April 2019

Transfusion-related Non-conformances

Author: Terri Molloy MLT CQA (ASQ), Staff Technologist, IQMH, Centre for Accreditation

The Institute for Quality Management in Healthcare (IQMH) Centre for Accreditation Medical Laboratory Accreditation Requirements Version 7.1 came into effect in April 2017 and has been used as the basis for over 100 assessments. In 2018, 25 surveillance visits and 53 full assessment visits were completed.

 

The following is a review of the top non-conformances identified for hospital transfusion services from the visits completed in Ontario for 2018.

 

There were approximately 100 Transfusion medicine-specific requirements cited in 2018.

 

Collating the non-conformances into categories can help us to understand what issues present challenges for transfusion medicine laboratories.

 

The top issues are in order of citations noted:

 

Procedures/Processes – 15
There are hundreds of procedures written and followed for a transfusion service to function well. Gaps in understanding, compliance and consistency continue to be problematic. Several tools can help you identify gaps in procedure and process compliance.

 

  1. Adding a validation step to your process for writing and reviewing procedures where staff follow a procedure line by line when it is first drafted can avoid missing key steps down the road.
  2. Change up your internal audit process.
  • Revising the internal audit process to talk through a procedure with staff while they do it,
  • Ask key questions about a procedure and then look together to make sure those steps are where they should be

Temperature monitoring processes – 14
Lab staff are the gatekeepers to ensuring that blood and blood products are maintained appropriately and not wasted where at all possible.
 
In order to ensure that all products are handled according to the strict requirements set out by the CSA Z902-15 Standards for blood and blood components, laboratory staff should review and understand the parameters set for all products.

 
Competency assessments that include questions around storage and the measures required for the safety of the blood supply can help to ensure confidence in these processes and help staff to deal with problems before they occur.

 

Competency assessment of hospital staff – 13
Training and ongoing evaluation of competency is a challenge no matter where you work.
 
Communication with all staff involved in the transfusion process starts with the Transfusion Medicine Committee. A committee that is well represented and connects with educators within the facility can utilize support from the laboratory to improve these outcomes.
 
Follow up audits should be used to identify areas of weakness and help to update training to ensure it remains effective.

 

Procedures/Processes shared outside the lab – 10
When procedures are written and shared with users of a service, it can be difficult to know if they are accessed, used appropriately and still current for use.
 
As we suggested earlier, a validation step where the users are asked to provide feedback on the steps in the procedure may help to make the process more valuable for all concerned.
 
Follow up audits, using a pre-determined list of key steps will ensure that there has been effective uptake of the material.

 

Transport of products – 8
Many checks and balances are required when these precious products leave the safe confines of the laboratory.
 
Targeted training and well-written procedures are the first steps in creating a safe process. Audits can help to ensure that staff understand and follow the procedures as well as ensure that the supplies needed are always available.

 

Hopefully this compilation will assist Ontario transfusion services in assessing their own quality improvement, internal auditing and accreditation requirements. For more information about IQMH, please visit our website at: iqmh.org

 


 

Ontario AB Plasma Audit 2018

Author: Alison Wendt MLT, Regional Project Coordinator ORBCoN Central Region

The Ontario Regional Blood Coordinating Network (ORBCoN) conducted a provincial AB plasma audit in 2018 in order to gather more detailed information on the utilization of AB plasma in Ontario.

 

Nationally a downward trend in plasma utilization has been seen with an increase in the proportion of AB plasma requested by hospitals. Approximately 3% of the general population of Canada is group AB, however hospital requests for AB plasma represent 14% of the plasma demand1. AB plasma is considered to be the universal plasma donor group since it lacks anti-A and anti-B and can be given to patients of any ABO blood group. AB plasma is used for initial resuscitation of massively bleeding patients and in urgent situations where there is no blood group on file.

 

This was the first provincial AB plasma utilization audit performed and the goal was to determine: the disposition of AB plasma in Ontario, AB to AB recipients, AB to non-AB recipients with the primary objective to quantify the amount of AB plasma being transfused to non-AB recipients and to determine the reasons for this use.

 

All Ontario hospitals with a transfusion medicine laboratory (n=150) were invited to participate in the audit. As with all provincial audits conducted by ORBCoN, participation is not mandatory, however participating helps hospitals meet regulatory requirements for performing regular audits2,3. The data points surveyed were determined and collected over a three month period using LimeSurvey™ 3.13.1, a statistical web-based survey tool. Data capture points included:

 

  • AB plasma transfused to AB recipient
  • AB plasma transfused to non-AB recipient
    • due to massive hemorrhage protocol (MHP) with no blood group on file
    • thawed for another patient and/or for MHP – transfused to another patient to avoid outdating
    • frozen product near expiry – thawed and transfused to avoid outdating
    • due to only plasma group available in stock at the time of transfusion
    • for plasma exchange
    • with ABO incompatible renal transplant
    • who is a neonate
    • other reasons not listed
  • Disposition other than transfused
    • AB Plasma redistributed to another site
    • AB Plasma transferred with patient to another site
    • AB Plasma frozen and outdated
    • AB Plasma thawed for MHP, not used and outdated
    • AB Plasma ordered, thawed, not used and outdated
    • AB Plasma discarded, not outdated
    • broken in plasma thawer
    • other reasons not listed

 

Verification and validation procedures took place monthly during the data collection period and at the end of the final data entry period. As part of the verification process, all the data were reviewed for any duplicate, missing or discrepant entries. Audit data was exported for analysis by ORBCoN, both cumulatively (total provincial participants) and by region.

 

Eighty-two (82) hospitals participated, capturing 89.5% of the provincial AB plasma shipped by Canadian Blood Services during the audit period. Not all hospitals stock and/or transfuse plasma therefore not all hospitals in the province were able to participate in the audit. Audit results showed that 24.7% of AB plasma was transfused to an AB recipient and 75.3% to a non-AB recipient. A difference was seen between the three regions of the province (Central (CE), Northern and Eastern (NE), and South West (SW) Ontario).

 

The most common reasons for transfusing group AB plasma to patients of other ABO blood groups were: (1) for use in a MHP before the patient’s blood group was known (32.4%) and (2) to avoid outdate of plasma originally thawed for a MHP but not used (24.8%).

 

The disposition of AB plasma for reasons other than transfusion was relatively small, with the highest percentage being outdated due to being thawed for a MHP but not used and outdated (7.0%).

 

The disposition of AB plasma in Ontario, AB to AB recipients, AB to non-AB recipients was determined with a high percentage (75.3%) of AB plasma being transfused to non-AB recipients. A recent international survey by the BEST Collaborative showed that 73% of group AB plasma was transfused to non-AB recipients4, a finding similar to that shown by this Ontario audit. Knowing where AB plasma is being transfused will help to develop strategies to aid in the reduction of unnecessary AB plasma transfusions and lead to the sustainability of AB plasma supply.

 

Participating hospitals received a report with site specific data in April 2019.

 

The complete AB Plasma Audit Report will be posted April 2019 www.transfusionontario.org.

 

References:

  1. Canadian Blood Services [Internet]. Toronto: Blood Brief;2018.An Update on AB Plasma;Aug.2018[cited 2019 March 11]; Available from: https://blood.ca/sites/default/files/2018-AB%20Plasma-Overview.pdf
  2. Canadian Standards Association. CSA-Z902-15 Blood and Blood Components. 2015 edition. Toronto (ON): Canadian Standards Association; 2015: 4.6.2.5, 4.6.3.1, 4.6.3.2.
  3. Canadian Society for Transfusion Medicine. CSTM/SCTM Standards for Hospital Transfusion Services. 2017 edition. Markham(ON): Canadian Society for Transfusion Medicine; 2017: 1.9, 8.1.1, 8.1.2, 9.5
  4. Zeller MP, Barty R, Dunbar NM, et al, on behalf of the Biomedical Excellence for Safer Transfusion (BEST) Collaborative. An international investigation into AB plasma administration in hospitals: how many AB plasma units were infused? The HABSWIN study. Transfusion 2018;58:151-7

March 2019

Quality Improvement Initiatives and their Effect on Red Blood Cell and Frozen Plasma Utilization Rates

Author: Troy Thompson MLT, BAHSc (Hons), Regional Manager, Ontario Regional Blood Coordinating Network

A recent publication in the journal Transfusion1 highlights the wide variation in red blood cell (RBC) and frozen plasma (FP) utilization (includes transfused, discarded and outdated) rates across 62 community hospitals in Ontario. The article also highlighted the importance of quality improvement (QI) initiatives and their impact on RBC and FP utilization rates. Quality improvement initiatives included in the study were the presence of blood utilization guidelines, blood product order sets, the use of a technologist prospective order screening process, or any combination of these initiatives. Utilization rates were obtained by using the total number of products shipped to each hospital site (Canadian Blood Services shipment data) as the numerator and the Active Inpatient Treatment Days (AITD; obtained from the Ministry of Health and Long Term Care Health Data portal) as the denominator. This formula accounts for hospital variations in size and inpatient activity and for this study the AITD data excluded inpatients from mental health, chronic care, rehabilitation, pediatrics, child mental health and nurseries. Survey results obtained from each hospital in the study provided information on any QI initiatives that had been implemented. Comparisons using statistical analysis tools were made using the hospital’s RBC/AITD and FP/AITD utilization rates and the impact of various QI initiatives on these rates.

 

Figure 1. Red Blood Cell Utilization per 100 Active Inpatient Treatment Days (AITD) for Ontario Community Hospitals* for the Fiscal Year 2016-2017.

Highlights of the Study:

  • RBC and FP utilization rates decreased from 2012 to 2017.
  • There was a 10-fold difference in RBC and FP utilization rates between the highest and lowest hospitals.
  • Smaller hospitals (p < 0.05) and sites with any QI initiatives (p = 0.006) were associated with lower FP utilization.
  • Hospitals sites with RBC utilization guidelines (p = 0.05) and with technologists who prospectively screened transfusion orders (p = 0.01) had lower RBC utilization rates.
  • RBC utilization rates decreased after the implementation of RBC guidelines (p=0.02) and order sets (p=0.005).

There is a limitation to this study in that hospital sites that have a high proportion of outpatient and pediatric transfusion activity may show falsely elevated RBC/AITD ratios. These data can be used as a first step in determining whether a hospital has a high RBC/AITD and/or FP/AITD ratio out of line with their peers. Those hospitals that have “higher” utilization ratios can determine if there is a valid reason for the high ratio or if there needs to be quality improvement initiatives implemented to reduce potentially inappropriate utilization.

 

The results of this study highlight the importance of the implementation of QI initiatives in helping to reduce RBC and FP utilization rates. Similar to the findings in other studies2,3, the impact of implementing multiple QI measures has a greater effect in reducing utilization rates compared to a single intervention. This study did not evaluate the impact of medical oversight and back-up and this has a potential effect on both the implementation and the success of any QI initiatives. Additional research should be conducted on the impact of various QI initiatives with and without medical oversight and back-up as this is an important variable in any QI initiative’s success or failure.

 

For sites interested in quality improvement initiatives related to the utilization of blood and blood products please visit www.transfusionontario.org and look under the Quality Improvement tab for tools and resources.*

References:

  1. Qiang JK, Thompson T, Callum J, Pinkerton P, Lin Y. Variations in RBC and frozen plasma utilization rates across 62 Ontario community hospitals. Transfusion 2019 Feb 6; 59 (2); https://doi.org/10.1111/trf.15070
  2. Lin Y, Cserti-Gazdewich C, Lieberman L, Pendergrast J, Rammler W, Skinner I, Callum J. Improving transfusion practice with guidelines and prospective auditing by medical laboratory technologists. Transfusion 2016 Nov 7; 56(11); https://doi.org/10.1111/trf.13848
  3. Thakkar RN, Lee KH, Ness PM, Wintermeyer TL, Johnson DL, Liu E et al. Transfusion. Relative impact of a patient blood management program on utilization of all three major blood components. 2016 Sep; 56; http://doi.org/10.1111/trf.13718

Conserving the Supply of Type O Rh Negative Red Cells: What is the Maximum Age of Child-bearing Potential in Ontario Women?

Author: Allison Collins MD FRDPC, Physician Clinical Project Coordinator, Ontario Regional Blood Coordinating Network

The demand for type O Rh negative (O neg) red cells continually exceeds the supply, resulting in a perpetual state of shortage. While 6-7% of the Canadian population is blood type O neg, a disproportionate 10% of Canadian Blood Services (CBS) blood donors are of this blood type due to active efforts on behalf of CBS to recruit and retain them. Hospitals, however, request that 11.5% of their red cell inventory be type O neg (Dr. K. Webert, CBS Blood Brief June 2018, available at www.blood.ca). This places a strain on the limited supply of O neg blood in Canada.

 

Patients requiring transfusion prior to the determination of their ABO and Rh(D) type must receive type O red cells. Because of the high immunogenicity of the Rh(D) antigen, and the potential risk of hemolytic disease of the fetus and newborn, female children and women of “child-bearing potential” should receive type O neg red cells if emergency transfusion is required. Transfusion medicine lists from the Choosing Wisely® and Choosing Wisely Canada campaigns (www.choosingwisely.org and www.choosingwiselycanada.org), and the National Advisory Committee on Blood and Blood Products (www.nacblood.ca) recommend that O neg red cells should be reserved for O neg patients, and for women of child-bearing potential with an unknown blood type and requiring emergency red cell transfusion.

 

The maximum age used to define child-bearing potential varies between hospitals throughout Ontario. The Canadian Institute for Health Information (CIHI) publishes on its website information about the maternal age of Canadian residents, but combines all women aged 40 years and older into one group (www.cihi.ca). The CIHI was contracted by ORBCoN to provide more granular data for Ontario women aged 40 years and older, and to provide this information for each Ontario Local Health Integration Network (LHIN). The data from fiscal years 2013-14 to 2017-18 show that 99.5% of Ontario women deliver their babies by age 44 years or younger. Data by LHIN is shown in the Table. This data has been collected by ORBCoN since 2007, and there is no evidence of a significant upwards trend in maternal age.

If your hospital is using a maternal age of more than 45 years to define child-bearing potential, you are encouraged to look at hospital-specific data to see if your hospital differs significantly from the overall LHIN. If not, you may wish to review your policies for the use of type O neg red cells.

 

Type O neg red cells should be reserved for patients who truly need them.The detailed report, including trend data and a slide deck, is available on the ORBCoN website www.transfusionontario.org under the “Blood Utilization” tab.

 

February 2019

Fibrinogen Replacement – What is the Latest News?

Authors: Wendy Owens, ART B Comm, Program Manager and Allison Collins MD FR CPC, Physician Clinical Project Coordinator, Ontario Regional Blood Coordinating Network

Fibrinogen is used in the management of trauma, surgical and obstetrical patients to help treat massive bleeding. Sources of fibrinogen available from Canadian Blood Services (CBS) include frozen plasma, cryoprecipitate, and fibrinogen concentrate. Until recently, there has been controversy over which was the best source of fibrinogen to use to treat massively bleeding patients. Is one better than the other?

 

Plasma is generally used in the management of massively bleeding patients but less for its fibrinogen content than as a source of the whole spectrum of coagulation components. Both cryoprecipitate and fibrinogen concentrate provide a larger dose of fibrinogen per volume.

 

Few studies have been done to directly compare the efficacy of cryoprecipitate versus fibrinogen concentrate so there has been a relatively slow uptake of fibrinogen concentrate across Canada and in particular, in Ontario which uses about 80% of all cryoprecipitate that CBS produces (in comparison, Ontario uses approximately 50% of what CBS produces for other blood components).

 

CBS targets the production and procurement of all blood components and products to address hospital needs. This can be challenging over holiday periods, when blood donations may be lower than in regular periods. In order to ensure that a sufficient number of platelets would be available over the December 2018 holiday season, a decision was made to divert production from cryoprecipitate in favour of platelets. (1) Unfortunately, demand for cryoprecipitate in Ontario turned out to be much higher than normal during this time and cryoprecipitate stocks ran low.

 

Both the National and Ontario Emergency Blood Management Committees were convened when CBS predicted that the inventory of cryoprecipitate would not meet hospital needs. A Green Advisory Phase was declared, and discussions began on contingencies for how this situation could be managed, particularly in Ontario where the demand was so high.

 

Transfusion experts on the Ontario Emergency Blood Management Committee suggested that the largest users of cryoprecipitate (most of the large teaching hospitals in the province) could make the switch over to using fibrinogen concentrate during the low inventory period, thus freeing up cryoprecipitate for any hospitals that did not yet have policies and procedures in place to stock and use fibrinogen concentrate. Many, but not all, of these large user hospitals had introduced fibrinogen concentrate for use in cardiac surgery, where there was a clinical trial underway (FIBrinogen REplacement in Surgery or FIBRES study). (2)

 

As a result of these actions by Ontario hospitals as well as those in other provinces, CBS was able to meet hospital demand for cryoprecipitate during this low inventory period and ensure patients’ needs were met, not only in Ontario but across Canada.

 

The National Advisory Committee on Blood and Blood Products recently released a revised statement on Fibrinogen Concentrate. (3) The July 2018 statement provides recommendations on the use and dosing of fibrinogen and states that fibrinogen concentrate, plasma and cryoprecipitate should be considered interchangeable. Decisions made on which of these products to use should be dependent on the clinical situation as well as the availability of the product.

 

Questions:
What should you do if your hospital has not yet introduced processes to accept and use fibrinogen concentrate?

 

Hospitals that have not yet developed a policy and procedures to stock, issue and infuse fibrinogen concentrate are being encouraged to do so to ensure they would have access to a source of fibrinogen replacement in the event that future shortages of cryoprecipitate occur.

 

How should you go about introducing this product in your hospital?

 

ORBCoN has recently revised and updated their ‘Introducing a New Blood Component or Product to Your Hospital Toolkit’. (4) In this document are steps to walk you through the process of introducing a new product into your inventory – from developing clinical guidelines, determining stock levels, seeking clinical committee approval and developing guidelines for nursing for product administration. Checklists are provided to further help support introduction of the product. An example of a Blood Component or Product Administration Guidelines/Monograph is provided using fibrinogen concentrate as the example product.

 

How do you decide if your hospital should consider stocking fibrinogen concentrate?

 

If you currently stock cryoprecipitate, you should consider having the ability to use fibrinogen concentrate as an alternative source of fibrinogen replacement, even if your preferred method of fibrinogen replacement is cryoprecipitate. There may be some inventory management advantages to stocking fibrinogen concentrate if you are a smaller site that only stocks cryoprecipitate and rarely uses it. Fibrinogen concentrate generally has a longer shelf life than cryoprecipitate and is much easier to redistribute to avoid wastage due to expiry.

 

If you are looking for additional support, you can contact your Regional Project Coordinator with ORBCoN and they can help connect you with hospitals which have already implemented this product and could potentially share their experience and/or policy and procedures.

 

References:

  1. Canadian Blood Services. 2018 Holiday Message and Inventory Update – Customer Letter #2018-48. ; 2018.
  2. Keyvan Karkouti, Jeannie Callum, Vivek Rao et al. Protocol for a phase III, non-inferiority, randomised comparison of a new fibrinogen concentrate versus cryoprecipitate for treating acquired hypofibrinogenemia, in bleeding cardiac surgical patients: the FIBRES trial. BMJ Open. 2018 April.
  3. National Advisory Committee on Blood and Blood Products. nacblood.ca. [Online].; 2018 [cited 2019 January 15. Available from: http://www.nacblood.ca/resources/guidelines/fibrinogen.html.
  4. Ontario Regional Blood Coordinating Network. transfusionontario.org. [Online].; 2018 [cited 2019 January 15. Available from: http://transfusionontario.org/en/documents/?cat=new-product.

On the Road to a Massive Hemorrhage Protocol (MHP): Updated February 2019

Author: Stephanie Cope, Administrative Project Coordinator, CE ORBCoN

In the June 2018 edition of this newsletter, we reported results of a baseline survey (n=150 Ontario hospitals) that looked at determining the proportion of hospitals with a formal, implemented Massive Hemorrhage Protocol (MHP) and the components it included – we were essentially ‘building’ our case for a Provincial MHP. We concluded from the survey that one third of Ontario hospitals did not have a formal MHP and those who did, had marked variability in all aspects of the protocols regardless of hospital size, specialties and/or services available onsite.

 

Using the survey results as well as published evidence, a multi-disciplinary panel of experts within Ontario (through Delphi-exercise to reach consensus) drafted recommendation statements for inclusion in a provincial MHP toolkit. The draft recommendations were circulated for external stakeholder review to all Ontario Transfusion Medicine Laboratories (for further dissemination throughout respective institutions) as well as circulated to the Trauma Association of Canada. The external review period closed December 17, 2018. We thank all those that took the time to review and provide feedback!

