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In response, a Massive Hemorrhage Protocol toolkit was developed and disseminated province-wide in 2021. This study compares Massive Hemorrhage Protocol adoption and content in Ontario hospitals in 2023 versus 2018 using a pre- and post-toolkit rollout survey.<\/jats:p>\n          <\/jats:sec>\n          <jats:sec>\n            <jats:title>Methods<\/jats:title>\n            <jats:p>A 98-question survey was emailed to transfusion medicine laboratory directors or their delegate at 159 hospitals in 2023, 2 years after a provincial Massive Hemorrhage Protocol toolkit rollout that included a 1-day virtual symposium. Results were compared with the 2018 survey containing 82 identical core questions using Chi-square test, Fisher exact test, and Wilcoxon rank-sum nonparametric tests for quantitative data, and content analysis for qualitative data.  <\/jats:p>\n          <\/jats:sec>\n          <jats:sec>\n            <jats:title>Results<\/jats:title>\n            <jats:p>The 2023 survey achieved a 100% response rate (<jats:italic>n<\/jats:italic>\u2009=\u2009159); most respondents (<jats:italic>n<\/jats:italic>\u2009=\u2009156) were transfusion staff. Hospitals with a Massive Hemorrhage Protocol increased significantly from 65% (<jats:italic>n<\/jats:italic>\u2009=\u2009150) in 2018 to 77% (<jats:italic>n<\/jats:italic>\u2009=\u2009159) in 2023 (<jats:italic>p<\/jats:italic>\u2009=\u20090.02). Small transfusion hospitals (&lt;\u20095000 red blood cell units transfused\/year) saw an increase in Massive Hemorrhage Protocol adoption from 60 to 74% (<jats:italic>p<\/jats:italic>\u2009=\u20090.02). By 2023, 95% (<jats:italic>n<\/jats:italic>\u2009=\u2009159) of hospitals had\/were implementing a Massive Hemorrhage Protocol. However, gaps in alignment to evidence-based recommendations remained, including hypothermia monitoring (missing in 25% of Massive Hemorrhage Protocols) tranexamic acid dosing (missing in 19%), and quality metric tracking (missing in 55%). Pediatric content was absent in 45% of Massive Hemorrhage Protocols in health centers caring for children.  <\/jats:p>\n          <\/jats:sec>\n          <jats:sec>\n            <jats:title>Conclusion<\/jats:title>\n            <jats:p>The provincial Massive Hemorrhage Protocol toolkit\u2019s dissemination was feasible and associated with increased adoption in Ontario hospitals. Two-years post rollout, 77% of provincial hospitals have Massive Hemorrhage Protocols in place. Opportunities remain to align contents with evidence-based recommendations and expand to remaining hospitals. This strategy could guide other jurisdictions to improve Massive Hemorrhage Protocol adoption and harmonize practices.<\/jats:p>\n          <\/jats:sec>","DOI":"10.1007\/s43678-025-00929-y","type":"journal-article","created":{"date-parts":[[2025,5,22]],"date-time":"2025-05-22T01:46:10Z","timestamp":1747878370000},"page":"614-625","update-policy":"https:\/\/doi.org\/10.1007\/springer_crossmark_policy","source":"Crossref","is-referenced-by-count":4,"title":["Massive Hemorrhage Protocol adoption and standardization with a provincial toolkit: a follow-up survey of Ontario hospitals"],"prefix":"10.1007","volume":"27","author":[{"ORCID":"https:\/\/orcid.org\/0000-0003-4726-8242","authenticated-orcid":false,"given":"Chantalle L.","family":"Grant","sequence":"first","affiliation":[],"role":[{"vocabulary":"crossref","role":"author"}]},{"ORCID":"https:\/\/orcid.org\/0000-0003-4292-3105","authenticated-orcid":false,"given":"Omar