2025 Audit of Major Haemorrhage Protocol

Key objectives

The key objectives of the audit were to:

Assess the configuration of services and the governance around major haemorrhage nationally
Evaluate the activation and operation of the Major Haemorrhage Protocol (MHP)
Assess the appropriateness and timeliness of blood component provision and administration

What did we audit?

All NHS sites in England, Northern Ireland, Scotland and Wales, and independent hospitals that manage major haemorrhage, were invited to enrol in the audit.

Data were collected using a recent retrospective approach, since a fully retrospective approach was unlikely to yield all the data we were trying to collect. The time period covered was April to June 2025. The audit sample was all patients, including those aged under 16 years, for whom the MHP was activated, and also patients receiving large numbers of components when the MHP was not activated.

The suggested definition of major haemorrhage was 5 units of RBC in 4 hours and/or 10 RBC in 24 hours, but sites could apply their own criteria in line with local practice. The target number of patients was 40 per site, although there was no minimum sample.

In addition to collecting data on how major haemorrhage management followed the local protocol, we asked sites to provide organisational data to allow us to set practice within the context of local care delivery. The organisational questionnaire can be found in Appendix B of the report. Sites could opt to respond either as a single hospital, or a collection of hospitals managed by a Trust or a Board, depending on local arrangements for managing any major haemorrhage.

Who took part?

186 sites contributed data
3792 patients were analysed

What did we find?

Full report (PDF 781KB)

Key findings

Standard 1: MHPs availability and activation

MHPs include a clear mechanism for contacting all relevant team members and support staff.

100% of sites have an MHP
67% (115/172) of sites have a separate paediatric MHP
Variation in activation methods including: 2222 (120/172, 72%), another emergency number (13/172, 12%), a direct call to the lab (34/172, 20%)
53% (63/120) of sites using 2222 also require a separate call to the lab
5% (17/132) of Trusts with multiple sites have different activation methods across sites

Standard 2: Training and education of staff

Clinical staff involved in frontline care are trained to recognise major blood loss early, are familiar with the contents of MHPs, and know when to activate and deactivate the local MHP.

MHP was activated in 96% (3640/3792) of cases and activation was in line with the organisation’s MHP 93% of the time (3394/3640)
MHP was ‘stood down’ in 54% (2042/3792) 54% cases
MH simulation training or drills were carried out in 86% (148/172) of sites
16% (23/148) do these less than once per year and 39% (58/148) only annually
67% (99/148) involve both laboratory and clinical staff
77% (133/172) of sites audit MHP activations but 33% (44/133) only do this annually or less frequently

Standard 3: Emergency red cells

Strategies are in place to ensure that:

Emergency blood components are readily available for treatment of life-threatening bleeding, including prompt access to group O red blood cells (RBCs) as emergency stock.
Group O RhD- and K-negative RBCs are prioritised for females of childbearing potential (aged<50 years) and in patients whose sex is unknown.
83% (142/172) of sites have a policy for issuing group O positive units to male patients and female patients over the age of 50 years
32% (43/133) of sites with remote blood fridges have them stocked with both O negative and O positive emergency RBC units
Of 924 male patients receiving emergency group O, 412 (45%) received O negative
99% (170/172) of sites include the need to send a group and screen sample in their MHP
In 25% of the cases where group specific blood was not issued (232/875), this was due to sampling problems: no sample (21%, 183/875), insufficient (1%, 6/875) or rejection (4%, 34/875)
The median time from MHP activation to the release of RBC was 4 minutes, from release to collection 4 minutes and from collection to use 10 minutes.
The overall median time from MHP activation to first RBC unit transfused was 20 minutes
The median time to receipt of patient’s own blood type was 52 minutes

Standard 4: Policies for rapid release of other components/ products

Policies and procedures cover the rapid release of blood components and products for major haemorrhage including the reversal of anticoagulants.

72% (124/172) of sites include guidance on reversal of anticoagulation in their MHP
16% (607/3792) of patients were on some form of anticoagulation
Where those patients received haemostatic agents, 90% (327/364) were in line with local guidelines
26% (45/172) of sites keep pre-thawed FFP (fresh frozen plasma) for major haemorrhage. Only 12 keep this in remote fridges
The median time from MHP activation to FFP release was 27 minutes

Standard 5: Component ratios

If major bleeding is ongoing and results of standard coagulation tests or near-patient tests are not available, FFP is transfused in at least a 1:2 ratio with units of RBCs (1:1 ratio in traumatic haemorrhage).