 

Once careful review of the feedback is complete, and the recommendations finalized, the expert panel will be broken up into subgroups to begin work on the provincial MHP toolkit. The multipart provincial MHP toolkit will include policies, procedures, checklists, forms, training material, simulation exercises and quality metrics. While implementing a single protocol for the province is preferred and would ensure compliance and standardized care to all patients, it is recognized that there is not a one-size-fits-all solution given the diversity of hospitals. As such, guidance for select patient populations as well as for smaller and /or remote hospitals remains a top priority in the creation of the toolkit. In addition to the materials in the toolkit, the rationale for each recommendation as well as supporting references will be provided and will aid in the implementation of the recommendations.

 

To assist in the quality improvement and tracking of the recommended quality metrics, the team will be investigating the option of an on-line data entry portal for outcome reporting which hospitals could utilize to review data for quality assurance purposes or produce reports for regulatory purposes.

 

Have you been busy with massive hemorrhage activities at your hospital? We would love to hear from you and even feature your hospital work in our newsletter! Suggestions for the provincial toolkit are welcome and can be directed to stephanie.cope@sunnybrook.ca.

 

Reference:

  1. Chin V, Cope S, Hsiung Yeh C, et al. Massive hemorrhage protocol survey: Marked variability and absent in one-third of hospital in Ontario, Canada. Injury, Int. J Care Injured 2019; 50:46-53.

 

Discharge information sheet – What post-transfusion reaction information should I include in a discharge information sheet for patients?

 

Question:

I am developing a discharge information sheet for patients who receive blood at our hospital. The foundation of this idea ensued after reviewing Bloody Easy—A handbook for Health Care Professionals (link to e-book here). The language speaks of possible transfusion reaction up to 6 hours post transfusion. I have captured the signs and symptoms, however the next piece “what to do when experiencing a reaction and when to seek medical attention and contact information for reporting reactions” seems a bit unclear as to the specific direction. Do you have standard information I should be providing patients or is it reasonable that the patients are simply informed to return to hospital?

 

Answer:

The standard information that should be relayed to the patient receiving blood is if you are going home after your transfusion, you should contact your health care provider if you feel unwell within the day after the transfusion. It should be noted that Transfusion-related acute lung injury (TRALI) can occur up to 6 hours post-transfusion (1) and Transfusion-associated circulatory overload (TACO) can present up to 12 hours post-transfusion (2). It would be best to expand the time-period to 12 hours post-transfusion in the discharge information sheet. Symptoms the patient should be aware of and report during the 12-hour period post-transfusion are:

  • fever, hives, shortness of breath, chest or back pain, red or pink urine, lightheaded-ness; and/or
  • headache (if Intravenous Immune Globulin – IVIG – was transfused).

 

ORBCoN’s sister blood program TTISS-ON (Transfusion Transmitted Injury Surveillance System Ontario) has a handy resource that may help you, posted on their website (link here). In addition to the TTISS-ON resource, ORBCoN developed a resource for patients going home after receiving Immune Globulin (IG) in our Immune Globulin Toolkit for Ontario titled Fact Sheet for IVIG Outpatients. The toolkit can be found at our website at http://transfusionontario.org under the “IVIG/SCIG” tab. There is also some information in our booklet Blood Transfusion: Information for Patients, v2 Long Version which can be found on our website under the “For Patients” tab, under Patient Booklet.

 

Denise Evanovitch
Regional Manager
Southwestern Ontario Ontario Regional Blood Coordinating Network (ORBCoN)

 

References:

  1. Callum, JL et al. Bloody Easy 4: Blood Transfusions, Blood Alternatives and Transfusion Reactions 4th Ed. Toronto: Ontario Regional Blood Coordinating Network; 2016.
  2. ISBT Working Party on Haemovigilance. Transfusion-associated circulatory overload (TACO) Draft revised reporting criteria. 2017 April. http://www.isbtweb.org/working-parties/haemovigilance/ Accessed 22 Jan 2019.

January 2019

Canadian Blood Services’ Hospital Disposition Reporting

By: Rob Romans, BSc, ART, Associate Director, Utilization/Account Management, Canadian Blood Services

The method of reporting disposition and inventory data to Canadian Blood Services has evolved over the years. Prior to April 2006, a manual paper form (known as the L69 report) was filled out and submitted. At that time, there were no published standardized definitions for the different form fields, and if anyone wanted to analyze the data, it had to first be manually entered into a database or spreadsheet.

 

In April 2006, an electronic data submission Adobe Reader (PDF) form was released. It included:

  • Definitions for the fields (what to include, what not to include)
  • Data was typed into the form and submitted attached to an email. Data was extracted and uploaded into the Canadian Blood Services biwarehouse, allowed for a series of hospital specific disposition trend reports to be generated to assist hospitals and for data analysis.

Then, in April 2014, a web-based reporting system was introduced, and the data collection was expanded to include reporting by ABO/Rh, inventory data, and plasma protein disposition data.

 

In 2018, we now are in the very early stages of a pilot to allow automatic data exchange of both inventory and disposition data between hospitals and Canadian Blood Services. A critical component of our data sharing advances is the ongoing introduction of automation to reduce transcription errors, and the adoption of common data definitions.

 

We recently discovered an example of a data definition interpretation that could compromise data integrity. Most hospitals follow this standard practice: If Hospital A receives a redistributed/transferred unit from Hospital B, and the unit was received out of specifications and needs to be discarded, it is Hospital A that receives and then discards the unit, and then records the event using the data field “discarded – improper storage”. Hospital A should follow up with Hospital B to explain the issue, and if preventable, they can take steps to prevent a reoccurrence.

 

However, non-standard practices can occur. For example, if instead of the scenario above, Hospital A may (or may not) send the unit back to Hospital B, which has to receive the unit back into inventory and then discard it. This is not ideal as it results in extra time spent packing and transporting the unit.

 

The Hospitals in the latter scenario may be concerned about being held accountable for reporting discards that were out of their control, but this shouldn’t be the case. Thankfully such events are infrequent. Rest assured that Canadian Blood Services understands that hospitals employ validated redistribution/transfer processes to maintain specifications during shipment. Further, inter-hospital movement of blood components is an effective strategy to reduce blood system wide outdates.

 

Currently, Canadian Blood Services’ Blood Component and Product Disposition System User Guide (version 3.0.1.1) is not explicit on what to do in this situation, but the next release will include details about how these circumstances should be handled for disposition reporting purposes and improved data integrity.

 

8 Rights of Transfusion 3×4″ Lanyard is in stock!

Good news! The 8 Rights of Transfusion 3×4” Lanyard Card is in stock again. This resource highlights eight important checks for administration of blood products/ components to be performed at the bedside. Lanyard cards are available as a quick reference to promote and reinforce the need for these eight checks and are bilingual.

 

As a result of a 2011 province-wide audit of blood administration at the bedside, The 8 Rights of Transfusion Lanyard Card along with some other tools were developed to help hospitals improve patient safety at the bedside. The 2018 Bedside Audit was completed on November 30th, 2018. The 2018 report will be released in the next couple of months. For more information on the bedside audit and tools, please click here.

 

To order The 8 Rights of Transfusion 3×4” Lanyard Card, visit our website at http://transfusionontario.org/ and click Order Resources under the ORBCoN Resources tab.

Bloody Easy Tech Assess: Advanced – If you got these wrong too, you were not alone (again!)!

By: Lisa Mantifel, Regional Project Coordinator, ORBCoN

In December’s newsletter, the five most challenging questions in Bloody Easy Tech Assess: Basic Competency 2017/2018 were discussed. Now we will focus on the Bloody Easy Tech Assess: Advanced Competency 2017/2018 and the top five questions that stumped users.

 

To recap, Tech Assess is an online educational program that tests theoretical knowledge in eleven areas of transfusion medicine and can be used as part of a laboratory competency assessment program. New tests are released approximately every year with a selection of previously used questions combined with at least 20% new questions. Previous year’s data on the top incorrectly answered questions in basic and advanced modules are reviewed each year by the ORBCoN working group. The questions that prove difficult for users are analyzed for issues with respect to:

  • Knowledge – does this question reveal a knowledge gap?
  • Misleading – is the question or are the answer options misleading or confusing?
  • Fair – is this question fair?
  • Is this question at the correct knowledge level (i.e. basic vs advanced)?

The five most challenging questions in Bloody Easy Tech Assess: Advanced Competency 2017/2018 version will be discussed below with regards to their fail rate, the logic behind the answer and if the question is reasonable or not. The data shown below is from April 30th, 2018 to December 13th, 2018.

Question 1: Donor Blood Collection and Testing Advanced

What is the maximum allowable age for allogeneic blood donation without a physician certificate?

a) 60 years of age if a first-time donor ✓
b) 70 years of age if a first-time donor
c) 70 years of age if a repeat donor 
d) 60 years of age if a repeat donor

 

The best answer is A. If a donor is donating for the first time, they must be under the age of 61 unless they have been examined by a licensed physician and certified suitable to donate (1). If a previous donor has donated in the past two years, they can donate even over the age of 66 (1). After this age, if the donor has donated in the past but not in the past two years, they need to be certified as suitable by a licensed physician (1). Technically, as long as the donor is certified as healthy enough to donate by a physician, there is no maximum age. This question is fair. The distractors (B, C, and D) are not misleading. The fail rate can be attributed to a knowledge gap in the criteria for acceptable blood donation.

Question 2: Reporting Advanced

If a dose of platelets is requested from Canadian Blood Services (CBS) but is discarded because it outdates because the physician no longer felt the patient requires it, how should this be recorded in the CBS Blood Component and Product Disposition System?

a) It should be recorded as a discard: patient related ✓
b) It should be recorded as a discard: due to expiry
c) It should be recorded as a discard: improper storage
d) It should be recorded as a discard: failed visual inspection

 

The correct answer is A. CBS Patient Blood Component and Product Disposition System User Guide defines patient-related discards as: the patient did not require the component, the patient did not show up for the transfusion, the patient is deceased, or the patient was transferred before the transfusion (2).

 

The wording of the question should be revised to eliminate the double-use of “because”. A suggestion might be:
“If a hospital transfusion service requests a dose of platelets from Canadian Blood Services (CBS) but it outdates because the physician no longer felt the patient requires it, how should this be recorded in the CBS Blood Component and Product Disposition System?”

 

The platelets were not discarded due to improper storage (C) or failing visual inspection (D). Option B is a good distractor as the platelet unit did expire, however the unit was ordered for a patient and discarded due to the patient not requiring the component anymore. The wording of the question will be reviewed by the ORBCoN working group, however the fail rate can be associated with the user not having a thorough understanding of the definitions within the CBS user guide.

Question 3: Blood Group (ABO / Rh) Advanced

Which of the following (weak-D) phenotypes are at risk of developing an anti-D if exposed to Rh positive red cells through pregnancy? Choose all that apply.

a)  Type 1
b)  Type 2
c)  Type 3
d) Type 11 ✓

 

The correct answer is D. Persons with weak D types 1, 2 and 3 are unlikely to make anti-D when transfused with D positive red blood cells (3). In 2015 an evaluation of scientific literature on weak D types concluded that people with weak D types 1, 2 and 3 can be treated as D positive during pregnancy (3). People with the less common weak D type 11 have been reported to make anti-D when transfused with D positive red blood cells (3). The question is well written and straight forward. The distractors are not confusing. The fail rate identifies a knowledge gap and the question is fair for the advanced level.

Question 4: Reporting Advanced

What is a recent additional requirement for hospital patient laboratory reports in Ontario?

a) The identification of the laboratory performing the test
b) The patient identification and location
c) The page number in relation to the total number of pages ✓
d) The date and time of specimen receipt by the laboratory

 

The correct answer is C. In the most recent version of the Institute for Quality Management in Healthcare (IQMH) Medical Laboratory Accreditation Requirements, the requirement to include the page number in relation to the total number of pages was added (4). Adding the page number to patient reports helps to ensure there is no confusion over the sequence of results, the completeness of the report and the final interpretation of the examination. Options A, B and D have been required on hospital patient laboratory reports for some time. The fail rate could be attributed to the question not identifying what regulatory body recently added the requirement, and lack of year to define how “recent” it was. The question will be flagged for review by the ORBCoN working group.

Question 5: Antibody Identification Advanced

Which of the following is true regarding differential adsorption?

a) The cells used are usually R1R2, R2R2 and rr
b) One cell must be negative for K, another negative for Jka and the third negative for Jkb
c) It is usually used when the patient has not been transfused
d) This is also known as an autoadsorption

 

The correct answer is B. Differential adsorption may be performed to complete antibody investigation on a recently transfused patient who presents with autoantibodies (5). The patient’s serum is divided into three aliquots and each aliquot is adsorbed with a different cell (typically an R1R1, R2R2 and rr) and among the three cells, one must be negative for K, another negative for Jka and the third negative for Jkb (5).

 

The difficulty of this question can be attributed to the user needing to know the method of differential adsorption. The distractors A, C and D are strong. Option A is incorrect because the cells used in the method are typically an R1R1, R2R2 and rr. Option C is incorrect because differential adsorption is used in cases where a patient has been recently transfused. Option D is incorrect. Autoadsorption is a method used to remove autoantibodies from serum or plasma using the patient’s own red blood cells (5). Autoadsorption can be used when a pre-transfusion sample is available.

 

Tech Assess is a tool that benefits MLTs, supervisors, laboratory managers and students in hospitals, blood services and post-secondary schools by aiding in documentation and assessment of knowledge in the field of transfusion medicine. If you have any questions, comments or feedback on these questions, or any ORBCoN resources, please contact ORBCoN here or at info@transfusionontario.org.

 

References:

  1. Canadian Standards Association. CSA Z902-15 Blood and blood components 5.2.2 Toronto: CSA Group; 2015.
  2. Canadian Blood Services. Blood Component and Product Disposition System User Guide Version 3.0.1.1; 2016. Appendix A – Data Entry Field Definitions p20.
  3. Fung MK ED. AABB Technical Manual 19th Edition Bethesda; 2017.
  4. IQMH. Institute for Quality Management in Healthcare (IQMH) Medical Laboratory Accreditation Requirements Verson 7.1: IQMH Centre for Accreditation; 2017.
  5. Harmening D. Modern Blood Banking and Transfusion Practices 6th Edition Philadelphia; 2012.


 

 

Question about target INRs when treating coagulopathic patients with frozen plasma or prothrombin complex concentrate (PCC)

Question:

On page 36 of Bloody Easy 4: Blood Transfusions, Blood Alternatives and Transfusion Reactions. A Guide to Transfusion Medicine Fourth Edition (1), the threshold INR for plasma transfusion is greater than or equal to 1.8. On page 126, regarding the use of prothrombin complex concentrate (PCC) for emergency warfarin reversal, the threshold INR is greater than or equal to 1.5. Why is the INR threshold for plasma 1.8, and the threshold for PCCs 1.5? Shouldn’t they be the same?

Answer by Dr. Allison Collins, MD:

Coagulation factors are at sufficient levels (30% of normal) for normal hemostasis at an INR of about 1.7 (2). The INR is a poor predictor of bleeding risk, particularly if only mildly elevated, and there is no good evidence for use of a target INR of 1.5 vs 1.8 for prevention or treatment of bleeding.

 

INR reversal with plasma is not as effective as INR reversal with PCC (3). With plasma, it is very difficult to get the INR below 1.8 (4) because the INR of plasma itself is about 1, and the coagulation factors in the transfused plasma become diluted as a result of the transfusion itself. So, if plasma is transfused to ‘correct’ an INR of less than 1.8, patients will be exposed to a blood product and possible transfusion-associated circulatory overload (TACO) or other adverse event, with no benefit in 40-99% of them (4, 5). Plasma may be indicated in conditions such as liver disease, disseminated intravascular coagulation, or massive transfusion when all coagulation factors are required. PCCs, which contain only the Vitamin K-dependent coagulation factors II, VII, IX, and X, are not usually used in these patients.

 

Because PCC is a ‘warfarin antidote’ containing specifically the Vitamin K dependent coagulation factors, correction to a near-normal INR is achievable and rapid (6). PCC, unlike plasma, is used for emergency warfarin reversal when the anticoagulated patient is bleeding or requires emergency surgery (defined as surgery within 6 hours). In a patient with an INR of 1.8 who needs emergency warfarin reversal PCC may still be indicated because, unlike the situation with plasma, a lower INR of at least 1.5 is achievable. The only time that plasma should be used for urgent warfarin reversal is when PCC is not available.

 

The bottom line: Plasma and PCCs are used for different reasons. The threshold is an INR <1.8 for plasma because that’s the best we can do for patients who need all the coagulation factors in plasma, but the threshold is an INR of <1.5 for PCC because it is possible, and we do not really know whether an INR of <1.5 or <1.8 is the optimal threshold.

 

Finally, non-urgent warfarin reversal is not achieved with either PCC or plasma (7). The better approach is to withhold warfarin and administer oral or intravenous Vitamin K.

 

References

  1. Callum, JL and et al. Bloody Easy 4: Blood Transfusions, Blood Alternatives and Transfusion Reactions. A Guide to Transfusion Medicine Fourth Edition. Toronto: Ontario Regional Blood Coordinating Network, 2016.
  2. Dzik WH. Predicting hemorrhage using preoperative coagulation screening assays. Current Hematology Reports 2004;3:324-30.
  3. Sarode R, Milling TJ, Refaai MA, et al. Efficacy and safety of a 4-factor prothrombin complex concentrate in patients on vitamin K antagonists presenting with major bleeding: a randomized, plasma-controlled, phase IIIb study. Circulation 2013;128:1234-43.
  4. Abdel-Wahab OI, Healy B, and Dzik WH. Effect of fresh-frozen plasma transfusion on prothrombin time and bleeding in patients with mild coagulation abnormalities. Transfusion 2006;46:1279-86.
  5. Warner MA, Hanson AC, Weister TJ, et al. Changes in international normalized ratios after plasma transfusion of varying doses in unique clinical environments. Anesthesia & Analgesia 2018;127(2):349-57.
  6. Pabinger I, Brenner B, Kalina S, et al. Prothrombin complex concentrate (Beriplex® P/N) for emergency anticoagulation reversal: a prospective multinational clinical trial. J Thrombosis and Haemostasis 2008;6:622-31.
  7. Callum JL, Waters JH, Shaz BH, et al. The AABB recommendations for the Choosing Wisely campaign of the American Board of Internal Medicine. Transfusion 2014;54:2344-

December 2018

Ontario Transfusion Transmitted Injuries Surveillance System (TTISS-ON)

By: Joanne Duncan, HRM, MSc, CCRP, McMaster Centre for Transfusion Research, Hamilton ON

 

The Transfusion Transmitted Injuries Surveillance System (TTISS) is a national surveillance and monitoring system for the reporting of adverse reactions to blood products (blood components and plasma derivatives) run by the Public Health Agency of Canada (PHAC). Each province is responsible to collect and report aggregate data, submitted voluntarily, by hospital Transfusion Medicine Laboratories (TML) or those responsible for reporting transfusion reactions in each hospital. Ontario is the largest user of blood components, accounting for 35% of all transfusion activity in Canada (based on the percentage of units of blood components transfused). Currently TTISS-ON participating hospitals capture over 94% of the transfusion activity in Ontario, representing 123 hospitals. For the past 15 years, McMaster University has been the home of TTISS-ON, continuing to coordinate and develop the program. TTISS-ON is an integral part of the Canadian national hemovigilance system, as it is the only reporting agency that collects ALL transfusion reactions, whether or not they are related to the blood quality.

 

From 2013 to 2017 the number of red blood cells and plasma transfused has been declining in Ontario while the number of pooled platelets and cryoprecipitate transfused has increased. During this time, 1,095 moderate to severe reactions were reported to TTISS-ON with TACO being the most reported reaction at 31% (Figure 1).

 

Figure 1: 2013 – 2017 Reportable (to TTISS-ON) Transfusion Reactions in Ontario N=1,095

 

Non-reportable reactions that are not captured by the national system include febrile non-hemolytic, delayed serologic and minor allergic reactions but in Ontario these more minor types of reactions are captured by a sentinel site model. Sentinel sites are a core of Ontario hospitals that report all reactions and comprise approximately a third of all transfusion reactions and transfusions that occur in the province. These sites capture all reactions (reportable and non-reportable), enabling TTISS-ON to understand the complete burden of reactions from minor to severe. For the period 2013 to 2017 the sentinel sites reported a total of 2,445 reactions to transfused blood components and plasma derivatives: 498 (20%) fell into the moderate to severe category and were reported to PHAC; and 1,947 (80%) were classified as minor non-reportable category being captured through the sentinel site model (Table 1).