I.","family":"Hajjaj","sequence":"additional","affiliation":[],"role":[{"vocabulary":"crossref","role":"author"}]},{"ORCID":"https:\/\/orcid.org\/0000-0001-6854-7326","authenticated-orcid":false,"given":"Kimmo","family":"Murto","sequence":"additional","affiliation":[],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Stephanie","family":"Cope","sequence":"additional","affiliation":[],"role":[{"vocabulary":"crossref","role":"author"}]},{"ORCID":"https:\/\/orcid.org\/0000-0001-6252-1192","authenticated-orcid":false,"given":"Andrew","family":"Petrosoniak","sequence":"additional","affiliation":[],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Troy","family":"Thompson","sequence":"additional","affiliation":[],"role":[{"vocabulary":"crossref","role":"author"}]},{"ORCID":"https:\/\/orcid.org\/0000-0001-6700-5197","authenticated-orcid":false,"given":"Katerina","family":"Pavenski","sequence":"additional","affiliation":[],"role":[{"vocabulary":"crossref","role":"author"}]},{"ORCID":"https:\/\/orcid.org\/0000-0001-6133-0677","authenticated-orcid":false,"given":"Jeannie L.","family":"Callum","sequence":"additional","affiliation":[],"role":[{"vocabulary":"crossref","role":"author"}]}],"member":"297","published-online":{"date-parts":[[2025,5,22]]},"reference":[{"key":"929_CR1","doi-asserted-by":"publisher","DOI":"10.1097\/TA.0b013e31819313bb","author":"BA Cotton","year":"2009","unstructured":"Cotton BA, Au BK, Nunez TC, Gunter OL, Robertson AM, Young P. 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Accessed 4 Sept 2024","DOI":"10.2818\/533179"}],"container-title":["Canadian Journal of Emergency Medicine"],"original-title":[],"language":"en","link":[{"URL":"https:\/\/link.springer.com\/content\/pdf\/10.1007\/s43678-025-00929-y.pdf","content-type":"application\/pdf","content-version":"vor","intended-application":"text-mining"},{"URL":"https:\/\/link.springer.com\/article\/10.1007\/s43678-025-00929-y\/fulltext.html","content-type":"text\/html","content-version":"vor","intended-application":"text-mining"},{"URL":"https:\/\/link.springer.com\/content\/pdf\/10.1007\/s43678-025-00929-y.pdf","content-type":"application\/pdf","content-version":"vor","intended-application":"similarity-checking"}],"deposited":{"date-parts":[[2025,9,6]],"date-time":"2025-09-06T15:15:02Z","timestamp":1757171702000},"score":1,"resource":{"primary":{"URL":"https:\/\/link.springer.com\/10.1007\/s43678-025-00929-y"}},"subtitle":[],"short-title":[],"issued":{"date-parts":[[2025,5,22]]},"references-count":40,"journal-issue":{"issue":"8","published-print":{"date-parts":[[2025,8]]}},"alternative-id":["929"],"URL":"https:\/\/doi.org\/10.1007\/s43678-025-00929-y","relation":{},"ISSN":["1481-8035","1481-8043"],"issn-type":[{"value":"1481-8035","type":"print"},{"value":"1481-8043","type":"electronic"}],"subject":[],"published":{"date-parts":[[2025,5,22]]},"assertion":[{"value":"8 November 2024","order":1,"name":"received","label":"Received","group":{"name":"ArticleHistory","label":"Article History"}},{"value":"15 April 2025","order":2,"name":"accepted","label":"Accepted","group":{"name":"ArticleHistory","label":"Article History"}},{"value":"22 May 2025","order":3,"name":"first_online","label":"First Online","group":{"name":"ArticleHistory","label":"Article History"}},{"order":1,"name":"Ethics","group":{"name":"EthicsHeading","label":"Declarations"}},{"value":"Dr Jeannie L Callum has received research support from Canadian Blood Services and Octapharma. Dr Kimmo Murto has an ongoing non-commercial and unfunded relationship with the Ontario Regional Blood Coordinating Network (ORBCoN) for designing, developing, deploying, and monitoring a province-wide standardized Massive Hemorrhage Protocol for children. Troy Thompson is program manager and Stephanie Cope is regional project coordinator of ORBCoN. ORBCoN is an Ontario Ministry of Health-funded organization and the views of the authors and ORBCoN do not necessarily reflect those of the Ontario Ministry of Health or the Government of Ontario. Dr Andrew Petrosoniak has previously served on an advisory board for and received honoraria from Astra Zeneca. He is also the co-owner of Advanced Performance Healthcare Design, a simulation-focused consulting firm.","order":2,"name":"Ethics","group":{"name":"EthicsHeading","label":"Conflicts of interest"}}]}}