In patients receiving >4 units of RBCs where no clotting tests were performed, 64% (155/241) were transfused FFP in at least a 1:2 ratio with RBCs
In patients with traumatic haemorrhage, 39% (160/415) were transfused FFP in a 1:1 ratio with RBCs

Standard 6: Tranexamic Acid

Tranexamic Acid (TxA) is recommended within 3 hrs of the onset of major bleeding but not recommended in gastrointestinal bleeding.

69% (2350/3792) of patients had documentation of receiving TxA
Where TxA was not given, there was an appropriate documented reason in 60% (820/1369) of cases
The median time to TxA administration was 31 minutes. 22% (212/954) of patients received TxA within 10 minutes of MHP activation.
14% (140/954) of patients received TxA >3 hours after onset of bleeding
36% (273/769) of patients with GI bleeding were given TxA

Standard 7: Haemostatic testing

Haemostatic (clotting) tests are performed to guide and ensure the appropriate use of haemostatic blood components.

Where Viscoelastic Haemostatic Assays (VHAs) [thromboelastography (TEG) / rotational thromboelastometry (ROTEM)] are in use, policies are in place to maintain these.

In patients transfused with FFP or cryoprecipitate, 73% (1204/1650) had haemostatic tests sent. 66% (791/1204) were conventional laboratory coagulation tests, 20% (238/1204) point of care Viscoelastic Haemostatic Assays (TEG/ ROTEM) and 14% (166/1204) had both
In patients receiving >4 units of RBC, haemostatic tests were sent in 79% (502/636)
58% (100/172) of sites use VHAs to guide transfusion therapy. 78% (78/100) have a policy in place for their use and maintenance
Only 24% (24/100) of sites have their VHA devices interfaced with other electronic systems: EPR at 11, LIMS at 4 and both EPR and LIMS at 9

Our recommendations

Standard 1 - Governance and protocol design

Our recommendations for governance and protocol design are:

Standardise MHP activation pathways within Trusts/Health Boards, ideally to a single, simple method (e.g. 2222 without additional steps)
Ensure specialty-specific MHPs (particularly paediatrics and obstetrics) are available, accessible, and aligned with national guidance
Ensure advice on reversal of anticoagulation is included within the MHP or linked protocols which are also readily accessible
Review organisation-wide communication strategies to ensure all clinical and laboratory staff understand activation and stand down processes
Engage laboratory, clinical, switchboard and portering teams jointly when designing or revising MHPs

Standard 2 - Training and simulation

Our recommendations for training and simulation given here.

Implement mandatory annual major haemorrhage simulations involving:

Clinical teams across high risk areas risk areas
Transfusion laboratory staff
Switchboard and portering services

Ensure training explicitly covers:

Correct activation and stand-down procedures down procedures
Appropriate use of group O RBCs
Importance of prompt G&S sampling
Use and limitations of TxA
Communication expectations between clinical and lab teams

Disseminate learning from each simulation organisation-wide.

Standard 3 - Emergency red cell provision

Our recommendations for emergency red cell provision are:

Review remote blood fridge stocking to ensure, where policy permits, availability of both O positive and O negative units
Reinforce guidance on prioritising O positive for males and females over 50 years to reduce demand on O negative stock
Include G&S sampling and emergency group O usage scenarios in drills to reduce cases where sampling issues prevent switch to group specific blood

Standard 4 - Coagulation and haemostatic testing

Our recommendations for coagulation and haemostatic testing are:

Increase adherence to national guidance recommending regular coagulation monitoring (laboratory or VHAs) during active haemorrhage
Ensure VHA devices have local algorithms and governance structures to support consistent use
Work towards IT integration of VHAs with EPR/LIMS to minimise transcription risk and improve audit quality

Standard 5 - Plasma and component therapy

Our recommendations for plasma and component therapy are:

Audit individual MHP activations, to include the type, volume and timing of components transfused
Improve compliance with recommended FFP:RBC ratios, especially in:
- trauma (target 1:1)
- cases with ongoing bleeding where testing is unavailable
Review operational factors contributing to the time to first FFP release and consider:
- local thawing capacity
- pre-thawed FFP availability
- workflow optimisation

Standard 6 - Tranexamic Acid use

Useful resources

Serious Hazards of Transfusion (SHOT) major haemorrhage simulation toolkit

NHS Blood and Transplant Patient Blood Management group O red cell toolkit

elearning for healthcare (elfh): Blood Component Use in Major Haemorrhage