 

Table 1: Sentinel Site reporting of all reactions N=2,445

Type of Reaction Blood Components Plasma Derivatives Total
Non-Reportable to TTISS (minor) 1,747 200 1,947 (80%)
Reportable to TTISS (moderate to severe) 359 139 498 (20%)
Total 2106 339 2445

 

By knowing the number of blood components transfused during this period (847,605 units), and number of reactions that occurred to blood components, we can calculate frequency of these transfusion reactions by type in Ontario.

 

Table 2: 2013 -2017 Sentinel Site Transfusion Reactions and Incidence N=2,106

Type of Reaction Blood Components
(n=847,605)
Incidence
Moderate to Severe (Reportable) n=359 (17 %)
Acute Hemolytic Reaction 16 1:52,975
Delayed Hemolytic Reaction 35 1:24,217
Bacterial Infection 6 1:141,268
Hypotensive Reaction 17 1:49,859
Post Transfusion Purpura (PTP) 1 1:847,605
Severe Allergic/Anaphylactic/Anaphylactoid 70 1:12,109
Anaphylactic Shock 4 1:211.901
Transfusion Associated Circulatory Overload (TACO) 156 1:5,433
Transfusion Associated Dyspnea (TAD) 7 1:121,086
Possible Transfusion Related Acute Lung Injury (TRALI) 12 1:70,634
TRALI 2 1:423,803
Other results of investigation 24 1:35,316
Unknown 10 1:84,761
Minor (Non-reportable) n=1,747 (83 %)
Febrile Non-Hemolytic Reaction 791 1:1,072
Delayed Serological Reaction 365 1:2,322
Minor Allergic Reaction 590 1:1,437
Total 2,106 1:402

 

TTISS-ON has made reporting of transfusion reactions easy and less confusing by providing a common online Canadian Adverse Transfusion Event Reaction (CATER) form that can be completed electronically and printed off for submitting to other regulatory agencies (CBS, plasma derivative manufacturers, and Canada Vigilance Program, Health Canada). To determine who to report a reaction to, TTISS-ON provides an Ontario Guide for Reporting Transfusion Reactions and an interactive online version. If your TML/Blood Bank reports transfusion reactions and are not already participating in TTISS-ON, register to become a member and obtain your login. “How to” instructional videos for entering and downloading your hospital’s data and making reports can be found on the TTISS-ON website. Look for our full 5-year report coming soon and download our TTISS-ON symptom reaction app from the app store. If you have any questions, contact Joanne Duncan, TTISS-ON Coordinator.

 

Bloody Easy Tech Assess: Basic – If you got this one wrong, you were not alone!

By: Lisa Mantifel, Regional Project Coordinator, ORBCoN

 

Launched in 2008, the Tech Assess program is an online educational tool for medical laboratory technologists (MLTs) to test their theoretical knowledge in eleven areas of transfusion medicine. This tool benefits MLTs, supervisors, laboratory managers and students in hospitals, blood services and post-secondary schools by aiding in documentation and assessment of knowledge in the field of transfusion medicine. This tool can serve as part of a laboratory competency assessment program.

 

The Tech Assess program is composed of eleven modules covering the core competencies in Transfusion Medicine and is offered at both the Basic and Advanced level. In addition, the program contains Solid Phase Techniques and Gel Techniques as optional and stand-alone modules that can be chosen within the basic level. New tests are released approximately every year with a selection of previously used questions and at least 20% new questions. Each new test is sent for external review and comment to technologists working in the field of transfusion medicine before release. This serves to validate the content as well as test out the wording of the questions to try and ensure they are clear and not misleading.

 

Previous year’s data on the top incorrectly answered questions in basic and advanced modules are reviewed each year by the ORBCoN working group. The questions that prove difficult for users are analyzed for issues with respect to:

  • Knowledge – does this question reveal a knowledge gap?
  • Misleading – is the question or are the answer options misleading or confusing?
  • Fair – is this question fair?
  • Is this question at the correct knowledge level (I.e. basic vs advanced)?

The five most challenging questions in Bloody Easy Tech Assess: Basic Competency 2017/2018 version will be discussed below with regards to their fail rate, the logic behind the answer and assess if the question is reasonable or not. The data shown below is from April 30th, 2018 to December 10th, 2018.

 

Question 1: Reporting Module – Basic Level

How long should records of tracking the final disposition of blood components be kept?

a) 10 years 
b) 50 years
c) Indefinitely
d) 1 month

In the most recent versions of national standards, record retention for final disposition of blood components was revised from ‘indefinite’ to 50 years (1) (2). The working group determined that the question was fair and reasonable as it addressed a knowledge gap. Therefore, the fail rate for this question was attributed to the fact that the users were not aware of the change in the Standards.

Question 2: Blood Group (ABO / Rh) Module – Basic Level

Interpret the following results:


a) Weak subgroup of A Rh Negative
b) Group O Rh negative, probable recent transfusion with Group A red cells
c) Group A Rh negative, probable recent transfusion with Group AB red cells
d) Group A Rh negative, probable recent transfusion with IVIG ✓

Problems with serum or plasma testing in this patient case is most likely the result of recent transfusion with IVIG which can contain ABO isoagglutinins (3). The working group assessed this question as a fair question as it tests the user’s concept application skills for ABO grouping interpretation. Selections a and b would not result in a strong reaction (4+) with anti-A, both options b and c would demonstrate mixed field reactions and option c would also show reactivity with anti-B. Therefore, the correct option is d. The fail rate on this question can be attributed to a knowledge gap. ABO interpretation is considered basic level competency.

Question 3: Antibody Screen – Gel Techniques Module

As mentioned above, solid phase and gel techniques are stand alone modules that the user can choose to complete. We have included this question from Gel Techniques in this article because many hospitals use gel methods, and therefore should have the basic knowledge of gel methods. Which statement most likely explains a mixed field reaction in a gel antibody screen?

a) Too much serum has been added to the gel tube
b) b) The patient has been transfused with a different blood group of RBCs
c) There is likely an anti-Sda present
d) May be caused from clots in a serum sample ✓

Clots, particulates or other artifacts may cause some RBCs to be entrapped at the top of the gel that may cause an anomalous result in a negative test. Clotting issues may be minimized with the use of EDTA plasma (4). The user must be aware that the cells present in a gel antibody screen (i.e. testing patient serumor plasma) are commercial cells, and therefore do not have a mixed cell population. They are also not used for cell grouping (choice b), as this test uses patient plasma or serum only, not their RBCs. Anti-Sda reacts at room temperature and is not considered clinically significant. Gel method does not usually detect anti-Sda.

The fail rate of this question can be attributed to the wording of the question. The question infers a true mixed field presentation versus a clot in the sample mimicking a mixed field. The question should be reworded, for example:

“Which statement most likely explains an appearance of a mixed field reaction in a gel antibody screen?” or,

“Which occurrence is most likely misjudged or misinterpreted as a mixed field reaction in a gel antibody screen?”

This question will be flagged for revision during the next Tech Assess review.

Question 4: Compatibility Testing Module – Basic Level

A nurse just called to request additional RBC units for a patient for whom you performed compatibility testing on 4 days prior. The patient has only had 1 RBC transfusion which was 2 days ago. The patient now requires 2 more units because of a bleed. What is your most appropriate course of action?

a) Use the pretransfusion sample from 4 days ago ✓
b) Inform the nurse that a new sample must be obtained
c) Request more information as to why the request for 2 more units is needed
d) See if any PST samples were drawn from the morning run that may be used

The correct answer is A. Recipients who have been transfused with a blood component containing red cells or pregnant within the preceding three months, or if the history of transfusion or pregnancy is uncertain or unknown, the blood sample for compatibility testing shall be collected within 96 hours prior to transfusion (1) (2). The original blood sample may be used to crossmatch additional units after transfusion for up to 96 hours (1). The fail rate on this question can be partly attributed to a knowledge gap however, the wording could be misleading as it does not make it clear that the patient had not been transfused prior to this sample being drawn. This question will be reworded to clarify that point the next time it is used.

Question 5: Quality Assurance Module – Basic Level

What is the acceptable shelf life of a unit of red cells, stored at 1°C to 6°C if the seal has been entered?

a) 4 hours
b) 6 hours
c) 24 hours ✓
d) 48 hours

The correct answer is C. An open system of RBCs must be stored at 1-6°C and used within 24 hours or be discarded. Refrigeration of the opened unit is essential and can no longer be used after 24 hours. This is to prevent the possibility of bacterial contamination and proliferation in the unit due to introduction of air when the unit was entered. If the unit is stored at room temperature, it is only acceptable to use it within 4 hours.

“If the sterile seal on a system containing blood components is breached at any time during processing, the system shall be treated as an open system from the time the breach occurred. In an open system, blood components stored at 1 to 6°C shall be given a reduced expiration time of 24 h (1).”

This question is fair, and this standard ensures the safety of the RBC unit. The fail rate identifies a knowledge gap.

If you have any question, comments or feedback on these questions, or any resource, please contact ORBCoN here or at info@transfusionontario.org.

References:

  1. CSA. CSA Z902-15 Blood and blood components: Canadian Standards Association; 2015.
  2. CSTM. Standards for Hospital Transfusion Services Version 4: CSTM; 2017.
  3. AABB. Technical Manual 19th Edition Fung MK, Eder AF, Spitalnik SL, Westhoff CM, editors.; 2017.
  4. Micro Typing Systems, Inc. Instructions for use MTS anti-IgG Card Florida: Ortho-Clinical Diagnostics Company; 2008-2016.

 

November 2018

Testing Blood Shortage Plans in Ontario Hospitals – 2018 Exercise Highlights.
How prepared are we?

By: Wendy Owens ART B Comm Program Manager, Allison Collins MD FRCPC Clinical Project Coordinator, Ontario Regional Blood Coordinating Network (ORBCoN) and Vice-Chair and Chair of the Ontario Contingency Planning Working Group.

 

On May 16th, 2018 at approximately 0900 EDT, Ontario hospitals received a fax notification from CBS signaling that a Provincial Blood Shortage Simulation Exercise was underway. The scenario involved contamination of a lot number of the additive solution in red blood cell units (saline-adenine-glucose-mannitol or SAGM) and resulted in an immediate Red Phase blood shortage across the province. Because the issue was with the additive solution, the shortage, in this scenario, only affected red blood cells and not any other components.

 

Three CBS centres were involved (Ottawa, Brampton and Winnipeg) along with 157 hospital sites across Ontario. Three CBS teleconferences (one by each of the CBS sites) were held to provide an update to participating hospitals and allow for some discussion on how the exercise was progressing. During these calls it became evident that there was a significant delay from when some hospitals received the initial notification compared to others. Lags up to an hour or more were reported in some regions.

 

The exercise proceeded throughout that day and into the following day. A Recovery Phase notification was issued from CBS at approximately 1430 EDT on May 17th from both the Ottawa and Brampton facilities but unfortunately was not issued from the Winnipeg site. Therefore, twelve hospitals in the Northwest part of the province were not aware that the exercise had ended until the following day when the post exercise survey was issued from ORBCoN.

 

During this exercise, the Ministry of Health and Long-Term Care tested out a fairly new provincial communication tool. This tool, the Emergency Management Communication Tool (EMCT), can be used  to share information on an emergent situation rapidly across many facilities. It has the advantage of not being dependent on individual email addresses to relay information as it uses a ‘dashboard’. As long as a person is logged on and monitoring the system, they receive notification of uploads and alerts. The major drawback to this system is that if a hospital does not have a dedicated person monitoring it, the information alerts will not be received. In the post exercise survey we asked hospitals about EMCT and 87% responded that they were now aware of this tool.

 

One hundred and thirty-nine hospitals reported that they participated in this provincial blood shortage exercise representing 89% of the hospital sites with transfusion services in the province. A total of 93.5% of hospitals that participated in this exercise answered that their hospital has a hospital specific blood shortage plan and 78% had updated it to the most recent version of the Ontario Contingency Plan for Managing Blood Shortages (version 3) released in February of 2017.

 

As part of the exercise, we asked hospital participants to perform a mock triage on their red blood cell requests during the time that the exercise was ‘live’. About half of hospitals did this and reported that a total of 931 units would have been deferred over this time period. If we estimate the number of units (on average) that would have been transfused in a 30 hour period in Ontario, this would represent about 75% of total red cell use that could have been deferred if we had been in a real Red Phase shortage situation.

 

Despite only half of hospitals reporting their deferral decisions, this represents a significant decrease in demand that could be achieved if we are faced with a critical shortage of red cells. One respondent commented that after going through the simulation of triage for the exercise, they would review their routine blood use to determine if they could reduce it at their hospital.

 

It was encouraging that more hospitals appeared to be working together regionally to effectively pool inventory across a number of sites (an example of this is described in the following article). This would facilitate better management of limited resources to help ensure equitable care for patients across a region during a blood shortage.

 

Table 1 – What progress has been made since our last blood shortage exercise?

Details 2014* (n=110) 2018 (n=139)
Hospitals that have an Emergency Blood Management Plan 92% 94%
Hospitals that have identified individuals to perform triage of blood requests 89% 87%
Hospitals that have a plan for redistribution during a blood shortage 58% 79%
Respondents that reported they document decisions around deferral of blood requests/surgery 63% 85%
Respondents that reported staff have been trained on their hospital plan 57% 82%
Respondents that reported their site will hold a debrief of the exercise 80% 83%

*Note: the 2014 Blood Shortage Exercise simulated a shortage of platelets therefore fewer hospitals participated

 

The biggest take-away from this exercise was that work still needs to be done to improve communication – from the notification process by CBS through to the internal hospital notification and methods used by the MOHLTC to provide updates and guidance during a blood shortage, challenges were reported.

 

Following this exercise, CBS has begun to investigate an automated solution to address the issues encountered with the fax notification process and the MOHLTC will be discussing how recommendations and guidance provided by the Ontario Emergency Blood Management Committee should be communicated to hospitals during a blood shortage.

 

Overall, participation in this exercise was overwhelmingly positive and Ontario is doing very well. We should feel very proud of the progress that has been made over the past decade and all the work that has gone into ensuring we will be prepared if we face a situation of severe blood shortage.

 

On behalf of the Provincial Contingency Planning Working Group, we sincerely thank all of those who participated in the planning of this exercise and took the time to participate and provide feedback. Together we can continue to improve Ontario’s preparedness!

 

 

Blood Shortage Mock Exercise – EORLA Experience

By: Hakan Buyukdere MD FRCPC, Alan Tinmouth MD FRCPC, Antonio Giulivi MD FRCPC
Hematopathology/Clinical Hematology, The Ottawa Hospital

 

On May 16-17, 2018 all Ontario hospitals, including 19 acute care hospitals under Eastern Ontario Regional Laboratory Association (EORLA) structure, participated in a province-wide blood shortage mock exercise. This event was led by both the Ontario Regional Blood Coordinating Network (ORBCoN) and Canadian Blood Services (CBS). All participating hospital Transfusion Services received notification from CBS about a red blood cell shortage affecting all blood groups resulting in a red phase shortage. Although it was not the primary method of communication, the provincial Emergency Management Communication Tool (EMCT) was also used to communicate the mock shortage to each hospital.

 

Following the Provincial Blood Shortage Plan, all EORLA sites then activated their local blood shortage protocols and started adjusting their red cell inventory levels according to the provincial and local emergency blood management plans. The sites which had Emergency Blood Management Committees (EBMC) notified their members and asked them to be available for an emergency meeting, and/or mock triaging of red cell transfusion requests and reviewing surgery lists for possibility of cancellations as outlined in their local plans. For hospitals without an EBMC, the local Transfusion Committee was contacted for similar purposes. Locally, the head of transfusion service or the transfusion committee chair worked with the manager/supervisor of the transfusion medicine laboratory to simulate triage of red cell transfusion requests and review elective surgery lists to determine which surgeries would be cancelled if this was a real situation. All EORLA transfusion services chose to review transfusion requests and surgery lists in real-time rather than performing the review retrospectively. Decisions regarding issuing red cell units and surgery cancellations were documented and then, with the exception of the Children’s Hospital of Eastern Ontario (CHEO), the decisions were sent to the Regional Transfusion Committee Chair at The Ottawa Hospital – General campus. The regional report as well as CHEO’s report were then sent to ORBCoN independently.

 

Reported results from participating EORLA Transfusion Medicine services indicated there was a total of 272 units of red blood cells ordered during the shortage exercise. Of these, 72 units were for surgical procedures and 200 units were requested for ward patients & outpatients. Of the 87 units ordered for outpatients, 70 would have been deferred in real shortage. Of the 113 inpatient red blood cell requests, 66 units would have been deferred.

 

Of the 72 surgical blood transfusion requests, 33 units would have been cancelled; 21 of these surgeries were orthopaedic, 8 were abdominal, 2 vascular and 2 abdominal procedures.

On the first day of the exercise, CBS organised a teleconference which gave opportunity to each hospital to express their concerns and feedback.

 

There were several lessons learned from this exercise:

 

1- Importance of having Transfusion Medicine committees and/or EBMCs for each hospital and proper designation of roles and responsibilities for each committee’s members. This needs to be reviewed periodically.

 

2- Effectiveness of current communication channels between CBS and regional hospitals, also between EMCT and local hospitals. A few sites reported short delays in receiving notifications from CBS in comparison to others. We also tested our regional communication among our sites.

 

3- Benefits of using Provincial and National Emergency Blood Management Guidelines and Toolkits for ongoing guidance.

 

4- Strategic value of pre-surgical or peri-operative transfusion evaluation by surgical team by analysing patient’s latest Hemoglobin, planned surgical technique and extent of procedure, underlying comorbidities and any previous transfusion history.

 

5- Deciding when to transfer patients from peripheral hospitals to more central major sites. After close discussions, we all agreed that patient transfers during a real blood shortage should be based on patient’s overall health status rather than their requirement for a blood transfusion. Clear communication on the transfer needs to occur between referring and receiving hospital physicians.

 

All EORLA sites reported very positive outcomes and member hospitals expressed their gratitude for regional collaboration. Surveys sent by ORBCoN were completed by each EORLA Transfusion Medicine service and reported back to ORBCoN.

 

We would like to thank all member hospitals for their continuous dedication and commitment to collaborative excellence.

 

October 2018

Provincial Platelet Audit – Preliminary Pediatric Results

By: Troy Thompson MLT, BAHSc (Hons), Regional Manager, Ontario Regional Blood Coordinating Network (ORBCoN) Central Region

A provincial platelet audit was held January to April 2017, with 69 hospitals participating in the audit, representing approximately 90% of the platelet utilization activity provincially. Of the 1903 platelet orders audited during this period, 210 orders were for “pediatric” patients (≤18 years of age). Pediatric platelet order data are being analyzed separately from “adult” platelet orders as the adjudication of these orders were conducted with different adjudication criteria. Ongoing analyses of these data continue and will focus on hospital service areas and sub specialties where transfusions do not meet appropriate criteria. Here we present only very preliminary results of the data analysis.

 

The top 3 ordering specialties for pediatric platelet orders were Pediatrics – 123/210-59%; Other category – 49/210-23%; and Neonatology – 27/210-13%. (Figure 1).


Figure 1. Ordering Specialties for Pediatric Platelet Orders.

 

Pediatric platelet orders were issued to Inpatient-Other and Inpatient-ICU locations in 68% of the orders with Outpatient clinic (OP) – Hematology – 10%; OP Clinic – Oncology – 7%; and OP Clinic Other – 7% of the platelet orders. (Figure 2).


Figure 2. Issue Location of Pediatric Platelet Orders.

 

The transfusion indication for platelets was separated into 3 major categories and the results for pediatric orders were: Prophylactic (non-bleeding, no procedure) – 85% of orders; Therapeutic (currently bleeding) – 13% of orders; and Prophylactic (before invasive procedure) – 2% of platelet orders.

 

Pre-transfusion platelet counts for pediatric platelet orders were divided into ranges and are displayed in the table below. Different platelet thresholds are considered appropriate depending on the clinical circumstances.

Pre-transfusion platelet counts Total #/(%)
No platelet count 3 (1)
≤10 44 (21)
11-25 61 (29)
26-50 69 (33)
51-99 22 (11)
≥100 11 (5)

Data analyses continues and will include the appropriateness of each order and additional sub-analyses of the differences between community and teaching hospitals and those hospitals that have introduced platelet guidelines, order sets and prospective screening processes vs. hospitals that do not have these processes in place. There may be differences in the creation and uptake of pediatric platelet guidelines at pediatric specialty hospitals compared to those hospitals that have less pediatric centred services.

