• Alice Gray, Lucas B Chartier, Katerina Pavenski, Melissa McGowan, Gerald Lebovic, and Andrew Petrosoniak.
• Department of Medicine, Division of Emergency Medicine, University of Toronto, Toronto, Canada.
• CJEM. 2021 Jan 1; 23 (1): 54-62.

IntroductionMassive hemorrhage protocols are widely used to facilitate the administration of blood components to bleeding trauma patients. Delays in this process are associated with worse patient outcomes. We used in situ simulation as a novel and iterative quality improvement technique to reduce the mean time between massive hemorrhage protocol activation and blood administration during actual trauma resuscitations.MethodsWe completed monthly, risk-informed unannounced in situ trauma simulations at a Canadian Level 1 trauma centre. We identified three major latent safety threats: (1) massive hemorrhage protocol activation; (2) transport of blood components; and (3) situational awareness of team members. Process improvements for each latent safety threats were tested and implemented during subsequent in situ simulation sessions. We evaluated the effect of this simulation-based intervention on the care of patients before, during and after the intervention. Demographic, clinical and massive hemorrhage protocol data were collected. The primary outcome was mean time between massive hemorrhage protocol activation and blood administration during actual trauma resuscitations as analyzed using a two-sample t test.ResultsEach group was similar in demographic and injury characteristics. The time from massive hemorrhage protocol activation to blood administration decreased from 11.6 min pre-intervention to 9.1 min post-intervention. This represented a significant reduction (2.5 min, 95% confidence interval, 0.03-5.08) following the in situ simulation-based quality improvement intervention.ConclusionsA comprehensive, in situ simulation-based quality improvement project was associated with a significant reduction in the mean time between massive hemorrhage protocol activation and blood administration among injured patients. In situ simulation represents a novel approach to the identification and mitigation of latent safety threats during massive hemorrhage protocol activation.

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