from 65% in 2018 to 77% in 2023. Notably, there was a significant increase in adoption among smaller hospitals (<5000 RBCs transfused per year) from 60% in 2018 to 74% in 2023. The survey found a significant increase in MHPs that included pre-defined transfusion packs from 61% in 2018 to 86% in 2023 and those that included laboratory-testing frequencies from 63% in 2018 to 87% in 2023.
Barriers to adoption Five years later we know we are heading in the right direction by standardizing the care of the massively bleeding patient but we know gaps in evidence-based care remain. According to our 2023 survey, eight hospitals still had no MHP in place with no immediate plans to implement a protocol. Variability in protocols remains a concern with the absence of hypothermia monitoring in 25% and lack of TXA administration in 19% of protocols. The pediatric population was under represented in 45% of MHPs.
The MHP recommends a multi-disciplinary committee review of all activations for quality assurance yet in 2023 only two-thirds responded that they conduct regular debriefs and 55% responded that they do not track quality metrics.
“The following quality metrics should be tracked on all activations of the protocol and the data reviewed quarterly at the hospital transfusion committee or the medical advisory committee”
Figure 3. Metrics (click to enlarge the image)
Model for success Following the first release of Ontario’s MHP and armed with the 2023 survey results; we conducted a second modified Delphi exercise. This led to the release of Ontario’s MHP 2.0 in March 2025. These new recommendations follow an updated literature review and can be found here. We used multiple implementation strategies to address anticipated barriers to change including both lab and bedside tools; on-site hospital site visits, educational symposiums, eLearning, simulation videos, and algorithms.
The Ontario MHP initiative is an outstanding example of a grassroots effort responding to the real-time needs of clinicians and patients. The initiative has demonstrated feasibility, and the widespread dissemination of the provincial toolkit has supported the practical adoption of a standardized protocol. We will continue to monitor the implementation of this protocol with a particular focus on key quality metrics. This includes the development of a Quality Dashboard to track inappropriate activations and blood product wastage.
The net result is an initiative scaled for impact across a large geographical area that will affect patient outcomes and system-wide efficiency.
References
1. Chin V, Cope S, Yeh CH, et al. Massive hemorrhage protocol survey: Marked variability and absent in one-third of hospitals in Ontario, Canada. Injury. 2019 Jan;50(1):46-53. 2. Callum JL, Yeh CH, Petrosoniak A, et al. A regional massive haemorrhage protocol developed through a modified Delphi technique. CMAJO 2019 Sep 3;7(3):E546-E561.