 

The auditing and evaluation of blood product utilization is a very important exercise and should be a routine activity at each hospital. One of the purposes of each hospital’s Transfusion Committee is to set criteria for the evaluation of ordering practices and to ensure regular evaluations of blood transfusion practices are conducted.1

 

The results of this provincial audit will provide each participating hospital with their adjudication results and the final report will also include recommendations aimed at improving provincial platelet utilization.

 

Look for the final platelet audit report posted at www.transfusionontario.org in the near future!

 

References:

  1. CSA Z902-15 Canadian Standards Association Standards for Blood and Blood Components December 2015; CSA Group

 

Golden Horseshoe Education Supporting Transfusionists (GHEST) Symposium 2018

By: Sheena Scheuermann, Regional Project Coordinator, SW ORBCoN

The mission of GHEST is to promote education, research, and best practices in Transfusion Medicine throughout the Golden Horseshoe region. The model is intended to be a non-profit venture therefore the symposiums are held at minimal cost to participants.

 

This year’s event was held in Hamilton, Ontario and the theme was Massive Hemorrhage and New Considerations in Transfusion Medicine. The symposium was well attended with 142 registrants for the day. We were very fortunate this year to have a patient speaker, Ms. Margaret Harvey who set the tone for the day by telling us her journey before, during and after her trauma and reiterating that the impact of trauma does not end once a patient leaves the hospital. Dr. Katerina Pavenski provided an update on the Massive Hemorrhage Protocol for Ontario and following the massive hemorrhage theme Dr. Michelle Zeller reviewed studies of group A plasma being used instead of AB in massive hemorrhage.

 

Regarding new considerations in Transfusion Medicine, Dr. Ruby Shanker presented “Inclusion of Gender Identity within Diagnostic Medicine”. This was a thought-provoking talk with many things to consider for medical professionals. Dr. Margaret Fearon from Canadian Blood Services presented “New Risks: Zika, West Nile and those unknown and what do we do?” which provided an excellent update on the impact these new diseases have on the blood supply. Troy Thompson presented an update on the Ontario Transfusion Quality Improvement Plan and Danielle Watson presented the Grey Bruce Health Services successes and challenges implementing such a program. The day was rounded out with case study presentations by Laura Aseltine, Felicia Dollinger and Melina Zarb. Including more case studies in the program has been a suggestion from attendees in the past.

 

Thank you to our Sponsors Octapharma, Grifols, CSTM and ORBCoN! And once again a huge thank you to the speakers and organizing committee for another successful GHEST event. Presentations will be posted on transfusionontario.org and ghestontario.com.

 

September 2018

Positive Patient Identification and Independent Double Checks: Why are these important in transfusion safety?

By: Bev Weaver, TSO, Senior MLT, Kingston Health Sciences Centre

The administration of blood and blood components and the management of the transfused patient are complex and multi-step processes with various opportunities for errors to occur. The Serious Hazards of Transfusion (SHOT-UK Hemovigilance System) reports1 demonstrate that cases of incorrect transfusion often result from a sequence of errors involving failure to detect the correct identity of the patient and/or the blood component.

 

The safe administration of blood components and products requires that the health care professional and Blood Bank personnel work together to meet the patient’s needs. Systematic policy and procedural guidelines are emphasized to maximize patient safety during transfusions.

 

Positive patient identification is a crucial component of transfusion safety. If patient identification is incorrect it can have potentially fatal consequences. An acute adverse reaction can be caused by transfusing 3 mls of the wrong blood.2

 

You must accurately identify the patient at the bedside when collecting a blood sample to ensure that the sample has been drawn on the correct patient and that the sample tubes are labeled accurately. This must occur before leaving the patient’s bedside. Protect your patient and yourself: only label samples that you have drawn from the patient.

 

Ask the patient for their first and last name and their date of birth if they are able to verbally respond. Always check that the patient’s name, date of birth and unique identifier (usually a hospital registration number) on the armband matches with the orders and labels. Some hospitals have incorporated new positive patient identification technology as the new standard for safety. A computerized system uses a barcode, radio frequency identification (RFID), or another electronically readable component contained in a patient’s armband to confirm identity. In the context of transfusion safety, the armband is scanned prior to sample draws and prior to any transfusions.

 

Mistakes happen even when people are doing their best. According to publicized data about blood administration, the general rate of errors of commission is 3 in 1000, the general rate of errors of omission when no reminders exist is 1 in 100, and the general error rate in a highly stressed environment with rapidly occurring activities is 1 in 4.3

 

The institute for Safe Medication Practices Canada (ISMP Canada) recommends conducting independent double checks with selected high-risk processes and high-alert drugs.4 Independent double checks are not intended to question the practitioners’ skills or competence; rather, they acknowledge the high-risk nature or complexity of the work and the fact that all practitioners are only human and therefore fallible. Many Canadian hospitals have implemented independent double check processes in an effort to enhance patient safety.

 

Before beginning the transfusion, two practitioners independently check the following information in the presence of the intended recipient:

  • If the patient is capable, they are positively identified by asking them to state their surname, first name, and date of birth.
  • The patient’s surname, first name and unique number on the blood component are identical to the patient’s identification bracelet.
  • Donor unit identification – The donor unit identification number on the hospital transfusion label attached to one side of the blood bag agrees with the Canadian Blood Services label attached to the other side of the blood bag.
  • The ABO and Rh type on the hospital transfusion label attached to the one side of the blood pack agrees with the Canadian Blood Services label attached to the other side of the blood bag.
  • When performed, the compatibility test result on the transfusion label attached to one side of the blood pack is verified to be ‘compatible’.
  • Any discrepancies found during the independent double check must be addressed before beginning the transfusion.
  • Notify the Blood Bank about any unresolved discrepancies and return the blood bag to the lab if so advised.

The greatest transfusion risk to patients occurs at the bedside; from obtaining a blood sample to transfusing a product. The number one cause of an acute hemolytic transfusion reaction is failure to check the patient armband. Imbedding positive patient identification and independent double checks in transfusion practices will enhance patient safety.

 

References:

  1. https://www.shotuk.org/shot-reports/
  2. Society for Advancement of Blood Management (SABM). Blood Administration Safety. 2015.
  3. Institute for Safe Medication Practices Canada (2005). Lowering the risk of Medication Errors: independent double checks. 5(1).
  4. Institute for Safe Medication Practices Canada (2005). Lowering the risk of Medication Errors: independent double checks. 5(1).

 

Provincial Bedside Audit

By: Tracy Cameron, Regional Project Coordinator, NE ORBCoN

ORBCoN is conducting a 2018 Provincial Bedside Audit which commenced on Tuesday September 4th, 2018 and will end on Friday November 30th, 2018. All hospitals in Ontario have been invited to participate, and a communication was sent out in early July with a reminder communication sent out in August.

 

Similar to the previous provincial audit, there will be a paper audit form provided to perform the audit at the bedside and a web based audit tool to facilitate the data entry of the audit results. Hospitals will be able to review their own data, and provincial data will be summarised and shared in a report. In the previous provincial audit, most Research Ethics Board (REB) committees considered this type of audit to be a quality improvement initiative and did not require full ethics review, but be sure to check with your committee if you have concerns.
The number of audits to be performed will be based on your hospital’s classification.

 

Hospital Classification # of transfusion procedures/duration
Small Community 2 transfusion procedures or 3 months
Medium to Large Community 5 transfusion procedures or 3 months
Teaching 10 transfusion procedures or 3 months

The 2011 Provincial Bedside Audit had a total of 80 (51%) hospitals in the province participating and captured 359 transfusion procedures. The highest compliance with standards was seen in the category of patient identification. The lowest compliance was seen in the category of “order confirmation check”. The goal of the 2018 audit is to collect the data and compare the results with those from the previous audit to see if there have been improvements in compliance with current standards1,2 and critical steps in the process of blood administration. If you have any questions about this audit please contact us at info@transfusionontario.org

 

References:

  1. CSA Z902-15 Canadian Standards Association Standards for Blood and Blood Components December 2015; CSA Group
  2. Canadian Society for Transfusion Medicine Standards for Hospital Transfusion Services; v4 April 2017; CSTM

 

 

 

When should a blood infusion set be changed during a blood transfusion?
By: Leonor De Biasio, Clinical Project Coordinator, Transfusion Safety Nurse, CE ORBCoN

 

One of the key elements of administering blood components to patients is optimal safety of the blood transfusion. Optimal safety is comprised of several components and one is avoidance of any adverse transfusion reactions, which include transmission of infectious microorganisms. One recommended method to ensure minimizing bacterial growth or contamination is to replace the blood administration set at the most appropriate time during the administration process, especially if transfusing more than one unit. Consequently, the question arises “When should a blood infusion set be changed during the blood transfusion?”

 

Several organizations specializing in transfusion medicine have developed and published recommendations and/or standards for the appropriate time to replace infusion sets. It has been noted by health care professionals that the recommendations or standards published by these organizations vary from one another. Because of these diverse recommendations or standards available, these have posed a slight challenge to some health care professionals as to which recommendation or standard should be exercised in their practice. Below are excerpts of just a few of the recommendations and standards that are published.

 

2014 AABB Technical Manual 18th Edition pg 555
If additional units are transfused the hospital’s guidelines and manufacturer’s recommendation should be consulted to determine whether the same blood administration tubing may be used for subsequent units. If there are no contraindications from the manufacturer, institutions frequently allow tubing to be reused as long as subsequent units are transfused within 4 hours of the start of the initial transfusion. Therefore, if more than 1 unit can be infused in 4 hours, blood administration tubing sets may be used for more than one component.

 

BEBA Version 2 pg. 19
Blood tubing must be changed at least every 2-4 units and within the number of hours specified by your hospital policy. In cases of massive transfusion, an add-on filter can be used to minimize the frequency of tubing changes.

 

2015 CSA Z902-15 Blood and Blood Components 11.4.13
Administration sets shall be changed at least once every 24 h. Standard blood administration sets shall be changed after 4 units of red blood cells or if the set becomes occluded. Add-on filters and specialized blood sets (e.g., rapid infuser sets) shall be changed at intervals as recommended by the manufacturer or in accordance with hospital policy.

 

2017 CSTM Standards for Hospital Transfusion Services Version 4 5.9.4.7
Administration sets shall be changed according to set or filter manufacturer’s recommendations or at least once every 24 hours or after 4 units of red cells. The administration set shall be changed immediately prior to the transfusion of platelets.

 

Infusion Nurses Society: 2016 Infusion Therapy Standards of Practice p.136
Change the transfusion administration set and filter after the completion of each unit or every 4 hours. If more than 1 unit can be infused in 4 hours, the transfusion set can be used for a 4-hour period (see Standard 42, Administration Set Change).

 

Infusion Nurses Society: Policy and Procedure for Infusion Therapy Fifth Edition p.225
The administration set is changed after the completion of each unit or every 4 hours; if more than 1 unit can be infused in 4 hours, the transfusion set can be used for a 4-hour period.

 


So, why the discrepancy? In 2008, Transfusion Medicine published a study by Blest et al., which suggested the reason for the variety in recommendations from 4 hours to 48 hours and from one unit to several units was a result of no formal evidence base on which to support or challenge current recommendations. Blest et al. concluded that further research is warranted and would need to include variables that impact frequency of change, including type of filter, age of blood and duration of blood component transfusion.


To our knowledge, there have not been any reports in Ontario of any adverse transfusion reactions attributed to bacterial contamination from blood infusion sets. Therefore, it is recommended that health care professionals involved in administration of blood follow blood administration standards and their institution’s policy and procedures for blood administration and replacement of blood infusion sets.

June 2018

On the Road to a Provincial Massive Hemorrhage Protocol (MHP)

By: Stephanie Cope, Administrative Project Coordinator, CE ORBCoN

All Ontario patients, including those that are massively bleeding, deserve quality, equitable and coordinated care. Previous studies have shown that there is inter-institutional variability across all aspects of a MHP. In order to understand Ontario practices, a baseline survey was sent November 30th 2017, to Transfusion Medicine (TM) Medical Directors/TM Leads at all Ontario hospitals with a transfusion service* (n=150) with an aim of determining the proportion of hospitals with a formal, implemented MHP and the components included. The survey question categories included; hospital demographics, activation criteria, communication, teams, blood draws, laboratory test menu, patient temperature management, transport, transfusion medicine, and quality metrics.

 

The survey received a 100% response rate with a total of 132 completed responses (17 hospitals provided a verbal response that they did not have a MHP and one partial response was received).

 

Ninety-seven hospitals (65%) had a MHP implemented although wide variation in practices was observed. There were at least ten different names given to a MHP, with “massive transfusion protocol” the most commonly used name at 68% of hospitals. One of the key goals of the provincial initiative is to eliminate the confusion of having multiple and varying protocols amongst Ontario hospitals as many healthcare professionals (e.g. medical trainees) have to rotate through or work at multiple hospitals.

 

The most common method of protocol activation was with a call to hospital locating at 87% followed by a call to the Transfusion Medicine Laboratory in 78% of hospitals.

 

There was wide variability in the triggers for MHP activation which included:

  • Volume of blood loss (70%)
  • Number of red blood cell (RBC) units transfused (60%)
  • Hemodynamic instability (32%)

Laboratory tests routinely drawn during protocol included:

  • CBC
  • INR
  • aPTT
  • Fibrinogen
  • Electrolytes
  • Group & Screen
  • Creatinine
  • Lactate
  • Blood gas
  • Ionized calcium, and calcium

Four hospitals also included ROTEM (although the test is available at nine hospitals) while no hospital utilized TEG for their protocol (although this is available in two hospitals).

 

Fibrinogen testing was available in 66% of hospitals.

 

The monitoring of patient temperature was included in 65% of protocols with warming blankets being the most common method (61%) to achieve normothermia.

 

The majority of hospitals reported transporting RBCs and plasma in containers validated to maintain acceptable temperatures whereas only 33% of platelets and 29% of cryoprecipitate issues were reported as being transported in validated containers. Components maintained in appropriate storage temperatures may be returned into inventory if not used which may help reduce wastage.

 

A significant gap was noted in the in-hospital transfer of products and samples with only 33% of hospitals using Porters for this role.

 

Group O Rh- negative RBCs are given to all patients with unknown blood group in 36% of hospitals. The remaining hospitals use O Rh-negative RBCs in the following patients:

  • Females <45 years (60%)
  • Patients with a history of anti-D (27%)
  • Females <50 years (20%)
  • All children (14%)
  • Women of child bearing age (11%)
  • Females <46 years (5%)

Fifty-nine hospitals reported having predefined blood/trauma ratio based packs with most using a ratio of 4:0:0:0; red blood cells: plasma: platelets: cryoprecipitate respectively in pack one. There was marked variability in subsequent blood packs.

 

Tranexamic acid (TXA) was included in 70% of MHPs.

 

The survey found that 69% of hospitals with a MHP do not track any quality metrics. The 31% of hospitals that do such tracking only did so for select cases.

 

A Delphi-method exercise was completed by a multidisciplinary panel that brought together experts from various disciplines including: emergency medicine, trauma, ICU, obstetrics, pediatrics, anesthesia, hemostasis, transfusion medicine, pre-hospital transport, nursing, and patients to name most. The purpose of the exercise was to reach consensus on recommendation statements for inclusion in a provincial MHP toolkit. The survey results and supporting literature for the recommendations were presented at ORBCoN’s Transfusion Committee Forum April 20, 2018. The presentations can be found at http://transfusionontario.org/en/documents/?cat=transfusion-committee-forum.

 

We know that one size does not fit all, but we know that standardized protocols do work. That is why we are working towards a multi-part provincial MHP protocol that will include policies and procedures, checklists, training and educational materials and much more, for the benefit of both large and small hospitals, and both adult and pediatric populations.

 

ORBCoN would like to thank all hospitals for their participation in the survey; it is this collaboration that allows us to do our job. We would also like to thank Victoria Chin, Dr. Calvin Yeh and our expert panel members for their dedication to this undertaking and, last but not least, to Drs. Jeannie Callum and Katerina Pavenski for leading us in this provincial initiative.

 

*Defined as a licensed laboratory transfusion service that receives blood components/products directly from Canadian Blood Services and may also provide blood components/products to another facility for either storage and administration, or administration only.

 

 

 

Bloody Easy Nursing Transfusion Medicine Boot Camp: Lab to Bedside

By: Leonor De Biasio, Clinical Project Coordinator, Transfusion Safety Nurse, CE ORBCoN

Transfusion is a familiar therapeutic practice in health care institutions, and nurses have an active involvement in transfusion practices. In Ontario, basic blood transfusion education usually begins in nursing schools and the education should continue throughout a nurse’s career. It has been noted by front line nursing staff that most of the training is minimal and self-directed. Several studies have noted that nurses need to have more extension in transfusion knowledge and skills to perform their responsibilities safely and effectively.

 

Ontario Transfusion Medicine (TM) clinicians identified that nurses have a vast amount of influence in their daily practices in the areas in which they work. To achieve best practices and cultural change in TM, transfusion educational training sessions targeting the Ontario nursing population would assist in cultivating transfusion knowledge. In 2017, the Ontario Regional Blood Coordinating Network (ORBCoN) considered the need for TM education for Ontario nurses. As a result, a working group was established to assist in the development of a pilot four-hour province wide educational videoconference geared for the nursing audience. On March 26, 2018, the event occurred at no cost to the participants.

 

The working group and speakers consisted of patient blood management (PBM) coordinators, transfusion safety officers (TSO), TM physicians, and an ORBCoN clinical project coordinator-transfusion safety nurse. The TM experts created an educational event to enhance the learning and build capacity in TM for Ontario nurses. The topics in the curriculum included:

  • Pretransfusion Testing: How quickly can we get blood?
  • Transfusion Guidelines: Less is Best
  • Best Practices: Hemoglobin Optimization
  • Administration Process: Informed Consent, Patient Preparation and Administration Procedures
  • Recognition, Management and Prevention of Transfusion Reactions and Errors

The Bloody Easy Nursing TM Boot Camp: Lab to Bedside event not only enhanced the knowledge and skills of Ontario nurses but it provided them with the ability to interact with TM experts across Ontario through webcasting capabilities via Ontario Telemedicine Network (OTN) from their institutions.

 

Prior to the event a pre assessment knowledge survey and registration through LimeSurvey™ was distributed to laboratory contacts and the nursing leadership teams throughout Ontario hospitals. The survey results presented 507 registrants. During the event, 59 institutions accessed the videoconference through OTN and 23 groups utilized webcasting capabilities from their home or office. After the event, a post assessment knowledge survey comprised of the same ten questions as the pre assessment knowledge survey, and an evaluation was distributed to all registrants and all respondents were to receive a certificate of attendance at completion. The post videoconference results indicated 92 respondents received and completed the post assessment knowledge survey and evaluation. One of the challenges noted after distribution of the post assessment knowledge survey and evaluation through LimeSurvey™, was several mail delivery failures. Reasons associated with the mail delivery failures were network security issues within the hospitals or inaccurate email addresses provided during registration.

 

The data received from both pre and post assessment knowledge surveys exhibited on average:

  • 57% of the participants answered the pre assessment questions correctly
  • 75% of the participants answered the post assessment questions correctly

The data below indicate some of the significant results from the evaluation survey.  

 

Overall rating of videoconference:

  • Excellent 34% (31)
  • Very Good 48% (44)
  • Good 4% (4)
  • Neutral 2% (2)
  • Poor 1% (1)

Will their practice change after attending the videoconference:

  • Most likely 58% (53)
  • Likely 25% (23)
  • Unlikely 7% (6)

Common themes that were revealed when asked about future topics:
massive hemorrhage, pediatrics, transfusion reactions

 

It is evident that the data captured from the surveys demonstrate that it is essential and there is a demand for continuous TM education for nurses. I would like to acknowledge the Ontario MOHLTC for their support; UHN, NBRHC, and LHSC for being the on-site host sites; and to the working group members and the speakers for volunteering their time and effort in making this event a success. Finally, thank you to all the health care professionals for their interest and participation in the event.

 

If you have not received the link to the post assessment knowledge survey and evaluation or received your certificate, please contact: leonor.debiasio@sunnybrook.ca.

 

 

May 2018

Tackling Ontario Transfusion Quality Improvement Plan Indicator Audits:
It May be Easier than You Think!

