Prehospital activation of a coordinated multidisciplinary hospital response in preparation for patients with severe hemorrhage: A statewide data linkage study of the New South Wales "Code Crimson" pathway

BACKGROUND: Hemorrhage is a leading cause of preventable death in trauma. Prehospital medical teams can streamline access to massive transfusion and definitive hemorrhage control by alerting in-hospital trauma teams of suspected life-threatening bleeding in unstable patients. This study reports the initial experience of an Australian "Code Crimson" (CC) pathway facilitating early multidisciplinary care for these patients. METHODS: This data-linkage study combined prehospital databases with a trauma registry of patients with an Injury Severity Score greater than 12 between 2017 and 2019. Four groups were created; prehospital CC activation with and without in-hospital links and patients with inpatient treatment consistent with CC, without one being activated. Diagnostic accuracy was estimated using capture-recapture methodology to replace the missing cell (no prehospital CC and Injury Severity Score < 12). RESULTS: Of 72 prehospital CC patients, 50 were linked with hospital data. Of 154 potentially missed patients, 42 had a prehospital link. Most CC patients were young men who sustained blunt trauma and required more prehospital interventions than non-CC patients. Code Crimson patients had more multisystem trauma, especially complex thoracic injuries (80%), while missed CC patients more frequently had single organ injuries (59%). Code Crimson patients required fewer hemorrhage control procedures (60% vs. 86%). Lower mortality was observed in CC patients despite greater hospital and intensive care unit length of stay. Despite a low sensitivity (0.49; 95% confidence interval [CI], 0.38-0.61) and good specificity (0.92; 95% CI, 0.86-0.96), the positive likelihood ratio was acceptable (6.42; 95% CI, 3.30-12.48). CONCLUSION: The initiation of a statewide CC process was highly specific for the need for hemorrhage control intervention in hospital, but further work is required to improve the sensitivity of prehospital activation. Patients who had a CC activation sustained more multisystem trauma but had lower mortality than those who did not. These results guide measures to improve this pathway. Copyright (C) 2022 Wolters Kluwer Health, Inc. All rights reserved.