Authors:
Danielle Watson, Charge Technologist, Grey Bruce Health Services
Lisa Ruston, Director, Quality, Risk and Medical Affairs, Peterborough Regional Health Centre
Yulia Lin MD, FRCPC, Transfusion Medicine Specialist, Sunnybrook Health Sciences Centre
Christine Cserti-Gazdewich MD, FRCPC, FASCP, Transfusion Medicine Specialist & Consultant Hematologist, University Health Network
Allison Collins MD FRCPC, ORBCoN Physician Clinical Coordinator

The Ontario Transfusion Quality Improvement Plan (OTQIP) was launched in 2015, with a goal of reducing unnecessary patient harm by improving the appropriate use of red cell transfusions. An important component of the program is the collection of indicator data for two quality indicators: the percentage of transfusions that occur with a pre-transfusion hemoglobin (Hb) of less than 80 g/L, and the percentage of single unit transfusions (defined as measurement of the Hb after the first unit is transfused and before the transfusion of subsequent units). The benchmark for each indicator is 80%, based on the results of an Ontario red cell utilisation audit performed in 2013. Indicator audit data can be entered into an online tool which allows a hospital to chart performance over time. So far, twelve Ontario hospitals are entering data into the audit tool. This article is intended to help other hospitals get involved in the OTQIP by gathering indicator data and entering it in the audit tool.

 

There seems to be some confusion about the data to be gathered by the indicator audits. These are not “appropriateness” audits, in which data on the patient’s signs, symptoms, co-morbidities, medical history, ordering physician, etc. are entered into the audit tool. Rather, the indicator audits are intended to provide a simple snapshot in time of transfusion practice. It is more important to track performance over time than to do large and complicated audits. So, rather than auditing 50 transfusions every quarter, measure 10 every six months, or something in between. Audit just one of the indicators if you can demonstrate that your hospital is performing reasonably well on the other one. Audit inpatients, outpatients, or ‘all-comers’ if you wish. Do not attempt to exclude bleeding patients or patients in specific inpatient locations unless you wish. The idea here is to keep things simple and make incremental change. We are trying to ‘eat the elephant’ just one bite at a time so we don’t choke on it. Every time you make a positive practice change, even if it is based on a small audit, you are making care safer for patients. In the end, that’s the goal!

 

There are several different approaches to doing these audits, and a few are presented here.

 

Method 1: Collecting audit data in real time as red cell orders are processed in the transfusion medicine laboratory (Grey Bruce Health Services):

 

In this corporation the technologists screen all transfusion orders for different time periods predetermined by site. When each transfusion order is received the technologist receiving the order would document 2 patient identifiers (MRN and initials), the pretransfusion hemoglobin (defined as within 12 hours of transfusion) and the number of units ordered. The next day a technologist working in Transfusion Medicine would follow up with the post-transfusion hemoglobin and document it (Note: the post-transfusion hemoglobin is not required for the OTQIP audit but is done at this corporation). The data would be recorded on an Excel spreadsheet or manually on a paper record, depending on the site. At the end of the data collection period all technologists share the responsibility for reporting into the QIP database, so that all become experienced with the use of the E-tool.

 

Method 2: Leveraging the power of your laboratory information system to gather audit data (University Health Network and Sunnybrook Health Sciences Centre):

 

At UHN, the blood bank information system (HCLL) is interfaced with the electronic patient record. For a given RBC transfusion, the most recent hemoglobin pre-transfusion is captured at the time of issue. The issue location of the patient is also captured. Thus, a report can be pulled generating the most recent Hb for RBC transfusion as well as the specific issue location. This report can be downloaded to generate the percent of pre-transfusion Hb < 80 g/L and can be broken down by location. For single unit transfusions using this same report, single units are defined as one transfusion given on one day.

 

At Sunnybrook, the report is done manually. A transfusion report is obtained for 5 days of transfusion which is about 75-100 RBC transfusions. For the first transfusion for each patient, the pre-transfusion hemoglobin is obtained. If there is more than one transfusion on the same day for a patient, the post-transfusion hemoglobin is also obtained. A single unit transfusion is defined as one unit given on a single calendar day or if more than one unit given on a day, then a single unit transfusion would have a pre and post-transfusion hemoglobin before the next transfusion. The report can then be separated into an inpatient and outpatient report based on location.

 

Method 3: Retrospective review of red cell transfusion data (Northumberland Hills Hospital).

 

This method is described for Meditech users. Periodically, print off a report of all red cell issues for a month, a quarter, or whatever time period will allow you to capture 10-50 transfusions, counting only the first transfusion for each patient. For example, the “BBK unit final disposition report” will do. Make up a worksheet with 5 columns labelled: Name, Date, Time, Hb and Number of Units. Look up a patient by name in the PCI module, go to the “Blood Bank Products” entries, select the first red cell unit issued for the time period being audited, and note the date and time of issue. In this screen, you can also see the patient location and choose not to include them in the audit if they are from, for example, the oncology clinic. Then go to the “Hematology” list, and note the pre-transfusion hemoglobin value. If there are multiple units transfused, select the first transfusion only, and determine if it’s a multi-unit transfusion if there is no Hb measurement between the time of the first and subsequent unit(s). Note the number of units transfused (either 1 or more than 1; the actual number beyond 1 doesn’t matter) and go on to the next patient. You can use patient ID number instead of name, of course, but it may be helpful to keep a list of chronically transfused patients so that they can be skipped whenever their name appears on the unit disposition report. This can take 1-3 hours per audit, depending on how many transfusions are audited. The data is easily summarized, either by hand or in a spreadsheet, then entered in the OTQIP audit tool.

 

Choose one of these auditing methods or develop your own and, remember, the best way to get something done is to get it started! The OTQIP and tools are available at www.transfusionontario.org. If your hospital is already gathering indicator data, please consider entering it into the OTQIP online audit tool if you are not already doing so.

 

 

 

The Ontario Transfusion Quality Improvement Plan and Choosing Wisely Canada:
It’s time for Medical Laboratory Technologist Choosing Wisely Statements

By: Denise Evanovitch, Regional Manager, SW ORBCoN

The Choosing Wisely movement began in the USA in 2012 and was physician driven. Choosing Wisely Canada (CWC) was launched in 2014 by a small group from the University of Toronto, the Canadian Medical Association and St. Michael’s hospital. It is now a global program that includes 20 different countries across 5 continents.

 

The purpose of the Choosing Wisely campaign is to bring attention to and reduce unnecessary tests, treatments, and procedures that do not add any value and worse, may cause patient harm.

 

If these processes are unnecessary, then why do they occur? There are many reasons. A few of them are:

  1. Practice habits are difficult to change, even when faced with new evidence
  2. Patients and their families can be misinformed and demand extra tests
  3. Lack of time for shared decision making between health care professionals and their patients/families
  4. Outdated computer and decision support systems that encourage over ordering
  5. Fear of malpractice
  6. Payment systems for clinicians that reward “doing something” rather than nothing

The Ontario Transfusion Quality Improvement Plan (OTQIP) Committee, ORBCoN and its working groups collaborated on developing the “Why Give Two When One will Do” OTQIP toolkit: http://transfusionontario.org/en/documents/?cat=quality-improvement-plan

 

Physicians and their professional associations have developed a myriad of Choosing Wisely statements. Transfusion Choosing Wisely statements were developed by AABB https://www.aabb.org/pbm/Documents/Choosing-Wisely-Five-Things-Physicians-and-Patients-Should-Question.PDF and the Canadian Society for Transfusion Medicine: http://www.transfusion.ca/Education/Choosing-Wisely

 

Some of the CWC recommendation statements related to transfusions include:

  1. Don’t transfuse more than one red cell unit at a time when transfusion is required in stable, non-bleeding patients
  2. Don’t order unnecessary pretransfusion testing for all preoperative patients
  3. Don’t routinely order preoperative autologous and directed donations

Nurses in Canada have developed their own profession’s Choosing Wisely statements: https://choosingwiselycanada.org/nursing/

 

At LABCON (the annual Canadian Society for Medical Laboratory Science-CSMLS conference) this year, I will be facilitating a session to begin the process of developing Choosing Wisely statements from a medical laboratory technologist’s point of view. Some statements will include transfusion but we will also be looking to the different specialties attending the session to broadly cover all laboratory aspects. Each statement must be backed by current literature. The ideas generated at the conference session will be collated and submitted for publication to share with the wider laboratory community and to generate even further interest among the technologists across Canada.

 

Do you have ideas for Choosing Wisely statements for technologists and other laboratory professionals? Please send your ideas and references to me at evanovd@mcmaster.ca

 

When health care professionals work together in quality improvement, our patients are the beneficiaries of improved healthcare. Isn’t that why we selected our profession in the first place?

 

 

April 2018

Platelets: Tips for Inventory Management in Shortages (Platelet TIMS)

By: Allison Collins MD FRCPC, ORBCoN Physician Clinical Coordinator

As part of the preparation for the upcoming blood shortage simulation exercise in Ontario, a document was prepared to assist hospitals in managing their platelet inventories in times of shortage. The full Tips for Inventory Management in Shortages (TIMS) document, including references, is available at: http://transfusionontario.org/en/download/platelet-tips-for-inventory-management-in-shortages-tims/. A summary is presented here.

 

Although transfusion of ABO identical platelets is the preferred approach, this may not be possible during shortages. Transfusion of cellular-incompatible platelets (a major mismatch) or plasma-incompatible platelets (a minor mismatch) may be necessary. In a cellular-incompatible transfusion, the donor platelets exhibit antigens not present in the recipient (e.g. group A platelets to a group O recipient). This may result in a decreased post-transfusion platelet count increment.

 

In a plasma-incompatible transfusion, the donor plasma contains antibodies to antigens present on the recipient’s red cells, which may lead to hemolysis in the recipient. Hemolysis is more likely if group O platelets containing high titre anti-A or anti-B are transfused into a non-group O recipient. For this reason, titres of anti-A and anti-B can be performed on group O platelets, and high titre components reserved for group O recipients. A method for performing titres is provided in the full Platelet TIMS document. It has been argued that asking for a ‘boutique’ inventory of group A platelets only, instead of performing titres on group O platelets, defers the burden of testing to sites which do accept group O platelets and perform titres on them (whether or not there is a platelet shortage). This approach should be avoided. Other options for managing unavoidable plasma-incompatible transfusions include limiting the volume of incompatible plasma transfused per 24 hour period, and volume-reducing the component.

 

If D positive platelets must be transfused to a D negative female of childbearing potential, Rh immune globulin (RhIG) prophylaxis should be administered. One 300µg dose of RhIG will cover multiple platelet transfusions for four weeks. RhIG prophylaxis is not required for males, or for females outside of their child bearing potential years (e.g. over the age of 45).

 

In times of platelet shortage, splitting of doses is an option for hospitals with the appropriate equipment and expertise. Lowering the platelet count threshold for prophylactic platelet transfusions should be considered, and recommended threshold adjustments are included in the Ontario Contingency Plan as Appendix F. Extension of platelet shelf life should only be considered if authorised by the National Advisory Committee on Blood and Blood Products (NAC) and/or the National Emergency Blood Management Committee (NEBMC).

 

Interested readers are referred to the Ontario Contingency Plan and the full Platelet TIMS document at http://transfusionontario.org/en/documents/?cat=emergency_blood.

 

 

 

2018 Ontario Blood Shortage Simulation Exercise – Question & Answers from the Orientation Webinar Sessions

By: Wendy Owens, ORBCoN; Dr. Allison Collins, ORBCoN; Helen Cheng, MOHLTC; Esther Sok, MOHLTC; Leonard Chu, MOHLTC; Lisa St-Croix, CBS

In February of this year, ORBCoN held a series of five webinars to provide information to hospitals preparing to participate in the planned provincial blood shortage exercise. The exercise, originally planned for the week of March 5th had to be deferred due to actual low inventory levels of red blood cells at Canadian Blood Services. The exercise will be re-scheduled and hospitals will all be notified as soon as the new date is chosen. In the meantime, we wanted to share with you, the questions that came up during the orientation webinars and the answers that were provided.

 

1. Question: Who will receive the notification during the exercise and will this be the same as for a real blood shortage situation?

 

Answer: The first notification a hospital would receive of a blood shortage will be through a fax sent to the fax number on file at CBS. These fax numbers are programmed into the sending fax machine. This notification would be completed in the same way in an exercise as for a real situation. Email notification to hospitals would be the secondary communication. This email would be sent to Transfusion Medicine Laboratory primary and secondary contacts on the CBS hospital contact list.

2. Question: Who should attend the CBS teleconference calls?

 

Answer: A point person in the Transfusion Medical Laboratory (TML) should attend these calls. This person can then share updates with others in the TML and with the Hospital Emergency Blood Management Committee (HEBMC). This should be covered in the Hospital Emergency Blood Management Plan.

3. Question: Could decisions around triage of blood orders for this exercise be made retrospectively as opposed to in ‘real time’ so as to better manage the workload and not impact patient care?

 

Answer: Yes. Hospitals can make and document their simulation decisions and actions retrospectively. Hospitals can participate in the exercise in a way to accommodate workload. For example, triage decisions may be made in a less rigorous manner for the exercise to simplify the process.

 

It would be helpful to clarify what process would be used if decisions were being made in a real blood shortage to ensure that those involved understand the different or abbreviated approach taken for the exercise.

4. Question: Can the post exercise survey questions be sent to hospitals prior to the simulation exercise?

 

Answer: The purpose of the exercise is to test existing communications and processes in the event of a real blood shortage situation. Providing surveys ahead of the exercise may unduly influence behaviour and answers received. The post-survey questions are consistent with the Ontario Contingency Plan for the Management of Blood Shortages. Therefore, the survey questions will not be sent out prior to the exercise.

5. Question: Can hospitals receive a copy of their own responses to the post exercise survey to keep on file?

 

Answer: Yes, this can be provided for hospitals once the report has been completed.

6. Question: The Ontario Contingency Planning toolkit mentions that autologous donation might be considered if there is a prolonged Amber phase or if there is a Red phase shortage. Would this actually still be an option?

 

Answer: Yes, autologous donation was left in as a consideration if the regular blood supply is limited. For elective surgeries, if the patient’s surgery may otherwise be delayed for an extended period, autologous donation may be one option, albeit likely not the first one. It might be a better option to try to optimize the patient’s hemoglobin prior to surgery to reduce the likelihood that they would need transfusion at all depending on the type of surgery they are having. Any alternatives to transfusion in general will need to be considered carefully during an actual blood shortage. Pre-autologous donation for surgery is no longer a recommended strategy for patients without rare blood types; however, in exceptional circumstances, it can still be an option.

7. Question: How will the Emergency Management Communication Tool (EMCT) inform users during the mock exercise?

 

Answer: EMCT is an Incident Management System-based tool that does not depend on knowing specific individuals’ email addresses. Incident tickets will be created on the EMCT test site for text messages. Users will receive automatic notifications via email and/or text message. Users may then log into the EMCT to view information on a dashboard display. Both tickets and dashboard will inform users about the exercise, and in a real blood shortage could inform about the status of any related information such as road closures or affected facilities or services across the province.

8. Question: What types of messages will be posted on EMCT for this exercise?

 

Answer: Because this is an interactive communication exercise, it is difficult to completely predict the content of messages. However, it is expected that the conversations will be high level and will relate to LHIN/regional concerns rather than detailed questions on products and services.

9. Question: Who should I inform if the hospital’s EMCT members list is outdated?

 

Answer: There is a one stop contact for all inquiries related to EMCT: EMCT@LHINS.on.ca

 

You can send an email to this address to remove old members and add new members. New members will be required to complete training modules, which take about an hour to complete, prior to being set-up in EMCT.

10. Question: Who at the hospital should be an EMCT user?

 

Answer: This could be, but not limited to: Executive personnel, Incident Management and Risk Management personnel and Operations emergency preparedness personnel. Most staff in hospital transfusion services would likely not need to register on EMCT. It would be the role of the registered EMCT users at each hospital to inform others within their facility of relevant information.

11. Question: Are there preventive measures for any misinterpretations of messages via EMCT? Is there a possibility that the exercise could be mistaken for a real situation?

 

Answer: There are two safeguards to help ensure this does not happen-
1. EMCT will be run on a TEST platform for this exercise
2. Standard practice requires EMCT to be prefaced by ‘EXERCISE EXERCISE’ or ‘SIMULATION SIMULATION’

12. Question: Would EMCT ever be used for CBS to notify hospitals of a blood shortage or to make decisions about allocation of blood?

 

Answer: No. This is not the intent or purpose of EMCT. CBS distributes blood in all provinces except Quebec. The EMCT is only an Ontario tool therefore, it would not be used to notify hospital transfusion services of important information. CBS does have users registered on the tool, however, they currently only have ‘observer status’. No clinical information is to be posted on EMCT for health information privacy therefore, it is not to be used for clinical management of patients. The purpose of using EMCT during this blood shortage exercise is to-
1. Raise awareness of the existence of the tool
2. Determine how the tool may be used for a blood shortage situation to help ensure rapid dissemination of information that may be helpful to decision makers.

13. Question: What should a hospital do if they have not registered on EMCT? Can they still participate in this Blood Shortage exercise?

 

Answer: The hospital can still participate in this blood shortage exercise in every other aspect than the EMCT portion. If a hospital still wants to register with EMCT, they can contact the email address mentioned above EMCT@LHINS.on.ca and request to be added on to the tool. New users are required to complete some training prior to being granted access to the tool.

If you have any additional questions about your contingency planning for blood shortages or the upcoming provincial blood shortage exercise, please do not hesitate to contact me at wowens@toh.ca.

 

March 2018

Transfusion of K negative RBC for Females of Child-bearing Potential

Authors:
D. Neurath, Manager, Transfusion Medicine, EORLA TOH sites
M. Tokessy, Change technologist, Transfusion Medicine, EORLA TOH General campus
H. Maddison Medical Technologist, Transfusion Medicine, EORLA TOH General campus
N. Cober Charge Technologist Transfusion Medicine, EORLA TOH Civic campus
S. Love Charge Technologist, Transfusion Medicine, EORLA TOH General campus
B. Ludington Medical Technologist Transfusion Medicine, EORLA TOH General campus

ABO and Rh(D) matching for red blood cell (RBC) transfusions is the standard of care to ensure safe blood transfusion and to circumvent alloimmunization to the D antigen. The prevention of Rh(D) alloimmunization is especially important for females of child bearing potential, in that maternal anti-D is known to cause hemolytic disease of the fetus and newborn (HDFN). Anti-K has been known to also cause severe HDFN. With no available prophylaxis, there is no protection for anti-K alloimmunization in pregnancies. While the incidence of K antigen is low, only 9%, its antigenic nature makes it a frequent antibody producer. Alloimmunization is mostly attributed to transfusion of K positive red blood cells (RBC). Selection of K negative RBC for blood transfusions to females of child-bearing potential will prevent development of anti-K in this vulnerable patient population.

 

A review was performed using the regular blood inventory to determine if sufficient number of K negative RBC units would be available for transfusions. It was determined that indeed we would have sufficient available inventory of K negative RBC for transfusions to female patients of child-bearing potential.

 

Each patient has a transfusion history check done prior to performing Type and Screen. All females identified as < 45 years old meet the criteria for selection of K negative RBC for blood transfusion to prevent alloimmunization. The existing inventory on hand is used without need for special requests from the Canadian Blood Services (CBS) for K negative RBC.

 

In May 2017 we implemented a process for all female patients of child-bearing potential to be transfused with K negative RBC. Between May 1, 2017 to December 31, 2017 there were 342 female patients in this category requiring blood transfusions of 1906 RBC units. The numbers include sickle cell exchanges; a total of 35 female patients requiring 721 RBC that were specifically requested from CBS for exchanges. Additionally, there were 13 patients requiring multiple transfusions, between 15 to 30 RBC units each. The K negative RBC inventory was most often sufficient and in-house phenotype was performed only when supply was depleted. The exception in this process occurs during a massive transfusion in which the critical situation does not allow it.

 

Considering the severity of hemolytic disease of the fetus and newborn due to anti-K and the readily available K negative RBC, we feel we are proactive in trying to eradicate anti-K alloimmunization by transfusion in the female population of child-bearing potential. The cost is negligible as the existing inventory of K typed RBC is mostly used.

 

What is the Canadian Obstetrical and Pediatric Transfusion Medicine Network (COPTN)?

Authors:
Gwen Clarke MD, Hematopathologist with Canadian Blood Services and Clinical Professor in the Department of Lab Med and Pathology at the University of Alberta
Lani Lieberman MD, Assistant Professor, University of Toronto and Transfusion Medicine Specialist, University Health Network and affiliated hospitals
Denise Evanovitch, ORBCoN Regional Manager, SW Ontario

The Canadian Obstetrical and Pediatric Transfusion Medicine Network (COPTN) is a subcommittee of the Canadian Society for Transfusion Medicine (CSTM) and was established in 2017. The membership consists of volunteer physicians, technologists and health care providers from across Canada with expertise in obstetrical and neonatal testing, transfusion and care. The subcommittee’s mandate is to assess, analyze and strive to implement best practices in pediatric and obstetrical transfusion practice in Canada. ORBCoN was invited to participate as a member of this group.

 

COPTN members frequently field obstetrical/neonatal questions from hospitals. Many of these issues are not included in transfusion and accreditation standards such as CSA, CSTM, IQMH and Accreditation Canada. Thus, there is a need for guidance on best practices in Canada for this patient group that is readily available for all pertinent specialties.

 

The COPTN’s objectives are to:

  • Survey practice related to pediatric and obstetrical laboratory testing and transfusion across various hospitals in Canada
  • Assess the literature regarding optimal transfusion practice and to share results with members
  • Discuss and develop national research projects in obstetrical and pediatric transfusion medicine
  • Develop best practice recommendations in pediatric and obstetrical transfusion practice
  • Serve as a forum to discuss challenging pediatric/obstetrical cases
  • Promote the safe use of blood products to pediatric and obstetrical patients

The first large scale initiative of COPTN is a Canada-wide survey of obstetrical and neonatal testing practices. It will be distributed to hospitals and other laboratories that conduct this type of testing (e.g. some Canadian Blood Services laboratories)and will be sent to participants in every province and territory. The purpose of the survey is to assess the current practice with regard to ABO, Rh, antibody screening, fetal-maternal hemorrhage assessment and RhIG administration. This analysis will provide a needs assessment of sorts to assist COPTN in prioritizing which guidance to develop first in order to provide the most benefit.

 

COPTN members developed the survey using the LimeSurvey® software and will be analyzing the results, which will be shared with the participating hospitals and laboratories. The survey does cover a large range of practice, so it is a longer one, but there is logic incorporated into the questions, so not all questions will require an answer from all respondents. It is divided into sections and you can stop and save your results at any time and continue completing the survey later. It will be distributed in the spring of 2018 and you will have six weeks to complete it. We would like a response from each hospital/laboratory. (rather than a single response from a health region).

 

We strongly encourage you to take the time to do this survey as the ultimate goal is to provide standardized, best care to obstetrical and neonatal patients throughout Canada. We look forward to your participation. Together, we can improve patient care across Canada.

 

 

 

February 2018

Blood transfusion camp: filling the gaps in medical education curriculum

By: Sasan Zandi, MD, PhD, Hematopathology resident, Laboratory medicine department, University of Toronto

Blood transfusion is one of the most commonly prescribed procedures by many disciplines in medicine and yet there is very little formal teaching in the existing medical education curriculum. In fact there are several studies in North America and Europe that report a high percentage of blood transfusions are inappropriate. Other studies have shown that a significant number of practicing physicians and residents are not able to obtain appropriate consent for transfusion mostly due to a knowledge gap or under- appreciation of the patient’s understanding and perception with regards to transfusion. Almost five years ago, a group of thoughtful and dedicated leaders in transfusion medicine recognized the deficiency in residents’ education and initiated a series of year-long transfusion workshops for the University of Toronto postgraduate students, dubbed as “Transfusion Camp”. This initiative soon drew the attention of the residents and the educators from other medical programs in Ontario and grew to a platform for teaching residents in various disciplines across the nation. The camp features University of Toronto educators in transfusion medicine who discuss the latest scientific findings in transfusion practice that have direct clinical impact on patient care.

 

I had the pleasure of participating in the 2017 transfusion camp with a group of friends and after spending a day in the camp, many of us realized that transfusion is not as simple of a procedure as we thought it was. We recognized that we all need to know a great deal more about the indications, appropriate choice of products, alternatives to transfusion and the side effects of transfusion in order to make the best possible decision for our patients. We all conceded that after the camp day, our practice and process of making decisions to transfuse blood and blood products and even the consent discussion would not be the same. Many of us felt that if we had this learning opportunity earlier we might have done things differently.

 

Another impressive fact about the transfusion camp apart from carefully selected content and objectives was the teaching model that was adapted. It is a combination of traditional didactic teaching and interactive learning formats that provides a forum to discuss various aspects of transfusion medicine and study real cases. The content of the lectures, videos and other educational material is also made publicly available to review prior to the course and to be used after the workshop as reference.

 

Witnessing the impact of the transfusion camp initiative in the daily practice of residents and subsequently improving the care we provide to patients, I think it is essential to include the transfusion education with the new camp format in the medical curriculum of all medical schools in Canada.

 

At the end I think it is incumbent upon me to recognize the tireless efforts of the extraordinary laboratory physicians Dr. Yulia Lin and Dr. Jeannie Callum who initiated this program and continue to strive to improve the quality of patient care by educating young physicians about transfusion.

“Hit the Repeat Button” How often is Antibody Identification required?

By Wendy Owens, ORBCoN Program Manager, NE Region

Antibody identification testing is initiated once a positive antibody screen test is detected. If a clinically significant antibody is identified, the result is reported and documented in the patient’s record. For patients who are chronic transfusion recipients, the question arises ‘Is it necessary to perform a full antibody identification each time that patient requires a crossmatch for transfusion?’

 

In 2017, ORBCoN performed a small ad hoc survey to ask hospitals in Ontario what their practice is with respect to repeat antibody identification testing. We received responses from 10 hospitals and they reported the following:

  • 1 hospital reported confirmation of the presence of the previously identified antibody and exclusion of new clinically significant antibodies using selected reagent red cells in addition to performing a serologic IgG crossmatch with antigen negative donor units
  • 3 hospitals reported they perform an antibody screen only and an IgG crossmatch with antigen negative donor units to detect the presence of any new antibodies. A more complete antibody identification is performed every two weeks
  • 2 hospitals reported they test as above however they only repeat an antibody identification every month
  • One group of four hospitals reported that they perform an antibody screen and crossmatch antigen negative donor units (IgG crossmatch). As long as the crossmatch is compatible and there is no change in the strength of the existing antibody these hospitals can follow this protocol. Their policy is to repeat the full antibody investigation only every six months (recently extended from three months after reviewing their historical data).

So, what is the correct practice? Why is there such variation in the approach taken? Is it acceptable to just perform an antibody screen and crossmatch antigen negative units if the patient has a previously identified clinically significant antibody?

 

What do the Standards say about this?
Canadian Standards state that when a clinically significant antibody has been identified, red blood cells that lack the corresponding antigen should be selected for transfusion and be shown to be compatible by serological crossmatch.1,2,3

 

It appears that all of the hospital reported practices comply with the minimum required by Standards, therefore all should be considered acceptable. As resources for hospital transfusion services become scarce, hospitals often need to adjust their practice to conserve these resources. Standards help ensure that decisions made will not jeopardize patient care and will ensure that practice is safe.

 

As far as determining the frequency of performing a repeat antibody investigation to detect the presence of a new antibody in patients who have been recently transfused, many hospitals elect to use antibody screening cells to check if there are any unexpected reactions (any reactivity with antigen negative cell detected or change in strength of reactions) in addition to compatibility testing of antigen negative units.

 

The justification for this being that if a new antibody has developed, the antigen compatible units plus the additional screening cells would provide evidence of a new antibody should unexpected positive reactions be detected. While this practice would be acceptable 4 for most cases, when a patient has developed antibodies against multiple antigens or to a high frequency antigen, screening cells may not provide a good indication if there is another underlying antibody present. Also, to be considered, if the new antibody reacts only with homozygous expressions of the corresponding antigen, the donor units selected for crossmatch may still appear to be compatible. Each hospital should perform a risk assessment to evaluate if the policy they select poses any risk to patient safety prior to implementing it. If an abbreviated investigational approach is adopted, monitoring for possible increased patient risk should take place to ensure the new policy is not causing increased patient harm. For example, monitor transfusion reaction rates.

 

While there is an argument to be made for standardizing processes, it is also important to accept that each hospital must have the flexibility to make decisions based on their own rationale and evaluation. So who is right? All of these practices can be considered acceptable. To repeat or not doesn’t necessarily have to be the question!

 

We encourage hospitals to share any results of their risk assessments by writing an article for the ORBCoN report and/or more formal publications. This may help other sites in considering if they should make a change to their current policy.

 

References:

  1. CSA Z902-15 Canadian Standards Association Standards for Blood and Blood Components December 2015; CSA Group
  2. Canadian Society for Transfusion Medicine Standards for Hospital Transfusion Services; v4 April 2017; CSTM
  3. Institute for Quality Management in Healthcare Medical Laboratory Accreditation Requirements v 7.1 April 2017: IQMH
  4. Fung MK et al Editors. AABB Technical Manual 19th edition; 2017: p378

 

 

 

January 2018

Physician Engagement: Discovering a Common Purpose

By: Stephanie Cope, Administrative Project Coordinator, ORBCoN CE Region

All healthcare professionals, regardless of their role or expertise have the same purpose, ensuring the best possible care for ‘their’ patients. In order to ensure the best possible care is provided, healthcare organizations and physician groups must be able to identify, implement and monitor the available evidence in medicine to ensure best practice(s) are being utilized. One of ORBCoN‘s mandates is to collaborate with transfusion medicine experts and end-users to provide high quality, relevant, evidence-based transfusion medicine educational resources. Achieving buy-in or acceptance for practice changes from the intended end-user groups requires a champion that is well respected, has adopted the new behavior/change and one who has the ability to model and lead their colleagues into current evidence based practices to provide the highest quality of care.

  

ORBCoN regularly evaluates the utilization and accessibility of its educational resources, ensuring they are meeting the educational needs of end-user groups. In 2015-16, it was determined that although the Bloody Easy (10 module) eLearning program was very comprehensive, it took a considerable amount of time to complete, resulting in underutilization by its intended users. Subsequently, this eLearning program was discontinued in order to focus our attention on creating new educational resources that would better meet the end-users’ needs.

  

A first step in increasing physician engagement with transfusion medicine educational resources was to conduct a qualitative analysis. This qualitative analysis would display a better understanding of the effectiveness and relevance of the current formats used to provide transfusion medicine continuing education to ordering physicians/TM Medical Directors. A transfusion medicine educational needs assessment survey was created (LimeSurveyTM) and distributed to all Ontario hospitals through the Laboratory Medical Director and Transfusion Committee Chairperson.

  

Thirty six responses were received. While the number of responses was lower than desired, 22 (61%) of the respondents were from the intended target audience (end-user) and represented all sizes of hospitals.

  

Table 1. What is your motivation when choosing a CME course?

Table 2. How do you prefer to access educational resources?


Table 3. Which of the following are you familiar with? 

As the world of transfusion medicine advances, the importance of providing relevant, current and evidence-based educational resources becomes paramount. Ensuring the potential content is evaluated by the end-user is critical in meeting educational requirements and standardizing transfusion medicine best practices. According to utilization statistics, the Bloody Easy resources are widely used throughout Ontario, Canada and beyond but a gap in user groups is recognized. In future, ORBCoN will strive to promote resources to healthcare practitioners outside of transfusion medicine to extend our education to ordering physicians (of other specialties) to encourage best practice and increase patient safety. A small number of hospitals have made Bloody Easy Lite completion a mandatory requirement for certain healthcare professionals, providing evidence that supports updating the content and the content delivery format. A top priority of ORBCoN is to ensure educational resources are relevant, user friendly and meet the needs of our intended end-users and help hospitals meet the ever increasingly stringent accreditation requirements.

  

ORBCoN would like to thank the following individuals/organizations for providing their support in ORBCoN’s evaluation initiatives over 2015-17: Canadian Blood Services, Choosing Wisely Canada; and Drs: Allison Collins, Elaine Leung, Lani Liebermann, Yulia Lin, Lois Shepherd and Michelle Zeller.

 

  

Bloody Easy on the Road

By: Allison Collins, MD, FRCPC, Clinical Project Coordinator, Transfusion Medicine Physician, ORBCoN

This is an article that does not ask you to do anything, or to learn a new concept, or to embark upon another project, so you can simply relax (or skip it). I am just going to review briefly my experience “on the road”, promoting evidence-based transfusion practices to community hospital physicians over the past four years. It’s been a really fun journey, and I can safely say that this is the best job that I have ever had!

  

The position of ORBCoN Physician Clinical Projects Coordinator was created in November 2013. By then ORBCoN had already made great strides working with hospital blood banks improving inventory management, re-distributing blood products, and auditing transfusion ordering practices, among many other things. Now it was time to give some more educational support to the prescribers of blood, with some friendly reminders about how to order safe and effective transfusions (and obtain informed consent for them). Not being a transfusion medicine specialist, but a general pathologist, I first had to scramble to ensure that my grasp of the subject was even just slightly firmer than that of the people in my audiences, many of whom ask very probing questions. Naturally, the real experts in this field are far too busy to travel any more than they already do, so my position fills in a few of the gaps. Which reminds me to give a big ‘thank you’ to all of the transfusion medicine specialists in Ontario and beyond who have been so generous with their advice and help over the years, and whose slides I so shamelessly borrow and adapt – you know who you are.

  

I have travelled all over the province, sometimes via the Ontario Telemedicine Network, but usually in person. The rough count of presentations so far is about eighty, concentrated mainly in the spring and fall to avoid freezing rain, blizzards, and slippery airport runways. My audiences range from four people to well over a hundred, and include nurses, laboratory technologists, midwives, pharmacists, other hospital staff and, of course, physicians. I suppose I ought to include the audiovisual tech guy at one meeting, who knew nothing about blood but who thought the talk was amusing (potential blood donor?). The knowledge and dedication of the laboratory technologists whom I meet never ceases to amaze me. Perhaps my real role is simply to reinforce the messages that they are already trying to get across in their hospitals, reinforcing the old adage that “no prophet is accepted in his own country”. Although not technically in the job description, I have rearranged meeting room chairs, signed for the delivery of the catering, and served as a source of advice for patients trying to navigate the parking pay machines and exit gates at various hospitals, the latter admittedly with the selfish goal of getting out of the parking lot myself.

  

ORBCoN audits have shown that we need to focus on the indications for and dosing of blood components such as red cells and plasma, which I do. However, I try to tailor the topics to the things the doctors want to hear about (if somebody tells me in advance) or to the things the blood bank staff wants the doctors to know more about (they are pretty good at telling me this in advance). So, we get into platelets, PCCs, warfarin reversal (yes, some people are still using plasma), direct-acting oral anticoagulants, albumin, cryoprecipitate, RHIG, informed consent, transfusion reactions, and on it goes. I have been to a few hospitals multiple times, and asked one anesthesiologist “What on earth is there left for us to discuss next year?”, to which he replied “Just go back to your first talk, we have probably forgotten it by now”. Very reassuring.

  

Finally, a little plug. If you would like to arrange for a presentation to your medical staff you can find me at allison.collins@sw.ca. Our resources at ORBCoN are not unlimited but I will do what I can; the more notice the better.

 

  

  

When should a post-transfusion hemoglobin sample be drawn?

  

The sample can be drawn anytime between 15 minutes and 24 hours post-transfusion1. There are no significant differences in hemoglobin levels over this time frame. Therefore, if a hemoglobin level is part of your patient assessment to determine if another unit of RBCs is required, there is no reason to delay the sample draw past 15 minutes, as excellent hemoglobin correlation exists at the post-transfusion sample draws of 15, 30, 60, and 120 minutes, as well as 24 hours2.

  

References:

  • Wiesen AR, Hospenthal DR, Byrd JC, et al. Equilibration of hemoglobin concentration after transfusion in medical inpatients not actively bleeding. Ann Intern Med 1994;121:278-80.
  • Elizalde JI, Clemente J, Marin JL, et al. Early changes in hemoglobin and hematocrit levels after packed red cell transfusion in patients with acute anemia. Transfusion 1997;37:573-76.   

 

December 2017

Surgery, Blood Transfusion and the Jehovah's Witness Patient

By: John Freedman, MD FRCPC, Professor Emeritus, Medicine, University of Toronto, St Michael's Hospital

For Jehovah’s Witness (JW) the ban on allogeneic blood has been official church doctrine since 1945, and whole blood, red cells, white cells, platelets and plasma are unacceptable to Jehovah’s Witnesses; this is non-negotiable. More recently, this has been modified and currently allows transfusion of ‘minor fractions of blood’ based on individual preference. Bloodless surgery and medicine (Patient Blood Management; PBM) has rapidly evolved over the past few decades. Starting in 1962, Ott and Cooley performed >500 open-heart surgeries on JW patients without use of blood transfusions. PBM continues to improve with new clinical, surgical, and pharmacologic strategies and offers an organized approach to surgery designed to minimize blood loss and to avoid transfusion. These multimodal protocols should be developed by a multidisciplinary team of anesthesiologists, critical care specialists, surgeons, internists, transfusionists, hematologists and bioethicists.

  

Elective surgery needs to be well planned. Both surgeon and anesthetist must meet with the patient to discuss the planned surgical procedure and its associated risks. In an open, non-judgmental fashion they must ascertain exactly what is acceptable to the individual patient. JW patients are generally very well informed and discussion and conclusions should be documented and witnessed. The patient should be encouraged to have a family member or their religious advisor present during this discussion if they wish. Each hospital will have access to a representative from the religion through the local JW hospital liaison committee. Ideally, 4-6 weeks is needed to allow optimization of the patient’s hemoglobin (Hb), if required, and for thorough discussion and planning e.g. are there alternatives to surgery or can the procedure be performed in stages or by a minimal access technique?

  

The preoperative process begins with a thorough history and a detailed physical examination. Preoperative counseling with informed consent is of paramount importance and patients are asked to clearly document which, if any, minor or major fractions of blood they would accept, as well as which bloodless-related preoperative, intraoperative, and postoperative measures they will accept. During the preoperative management, Hb levels should be optimized, and efforts should be made to correctly diagnose and treat any existing anemia. Since preoperative Hb is an important predictor of the need for transfusion one should ensure that these patients start with an adequate Hb. At referral the Hb, ferritin, B12 and folate levels should be checked. The results will determine which patients will benefit from a course of iron or erythropoietin (EPO). If time is short or oral iron therapy is ineffective or not tolerated then intravenous iron may be used. Patients may require both EPO and iron. EPO is expensive and has potential side effects including hypertension and thrombosis which may limit its use in patients over 70 years. It may not be acceptable to all JWs since some preparations contain a small amount of albumin. Also at this planning stage, drugs associated with increased bleeding should be stopped if possible prior to surgery; these include aspirin, NSAIDs and anticoagulants. Blood draws should be minimized and use of pediatric tubes for blood draws may be appropriate, especially if a large number of laboratory tests are being performed.

  

Intraoperative management of the JW patient is complex and requires a high level of technical skill and excellent communication between the surgical and anesthesia teams. Surgical approaches that reduce blood loss, such as handling tissue gently, recognizing potential sources of bleeding and rapidly controlling unexpected hemorrhage, are essential. Patient positioning should maximize access to the surgical field from multiple approaches. Administration of the antifibrinolytic agent, tranexamic acid, can be very useful in reducing blood loss and reducing transfusion in many types of surgery, particularly in cardiac and orthopedic surgery – regimens include intravenous and topical administration. Other techniques may include acute normovolemic hemodilution (ANH) and intraoperative autologous transfusion which may be acceptable to some JWs when performed in a closed system without blood storage; because these interventions are not accepted by all patients, they should be specifically addressed in the advanced directive form.

  

Postoperative measures include tolerance of anemia and minimization of blood draws — lower transfusion thresholds have become acceptable in recent years. Patients should be monitored closely for bleeding and adequate oxygenation. If acute postoperative bleeding is suspected, the surgeon should consider reoperation promptly. Postoperatively, judicious use of intravenous iron and EPO may be considered.

  

Many factors may influence individual patient responses on the advanced directive form. The individual freedom that the JW church provides JW patients in accepting or rejecting minor blood fractions or modern interventions allows for patients to incorporate their own values and the advice of their own support network in the decision-making process. The technical language of an advanced directive may be difficult for some individuals to comprehend, which could lead to inaccurate documentation of a patient’s wishes. Thus, patients should be counseled by physicians and/or trained professionals that are thoroughly familiar with the field of PBM. The counselor must understand both the options presented in the advanced directive and the patient’s beliefs. An attending or resident physician not thoroughly familiar or up to date with PBM techniques may not be able to take such vagaries into account when counseling patients. Treating patients who place restrictions on our medical practice which may ultimately result in morbidity or mortality can raise complex issues of a moral and ethical nature and may be a very stressful experience for all involved, particularly if things do not go well. Nonetheless, we must care for all patients, including JWs, in a professional, non-judgmental and confidential manner. We must work on the presumption that every adult patient has the capacity to make decisions about their care and to decide whether they refuse or agree to any treatment.

 
  

  

Transfusion Medicine Quality Improvement Baseline Survey

By: Troy Thompson, MLT BAHSc (Hons), ORBCoN Regional Manager, Central Region

“The continuous journey has to start somewhere!”

The Ontario Transfusion Quality Improvement Plan (OTQIP) committee conducted a survey in January 2017 to gather baseline data from hospitals on Transfusion Medicine quality improvement (QI) initiatives. As quality improvement is a continuous journey, each hospital may be at various points in the quality improvement spectrum. This article will highlight the QIP survey and the participating hospital’s QI activity.

 

In total, 50 hospital sites participated in the survey, with 31 (62%) sites answering that they have established and implemented transfusion guidelines for blood and blood product utilization. Of the 50 sites, red blood cell (RBC), platelet and plasma guidelines were implemented at 28 (56%), 24 (48%), and 22 (44%) sites respectively while 26 (52%) sites had implemented guidelines for prothrombin complex concentrates (a provision for PCC utilization) and 18 (36%) sites had implemented IVIG guidelines as per the Ministry of Health mandate for IVIG use in Ontario. Transfusion guidelines were approved by a hospital Medical Advisory Committee (MAC) at 29 (94%) sites which may help to support their consistent use. Implementing guidelines is a good place to start when attempting to reduce inappropriate transfusions; 6 (19%) sites answered that the guidelines are followed for “every transfusion order” and 16 (52%) sites answered that guidelines are followed for “most transfusion orders.” The implementation of transfusion order sets (electronic or other) is another strategy that may help in standardizing transfusion practice and 24 (48%) sites answered that they have implemented transfusion order sets. The prospective screening of transfusion orders by a Medical Laboratory Technologist is also an effective way to “curb” inappropriate utilization and 21 (42%) hospitals indicated that they had a prospective screening process in place. This strategy requires much more effort to implement but in combination with consistent medical back-up can be very successful in standardizing transfusion practices. Of those sites that utilize prospective screening, it occurs for “every” or “most transfusion orders” at 10 (48%) sites while 5 (24%) sites screen specific products/components and 6 (29%) sites will screen further if the transfusion order seems questionable.

  

In order to gauge quality improvement success, quality metrics should be measured and 35 (70%) sites indicated that they are measuring quality metrics. Many sites are collecting the percent of transfusions that occur in patients with pre-transfusion hemoglobins less than 80g/L and the percent of transfusions that are ordered as single RBC unit transfusions. These two metrics were also selected by the OTQIP committee and an electronic platform is available for hospitals to enter and track these data. http://etools.transfusionontario.org/. (Please contact ORBCoN if you do not have an account set up). All Ontario hospitals with transfusion services are encouraged to report in this tool because it provides hospitals with individual progress reports to share with their internal quality and transfusion committees and ORBCoN can generate combined data reports to monitor progress at a provincial level.

  

Quality improvement initiatives in Transfusion Medicine continue to increase and the reduction of unnecessary tests/procedures such as transfusion is a key component for patient safety as highlighted in the Choosing Wisely Canada campaign. Momentum in Transfusion Medicine QI is gaining and it is important to measure your progress as you work towards your goals. No matter what stage you are at in the QI journey, the journey starts with you, so check out the Ontario Transfusion Quality Improvement Plan at www.transfusionontario.org and make your QI goals today!

  

“Practice the philosophy of continued improvement; get a little bit better every single day.” Author unknown

 

  

   

Question submitted in response to June 2017 Newsletter article titled "How do we interpret the 60 minute rule"  Authored and Responded By: Yulia Lin, MD, FRCPC, Transfusion Medicine Specialist, Sunnybrook Health Sciences Centre

  

1. The study was performed on RBCs, but the standard is for all blood components. Is there no need to do studies on other blood components before generalizing the standard to include all components (i.e. plasma)?

  

The study was specifically performed for RBCs. Practically speaking and in my personal opinion, I don’t see much of an issue with the 60 minute rule being extended because:

  • Plasma is thawed at 37°C and I think there is minimal decay in the factors whether stays out of lab for 30 minutes vs. 60 minutes. Technically, it just has to be cooler than when it left the lab which will be the case.
  • Platelets are kept at room temperature so again 30 minutes vs 60 minutes shouldn’t really make a difference. The lack of agitation for 30 vs 60 minutes is not an issue considering that they may sit up to 24 hours during transport.
  • Cryoprecipitate also kept at room temperature after thawing again so 30 vs 60 minutes will not be an issue.

  

2. You mentioned a little section about blood products can also be returned to useable inventory provided they have not been outside of a controlled environment for more than the time recommended by the manufacturer. The standard (14.6.2) says the product must be maintained within the “parameters” described in the product monograph. I’m thinking parameters probably also includes temperature as well. As in, if a vial of WinRho was issued out of the lab and came back greater than 8 degrees, it cannot be returned to useable inventory. Your thoughts?

 

Interesting that you comment on the blood products – that specific section was actually added in conjunction with ORBCON. The parameters would also include temperature. For certain products, we have sought additional information from the manufacturers (outside of the product monograph) on product stability so that has helped us extend some products even longer.

 

November 2017

Transfusing Wisely at Scarborough and Rouge Hospital

By: Tina Irwin, Charge Technologist, Transfusion Medicine, Scarborough and Rouge Hospital

Choosing Wisely initiatives are necessary to improve utilization of blood products, to minimize the patient risks associated with transfusion and decrease the costs to hospitals and ultimately to healthcare by eliminating unnecessary testing and usage of this valuable commodity.

  

The first step to implementing Choosing Wisely initiatives in Transfusion Medicine is to establish a baseline audit to determine the strengths and weaknesses of current practices. With the support of the Transfusion Committee and the ONTraC nurse at Scarborough and Rouge Hospital, formerly The Scarborough Hospital (General / Birchmount), we established the criteria for our baseline audit. The patient focus group did not include Oncology, Hemodialysis or actively bleeding patients. Transfusion data from 50 eligible patients at each Campus, (Birchmount / General) was analyzed and compared.

  

Five main indicators were measured:

  1. Patients with a pre-transfusion hemoglobin <80 g/L.
  2. Single unit transfusions followed by hemoglobin (CBC) and patient reassessment.
  3. Patients with a post-transfusion hemoglobin value >100 g/L.
  4. Inappropriate transfusions based on our current guidelines.
  5. Patients without a post-transfusion hemoglobin value.

From the baseline audit data conducted in April 2016, it was evident that a plan must be initiated to improve our blood utilization. Between July 2016 and September 2016 we implemented several improvement strategies suggested by The Ontario Transfusion Quality Improvement Plan (OTQIP), ORBCoN, ONTraC, Bloody Easy and Choosing Wisely Canada.

  1. Standardized transfusion guidelines were established. The guidelines were delivered in laminated poster form to every department, nursing station and physician lounge across both hospital sites (General / Birchmount).
  2. Revision of our current blood transfusion order set to include a mandatory CBC or hemoglobin after each transfused unit of red blood cells.
  3. Physician education took place in the form of Medical Rounds from Dr. Allison Collins and Dr. Jackie Ostro. Letters from our Chief of Staff, Laboratory Medical Director and Transfusion Committee Chair were delivered notifying all physicians of the transfusion guidelines update, revised order set and our baseline audit results.
  4. Nursing education consisted of visiting each nursing unit and attending staff huddles to discuss transfusion requirements and guidelines with focus on post-transfusion hemoglobin values.
  5. Prospective screening of transfusion requests required training for Medical Laboratory Technologists and was implemented with extra support available upon request.
  6. A post implementation audit was performed by Tina Irwin et al. in November 2016 to determine the effectiveness of the implemented strategies. Additional audits were performed every 3-5 months thereafter, to measure sustainability (See results below).

Transfusion Audit April 2016-August 2017 Scarborough and Rouge Hospital (General / Birchmount Campus)

In addition to transfusion restrictions, it was determined by an audit that 40-50% of the group and screen tests in the Oncology department were unnecessary as the patients did not require a blood transfusion on that visit. We implemented a “BBHOLD” order in our LIS where a sample is collected but not tested unless a transfusion is indicated. As a result there has been a reduction in both group and screen testing and antibody investigations with an approximate savings of >$50,000/year in reagents and supplies.

  

The implemented Choosing Wisely initiatives, with interprofessional communication and continuous monitoring, have proven to be successful and sustainable for improving blood utilization at the Scarborough and Rouge Hospital (General / Birchmount).

  

 

Doing Away with the SickleDex: UHN Red Cell Disorders Program Policy Change

By: Christine M. Cserti-Gazdewich, MD, FRCPC, FASCP, Transfusion Medicine Specialist & Consultant Hematologist, University Health Network

Red cell transfusion (RBC) strategies in sickle cell disease (SCD) range from simple transfusions to therapeutic exchanges (TREx), aiming to improve tissue oxygenation as the quantity and/or quality of hemoglobin (Hb) increases. In TREx, sickle hemoglobin (HbS) is taken from its baseline levels to targets at or below those in sickle cell trait (SCT) (ie- HbS ≤30%). The assurance of trading out HbS (or the power to verify achieved vs expected HbS%) rests on assumptions that RBC are HbS-free. However, the odds of a SCT+ RBC increase by matching practices in SCD. Many transfusion services therefore test for SCT, so as to exclude HbS+ units allocated to SCD patients. If half of surveyed jurisdictions do this, which half is right?

 

In our program, ~3500 RBC units (or 1 in 10 units) are transfused annually to SCD patients. In our audit (12/5/2009 – 21/01/2017, >7.5 years), 26003 RBC were SCT-screened, at $10/test. Only 2-3 RBC/1000 were found to be SCT+. In the most recent fiscal year, SCT testing costed $44,300. For the 13 SCT+ units found, the number-needed-to-test was 341. Said another way, $3408 was spent to interdict any SCT+ unit. This excluded costs related to new workload or delays in care. The chance of SCT+ RBC incorporation in TREx was therefore deemed low, with stakeholders agreeing that such an event would also be inconsequential (in calculations or clinical outcomes).

 

We concluded that the cost of RBC SCT testing, against the benefits gained (or risks averted), could not justify continuation. Analogously, we accept crossmatch compatibility as a surrogate for antigen-negativity for those targets which are infrequent in their occurrence, expensive to select, and usually harmless on transfusion otherwise. In the spirit of informed decision-making, we have abandoned SCT testing of RBC.

  

References

  • Bello NA, Hyacinth HI, Roetker NS, et al. Sickle cell trait is not associated with an increased risk of heart failure or abnormalities of cardiac structure and function. Blood. 2017; 129(6):799-801.
  • Lanzkron S, Naik RP. Negative studies shape the state of sickle trait. Blood. 2017; 129(6): 661-662.
  • Liem RI, Chan C, Vu TT, et al. Association among sickle cell trait, fitness, and cardiovascular risk factors in CARDIA. Blood. 2017; 129(6):723-728.
  • Kelly S, Quirolo K, Marsh A, Neumayr L, Garcia A, Custer B. Erythrocytapheresis for chronic transfusion therapy in sickle cell disease: survey of current practices and review of the literature. Transfusion. 2016; 56(11):2877-2888.
  • Ould Amar AK. Red blood cells from donors with sickle cell trait: a safety issue for transfusion? Transfus Med. 2006;16(4): 248-253.
  • Quirolo K. How do I transfuse patients with sickle cell disease? Transfusion. 2010; 50(9): 1881-1886.
  • Yawn BP, Buchanan GR, Afenyi-Annan AN, et al. Management of sickle cell disease: summary of the 2014 evidence-based report by expert panel members. JAMA. 2014; 312(10): 1033-1048.
  • Yazer MH, Lozano M, Crighton G, et al. Transfusion service management of sickle-cell disease patients. Vox Sang. 2016; 110(3): 288-294.

 

October 2017

Testing the Triage Team –

The New Brunswick Experience

By: Anne Marie Robinson, Transfusion Medicine Supervisor, South East RHA, Horizons New Brunswick

February 16-19, 2016, the Provincial Emergency Blood Management Committee (PEBMC), Canadian Blood Services (CBS) and the Regional Health Authorities in New Brunswick participated in a simulation exercise to test the process in a Red Phase blood shortage. Previous exercises, both announced and unannounced, were focused on laboratory preparedness. The 2016 exercise was developed to highlight the importance of the triage team and the need for the participation of physicians, nurses and other health care professionals in managing a true shortage.

  

While there was advance notice, the actual date of the exercise was unknown to the Regional Health Authorities (RHAs). The Transfusion Medicine labs were notified by Fax and telephone call and then 2 sealed envelopes containing 10 scenarios were delivered with the CBS order that morning. We were provided with a Red phase inventory of red blood cells (RBCs) which were available to be allocated to our 10 patients.

  

The cases presented ranged from request for RBCs for chronically anaemic patient to motor vehicle crash and ruptured aortic aneurysm.

  

The triage team convened and reviewed 5 cases each day, using the guidelines in the National Emergency Blood Management Committee (NEBMC) Emergency framework for rationing of blood for massively bleeding patients during a red phase of a blood shortage – Synopsis for Triage Team to assist with allocation of red cells. The cases were reviewed one at a time and as a decision was reached, the inventory was reduced prior to review of the next case.

  

This exercise was invaluable in helping the members of our newly formed Triage team understand their roles and responsibilities.

  

  1. It brought home the reality that in a red phase shortage, there would be patients who would be denied transfusion and that those patients may not survive.
  2. It was very helpful in helping all of the members of the triage team in clarifying their roles. (Example Social workers, spiritual care, palliative care)
  3. It highlighted the physicians who were missing from our team (surgeons), liaison with ambulance services.
  4. The RHAs need to develop consistent messaging for patients affected by the shortage.
  5. Even though it was a paper exercise, it was a very emotional experience and reinforced the reality that in a severe blood shortage, we would be unable to treat our patients in the manner to which we are accustomed.
  6. Documentation of decision making is of crucial importance. A designated scribe is essential.

Our thanks to Gail Samaan, Health Care Consultant NB Department of Health and Dorothy Harris, Canadian Blood Services Hospital Liaison Specialist for development of the excellent scenarios.

  

 

Use of Irradiated Blood Components

By: Allison Collins, MD, FRCPC, Clinical Project Coordinator, Transfusion Medicine Physician, ORBCoN

Irradiated cellular blood components (red blood cells [RBCs], platelets, and granulocytes) are used for transfusion recipients at risk of transfusion-associated graft versus host disease (TA-GvHD). Immunocompetent T lymphocytes in the transfused component can attack the immune system of immunocompromised recipients, causing TA-GvHD, which is almost invariably fatal. Immunocompetent recipients can also develop TA-GvHD if transfused with HLA-similar (haploidentical or matched) components, in which case the donor blood is not recognised as foreign by the recipient, but the recipient tissues are recognised as foreign by viable donor T lymphocytes. Irradiated components are provided by Canadian Blood Services (CBS) for hospitals which do not have an on-site irradiator. Although leukoreduction appears to reduce the risk of TA-GvHD, it is not considered sufficient.

 

Bloody Easy 4, and Chapter 15 of the on-line version of the CBS Clinical Guide to Transfusion both discuss this topic, and provide lists of the type of recipients who must receive irradiated blood components1, 2. The National Advisory Committee on Blood and Blood Products (NAC) will also be publishing recommendations on the use of irradiated blood components. The draft document is available on the internet3, but watch the official NAC website for the final recommendations, due to be posted in the fall of 20174. Patients requiring irradiated components should wear an ID bracelet or carry a wallet card stating this fact.

 

Irradiated RBC components show more hemolysis than non-irradiated red cells, and contain higher concentrations of potassium. CBS and many hospitals have adopted the Council of Europe Guidelines for the use of irradiated components, which state that red cells may be irradiated up to 28 days after collection. They must then be transfused as soon as possible, but no later than 14 days after irradiation and, in any case, no later than 28 days after collection. The guideline is more strict for neonates5. Because of the lower quality of the component, irradiated RBCs should not be given to patients who do not require them.

 

What do you do if a transfusion is urgent, there is no on-site irradiator, and the delay for delivery of irradiated components is unacceptable to the ordering physician? A recent systematic review of TA-GvHD found that the storage duration of the implicated component was less than or equal to 10 days in 94% of 348 cases6. Other studies have shown that the oldest component implicated in TA-GvHD was less than or equal to 14 days old. Therefore, the use of non-irradiated components greater than 14 days old may be an alternative when irradiated blood is not available and the need for transfusion is urgent.

 

Situations Requiring Irradiated Blood Components1,2,3

  • intrauterine transfusion (IUT)
  • neonatal top-up transfusion or exchange transfusion if previous IUT
  • neonatal exchange transfusion unless transfusion would be delayed
  • neonatal top-up transfusion in neonate less than 4 months of age or less than 1200g
  • confirmed 22q11.2 deletion (Di George syndrome)
  • congenital cardiac abnormalities until 22q11.2 deletion excluded
  • congenital T-cell immunodeficiency
  • use of HLA-matched platelets
  • directed donation from first- or second-degree relatives
  • Hodgkin lymphoma
  • allogeneic and autologous hematopoietic stem cell or bone marrow recipients (see references for details)
  • current or previous therapy with purine analogues (fludarabine, cladribine, deoxycoformicin)
  • current or previous therapy with purine antagonists (bendamustine, clofarabine)
  • current or previous therapy with the potent T-cell inhibitor alemtuzumab (anti-CD52)
  • aplastic anemia treated with anti-thymocyte globulin
  • granulocyte transfusion (granulocyte concentrates are not provided by CBS but are provided by Héma-Québec)

References

  1. Callum JL et al. Bloody Easy 4: Blood Transfusions, Blood Alternatives and Transfusion Reactions, pages 70-71. Ontario Regional Blood Coordinating Network, 2016. Available at www.transfusionontario.org
  2. Clinical Guide to Transfusion, Chapter 15. Canadian Blood Services, 2017. Available at www.blood.ca
  3. National Advisory Committee on Blood and Blood Products, draft Recommendations for use of Irradiated Blood Components in Canada. Available at http://www.canadianneonatalnetwork.org/Portal/LinkClick.aspx?fileticket=itlU1wecNPw%3D&tabid=39
  4. National Advisory Committee on Blood and Blood Products www.nacblood.ca
  5. Guide to the preparation, use and quality assurance of blood components. Council of Europe, 2017, pages 188 and 274. Available at https://www.edqm.eu/en/blood-transfusion-guides-1608.html
  6. Kopolovic I et al. A systematic review of transfusion-associated graft-versus-host disease. Blood 2015;126(3):406. Available at www.bloodjournal.org

 

September 2017

Provincial Redistribution Update:

Change is afoot!

By: Tracy Cameron, Regional Project Coordinator, ORBCoN

With the growing anticipation of Canadian Blood Services (CBS) implementation of new insulated shipping containers (ICSs), Ontario hospitals are getting ready for a big change in how they ship components and products between sites as well as transport to the emergency rooms and operating suites.

  

CBS announced in early 2015 that they would be implementing new ICSs that would include a single packing configuration suitable for all seasons, allowing a greater number of products to be shipped to hospitals and eliminate the use of dry ice as a refrigerant for frozen products. But with the new ISCs comes a restriction for hospitals not to use them for redistribution or transfer of product, since the preconditioning of the plates used to maintain the temperature within the shipping container is a two stage process and requires specialized equipment. Hospitals are being asked to continue to use the J82 shipping containers to ship red blood cells (RBCs) and refrigerated blood products, as well as the E38 shipping containers to ship platelets and room temperature blood products for the purpose of redistribution, transport to other patient care areas, and for products transferred with a patient to external facilities. These containers will continue to be supplied by CBS and hospitals will be able to order them similar to placing an order for products. However the validation of these boxes will not be supported by CBS any longer.

  

What can hospitals expect for the redistribution program and transferring components and products with a patient?

  

ORBCoN has partnered with two hospitals to validate the J82 and E38 shipping containers at different temperature points that mimic possible ambient temperature conditions during transportation. The containers are being challenged at extreme warm temperatures (35 to 40°C), room temperature (19 to 25°C), mild temperatures (1 to 6°C) and extreme cold temperatures (-30 to -35°C). The data collected will determine how long the shipping containers can maintain the required acceptable temperatures for shipping components and products with a minimal payload and a maximum payload.

  

During the validation, questions arose regarding the packing configuration of the J82 containers and how hospitals currently precondition the ice packs for the container. In 2016 we asked hospitals what temperature freezer they had available and 59% of the hospitals responded saying they currently use a freezer with temperatures as cold as -40°C. Most hospitals were preconditioning freezer packs between -25 and -40°C. In a more recent survey we asked hospitals if they had access to a freezer with temperatures between -25 and -40°C and if they had room in their freezer for ice packs for preconditioning. Table 1 shows the results from the survey. The data justified keeping the packing configuration protocol to just preconditioning ice packs between -25 and -40°C and not expand the validation to include preconditioning ice packs in warmer freezers (-18 to -22°C). Hospitals wishing to participate in the redistribution program must meet the requirements of freezer temperature and size capacity to precondition ice packs.

 

The original CBS packing configuration for the J82 container required 2 ice packs to be preconditioned between -11 and -14°C for the products to maintain the required acceptable temperature for up to 24 hours. This packing configuration will be changing slightly to using only one freezer pack preconditioned between -25 and -40°C for at least 6 hours prior to use. This, along with a few other minor changes to the packing configuration, will be provided in an updated Provincial Redistribution Toolkit that is currently being revised by a provincial working group.

 

What can you expect to find in this toolkit?

 

The working group is revising operating procedure templates for the redistribution of fresh components as well as the redistribution of blood products using the J82 and E38 shipping containers. The operating procedure for the Golden Hour containers will also be updated and included. The toolkit will include a standardized inter-hospital transfer form that is to be used when redistributing any products as well as a new memorandum of understanding (MOU) for hospitals that are participating in the redistribution program. Revisions are also underway for the operating procedure template for transferring blood components and products with a patient to an external facility. A training package is being developed to help lab staff become familiar and competent with the revised redistribution process. The target date for the release of the toolkit is late October early November 2017.

  

Redistribution of frozen products may not be an option for some hospitals that do not have access to dry ice. CBS will phase out the use of dry ice to ship frozen products, and hospitals will have to use their own supply if they want to continue to redistribute frozen products. The working group recognizes this issue and ORBCoN and CBS have been notifying hospitals during site visits.

  

As always if you have any questions or concerns please contact us at info@transfusionontario.org

  

 

Blood Products and Critical Care

Transport in Ontario

By: Russell D. MacDonald, MD, MPH, FCFP, FRCPC, Ornge Transport Medicine

Ornge is the air medical and land critical care transport agency in the Province of Ontario. Using its fixed wing aircraft, helicopters, and land-based critical care transport vehicles, Ornge carries out approximately 20,000 patient transports each year, making it Canada’s largest critical care transport service. Advanced and critical care paramedics are highly skilled providers and function under a ‘delegated acts model’, under the auspices of a dedicated transport medicine physician. The paramedic scope makes it possible for them to provide care comparable to that in an intensive care unit.

 

Ornge is a key stakeholder in Ontario’s regionalized health care system, enabling patients to access specialized or tertiary care services in a timely manner. Most patient transports take place between two hospitals, referred to as ‘inter-facility’. Ornge’s helicopters also respond to ‘scene calls’, where the helicopter lands at the roadside, in a farmer’s field, or some remote location, to transport patients with acute life-threatening injury or illness directly from the scene to a hospital. For many, particularly in northern Ontario, Ornge is the only access to definitive care due to distance or lack of road access in remote communities.

 

In 2016, Ornge delivered 570 units of blood product to 335 patients. Common indications include hemorrhagic shock in trauma, post-partum hemorrhage, gastrointestinal bleeding, and hematologic malignancies. Ornge aircraft and crews do not carry blood products. Ornge acquires blood products from the sending facility, and administers them in partnership with sending facility staff. Ornge adopted Sunnybrook Health Sciences Centre’s practices for blood product administration, and modified them to meet the transport environment. All blood product administration requires an order from the Ornge transport medicine physician. The lack of blood products in many locations Ornge services poses a unique challenge to meet patient care needs. The longest transports occur in Northern Ontario, and the north accounts for a disproportionate number of calls. Many northern hospitals have limited or no blood product, and nursing stations do not have any. Each week, there are one or two patients that Ornge transports who meet indications for time-sensitive blood product administration, but no blood product is available.

 

Ornge carried out an environmental scan of Canadian critical care transport agencies to identify how they access blood products. In four provinces, transport agencies partnered with Canadian Blood Services to make blood product available at the transport agency’s bases, or accessible from a central blood bank in a timely manner.

 

Ornge’s Medical Director met with the Ontario Regional Blood Coordinating Network in June to discuss a partnership to develop an information exchange system to enhance traceability of all blood products administered by Ornge’s paramedics, and to develop ways to make blood products available at Ornge’s bases in northern Ontario. The partnership is in its infancy, with goals of meeting patient care needs and enhancing accountability for blood product used in delivery of care. For more information about Ornge or this initiative, please contact Troy Thompson (troy.thompson@sunnybrook.ca) or Dr. Russell MacDonald (rmacdonald@ornge.ca).

  

 

June 2017 Newsletter

How do we interpret the “60 minute” rule?

By: Yulia Lin, MD, FRCPC, Transfusion Medicine Specialist, Sunnybrook Health Sciences Centre

Six years ago, I wrote an article for the ORBCON newsletter entitled “How do we interpret the 30 minute rule?” The article referred to the CSA Z902-10 standard 10.10.5 (c) that states that “a blood component that has been returned to the transfusion service shall not be re-released unless a suitable temperature monitoring system indicates that the blood or the blood component has not reached an unacceptable temperature since being released or, in the absence of a temperature-monitoring system, that the blood component has not been outside of a controlled environment for more than 30 minutes (measured by occurrence, not cumulatively).” At that point, we reported on a survey of 110 Ontario hospitals (73% response rate) which showed variable interpretations of the CSA clause: 45% discarded RBC units based on time (30 minutes) alone; 13% discarded RBC units based on temperature (10oC) alone; 25% required that both time and temperature criteria were met; 13% discarded RBC units regardless of temperature or time spent outside of the blood bank. In 2009, 33 Ontario hospitals reported that they had discarded 457 RBC units for not meeting this standard.

 

I am delighted to report on the changes that have happened over the past 6 years! As a result of the impact of this standard, Dr. Sandra Ramirez-Arcos from Canadian Blood Services led multiple studies providing evidence that RBC units that have been outside of controlled temperatures for repeated exposures of 60 minutes had the same quality and were as safe from a bacterial contamination perspective as RBC units that had been outside of controlled temperatures for repeated exposures of 30 minutes1,2. The average temperature that was reached at 60 minutes was 14.2oC ± 0.2oC. Researchers, Marie Joëlle de Grandmont and Dr. Louis Thibault from Héma-Québec conducted similar studies with concordant results3. Based on these Canadian research findings, the CSA Z902-15 standards were updated from 30 minutes to 60 minutes.

 

So how do we apply this into our blood bank inventory practice? The CSA Z902-15 standard in fact does not specify that the temperature needs to be taken when a RBC unit is returned to the blood bank. Many blood banks have interpreted this clause as: if the RBC unit is returned to the blood bank from a clinical area within 60 minutes, it can be returned to inventory. A few institutions continue to measure the temperature of RBC units on return and some are mandated to if they are AABB accredited institutions. At our centre, we have instituted the following: For RBC units returned from a clinical area to the blood bank within 60 minutes, the temperature should not exceed 14oC. This reflects the data that was conducted in Canada by Ramirez-Arcos and de Grandmont1-3. The Canadian AABB-accredited institutions have also been granted a variance from the AABB standard 5.26 by the AABB Standards Program Committee.

 

Of course, the best case scenario is to avoid having RBC units returned from the ward. So as I finished off my article 6 years ago, I leave you with the same advice: we need to prevent returns of issued RBC units by making sure the patient is ready for and aware of the transfusion with the correct transfusion order, a properly completed consent and a patent intravenous line before the blood arrives on the ward. Happy SOP changing!

 

Editor’s note
Blood products such as albumin, IVIG, RHIG etc. may also be returned into usable inventory, provided that the product has not been outside of a controlled environment for more than the time recommended by the manufacturer.

 

References:

  1. Ramirez-Arcos S, Perkins H, Kou Y, Mastronardi C, Kumaran D, Taha M, Yi QL, McLaughlin N, Kahwash E, Lin Y, Acker J. Bacterial growth in red blood cell units exposed to uncontrolled temperatures: challenging the 30-minute rule. Vox Sang 2013;105: 100-7.
  2. Ramirez-Arcos S, Kou Y, Ducas E, Thibault L. Changing the 30-min Rule in Canada: The Effect of Room Temperature on Bacterial Growth in Red Blood Cells. Transfus Med Hemother 2016;43: 396-9.
  3. de Grandmont MJ, Ducas E, Girard M, Methot M, Brien M, Thibault L. Quality and safety of red blood cells stored in two additive solutions subjected to multiple room temperature exposures. Vox Sang 2014;107: 239-46.

 

Quality Indicators in the Ontario Transfusion Quality Improvement Plan: How Are You Doing?

By: Allison Collins MD FRCPC, ORBCoN Physician Clinical Coordinator

The Ontario Transfusion Quality Improvement Plan (“the OTQIP”) was introduced in April, 2016. The toolkit which accompanies the OTQIP includes a guidance document, a quality improvement plan narrative, recommendations for the use of blood components in adult inpatients, template order sets for adult inpatients, a template standard operating procedure for red cell order screening by blood bank technologists, an educational presentation about red cell order screening (including case studies), and a tracker tool to track audit results over time. The two quality indicators in the OTQIP are 1) percentage of red cell orders with a pre-transfusion hemoglobin less than 80 g/L and 2) the percentage of red cell transfusions which are single unit (one unit at a time) transfusions. The target goal for each of these indicators is 80%, based on the results of the 2013 ORBCoN Red Cell audit. For more details, including suggestions for how to do a simple audit, go to the ORBCoN website www.transfusionontario.org and click on the Quality Improvement tab.

 

As I travel around the province doing educational presentations about blood transfusion, I am asking hospitals if they are willing to share the data they have collected for the two indicators above. This a bit unscientific because hospitals may be auditing slightly different patient populations, but it may be helpful in these early days of implementing the OTQIP to show hospitals how they are doing compared to others. All data is presented without naming hospitals. The information has been of great interest to the audiences, some of whom may not be very familiar with the OTQIP or their own data. Here is what I have collected so far:
            

 

Notes to the graphs: The 2013 data in both graphs are from the 2013 ORBCoN Red Cell audit. Two hospitals are shown more than once in each graph because they have done multiple audits over time. Hospitals have data on one or the other indicator, or both. All are community hospitals except for two.

 

The graphs appear to indicate that restrictive transfusion thresholds are becoming more widely used, while the use of single unit transfusions is quite variable. The adoption of a single unit policy has actually been shown to reduce red cell utilisation more than adherence to restrictive pre-transfusion hemoglobin thresholds1.

 

All hospitals are encouraged to consider adapting the OTQIP to their own use, and/or to submit indicator data to ORBCoN using the tracker tool in the OTQIP toolkit. Then, we’ll have more robust data to show you and will be able to track overall provincial performance over time. The OTQIP could also be used to improve performance in the transfusion of other blood components, such as plasma.

 

References:

  1. Yang WW et al. Single-unit transfusions and hemoglobin trigger: relative impact on red cell utilization. Transfusion 2017;57:1163

 

What’s New from ORBCoN

ORBCoN strives to improve patient safety and standardize best practices in Transfusion Medicine by continuing to support the availability of educational resources to our Ontario stakeholders. The following new or revised resources are now available through transfusionontario.org.

An electronic tool has been developed in order to capture RBC quality improvement (QI) metrics. The QI metrics include the percentage of pre-transfusion hemoglobin <80 g/L and the percentage of single unit transfusions. This tool is available in the ORBCoN e-tools application.

ORBCoN also maintains awareness of accreditation requirements for Transfusion Medicine and monitors any potential needs that may arise and will continue to provide resources for Ontario hospitals to help meet these accreditation requirements. Bloody Easy Tech Assessments 2016 questions are now available through e-tools on transfusionontario.org.

 

New to e-tools? 
Contact your regional office to set up a site administrator.

 

Do you have a Transfusion Medicine quality improvement initiative or utilization improvement activity from your hospital that you would like featured in the ORBCoN Report? We want to hear from you, contact us at transfusionontario.org or contact your regional office.

 

May 2017 Newsletter

Educational Videoconference Symposium: Another Great Success 

By: Tracy Cameron, ORBCoN Project Coordinator, NE Ontario  
Since 2007, a partnership has existed between Canadian Blood Services (CBS) and the Ontario Regional Blood Coordinating Network (ORBCoN) to plan, co-chair, provide funding for, and execute annual transfusion medicine conferences. Each year a videoconference event is coordinated by ORBCoN and CBS, and is hosted at a community hospital. Hosting at a community hospital serves two purposes – the first is to provide the speakers with an on-site audience which helps in the delivery of the presentations; the second is to meet the objective of the event, which is to provide basic transfusion medicine education for non-transfusion specialists in community hospitals. The host site is also involved with the planning and often provides a local speaker whenever possible. This year we had two co-hosting sites, Health Sciences North and University Health Network – Toronto General. Topics are usually picked based on feedback from our community hospital partners on issues they often encounter and look for help with from larger centres, as well as suggested topics from previous year’s attendees.

This year’s conference focused on managing patients with GI bleeding and liver disease, with the objective of identifying key factors that determine the need for transfusion in community hospital emergency rooms when dealing with a GI bleed. There were four dynamic speakers that highlighted some tools to help assess the severity of the GI bleed, provided best practices for treating bleeding in patients with advanced liver disease, compared the available options for anticoagulant reversal in the GI bleed setting, and discussed strategies for improving red blood cell utilization.
 

How do we measure the success of this event?
One hundred and seven healthcare facilities joined the conference either by videoconferencing or webcasting through the Ontario Telemedicine Network. Twenty-three of those 107 sites were from out of province making this event a national one. There were also 9 Canadian Blood Services sites that attended, along with two pharmaceutical companies and 1 post-secondary institute. We believe that our high attendance rate and seeing our event uptake expand across the country is a good indication that this event is providing the necessary information for those who attend.

Who attended?
There were 1038 in attendance between the morning session and the afternoon session. The afternoon session was a repeat of the morning session and is designed to allow for flexibility in attendance due to conflicting responsibilities during working hours.

The figure below illustrates who was in attendance for this year’s event.

How did attendees evaluate the event?
96% of the attendees said they would recommend this educational event to their colleagues, and 77% indicated that after attending this event they would somewhat modify their practice behavior. Some of the comments received from attendees have included;

 

“This is a great learning experience, with wonderful speakers. I was able to come away with a better overall picture as to the care and decisions towards a patient.” 
“Very good topics, I believed they covered everything and it was really interesting”
“I liked that you had the two sessions, very helpful for staff that were on the job”


If you missed the presentations, you can access them via archive through the ORBCoN website on our webcasting centre and they will be available for one year. The PowerPoint presentations are also available on our “What’s New” on our main page and also in our presentation library under the ORBCoN Resources page.
 
If you have any suggestions for future topics that you would like to see covered by this event please send them to info@transfusionontario.org

 

Informed Consent for Transfusion

By: Dr. Allison Collins 
Transfusion of blood components and blood products may be life-saving, but is not without risk. As with other medical treatments, informed consent is required for blood transfusion. Justice Horace Krever, in his report on the blood system in Canada, defined the requirements for informed consent as follows:

  1. that the treating physician obtain informed consent from the patient, barring incompetency or an emergency procedure,
  2. that risks, benefits, and alternatives be presented in language the patient will understand and in a manner that permits questions, repetitions, and sufficient time for assimilation,
  3. that the discussion take place well in advance of the therapy to enable the patient to employ alternatives to allogeneic blood transfusion and,
  4. that the treating physician document in the patient’s chart that the risks, benefits, and alternatives to blood transfusion have been discussed (1). According to the Canadian Standards Association, transfusion services must have policies in place to ensure that informed consent is obtained before transfusion (2).

The Canadian Society for Transfusion Medicine has published recommendations to facilitate the process of informed consent to transfusion (3). These include providing prescribing physicians with up to date information about the risks, benefits, and alternatives to transfusion, providing orientation and ongoing education for physicians and other health care providers involved in the transfusion process, and auditing compliance with the informed consent process. Compliance with the informed consent process of less than 90% should prompt action to improve it.
 
The Canadian Medical Protective Association (CMPA) states that the obligation to obtain informed consent rests with the physician who orders the treatment (4). It also recommends that, even when patients waive aside all explanations or seem to be prepared to undergo a procedure or treatment without discussion, it should be explained that the risks should still be discussed. Print material, videos, and other handouts all support the consent discussion but do not replace it (5).
 
Nurses are important members of the health care team, but are not responsible for obtaining informed consent for transfusion. They will, however, explain the transfusion process to the patient and determine if informed consent has been obtained. The College of Nurses of Ontario Practice Guideline states that a nurse should not provide a treatment if there is any doubt about whether the patient understands and is capable of consenting to the treatment, even if there is an order (6).
 
The Ontario Regional Blood Coordinating Network (ORBCoN) provides lanyard cards summarizing the elements of informed consent and the risks of transfusion. Additional information is available in the ORBCoN publication “Bloody Easy 4”. Both can be ordered from ORBCoN if the transfusion medicine laboratory does not already have them on site (7).

References

  1. Krever, H. Commission of Inquiry in the Blood System in Canada, final report, Appendix H. Government of Canada publications. 1997
  2. CSA Standard Z902-15. Blood and Blood Components, clause 11.2.1. Canadian Standards Association 2015.
  3. Informed Consent – Position Paper. Canadian Society for Blood Transfusion 2012.
  4. Evans KG. Consent: A guide for Canadian physicians, fourth edition. Canadian Medical Protective Association May 2006, updated June 2016. Available at www.cmpa-acpm.ca
  5. Canadian Medical Protective Association Risk Fact Sheet Informed Consent 2016.
  6. Consent Practice Guideline. College of Nurses of Ontario 2017.
  7. Ontario Regional Blood Coordinating Network www.transfusionontario.org

 

 

 

 

April 2017 Newsletter


Transfusion Quality Improvement:
One Hospital’s Story 

By: Krista Walters, Charge Technologist, Mary Green, Laboratory Manager Niagara Health System (NHS) and Denise Evanovitch, ORBCoN Regional Manager, SW Ontario  

Niagara Health System (NHS) consists of five community hospitals: Douglas Memorial in Fort Erie, Greater Niagara General in Niagara Falls, Port Colborne, St. Catharines and Welland. NHS also provides Transfusion services to Hotel Dieu Shaver Rehabilitation Hospital.

  

Like other hospital transfusion services, NHS is continually looking to improve quality and safety in many areas, including transfusion. We have looked to ORBCoN and the Ontario Transfusion Quality Improvement Plan (OTQIP) for guidance, and actually, NHS was one of the hospitals that piloted the e-tool designed to collect and analyze the relevant quality improvement data.

 

Our successes to date include:

  1. An audit of all blood components to establish a baseline of appropriateness.
  2. Utilization guidelines for blood components and accompanying order set which was approved and deemed mandatory for use on February 9, 2017 by the Order Set Committee. This committee acts on behalf of the MAC on specific issues. The Chair of Order Set Committee, a physician, supports the use of order sets and regular auditing to gauge compliance. Follow up and discussions will occur with physicians and departments when components orders fall outside of the hospital’s guidelines.
  3. The % single unit RBC transfusions (ordered and transfused) rate is now a Corporate Quality and LHIN wide Indicator. We found this raised profile of TM issues within the corporation and we are hopeful that it will assist with physician buy in.

  
For the future, we will be:

  1. Auditing compliance post implementation of order set
  2. Implementing reflex laboratory tests once components are ordered for post transfusion testing. E.g. CBC post RBC and platelet transfusion, fibrinogen level after cryoprecipitate, etc.
  3. Auditing compliance after implementation of reflex orders.
  4. Ongoing audits to monitor progress.

   
Like all hospitals, we are not without challenges. MLTs who are core trained rotate through all departments and may only be scheduled in TM a few days a month. We ensure quality by constantly monitoring our key indicators, ensure our yearly competencies are completed and up to date and have excellent communication to keep staff informed.

  

Although staff may not feel comfortable screening transfusion orders and providing feedback to physicians, we encourage them to discuss unusual orders with the physician. Although we do not have a transfusion safety officer we connect with other hospitals within our network and work closely within our team to bring quality improvement initiatives forward and strive to encourage appropriate blood orders. We will be reporting our successes and opportunities for improvement to ORBCoN via their e-tool found on their website. We encourage all Ontario hospitals to do the same.


Archived Webcast Now Available!


The Ontario Regional Blood Coordinating Network (ORBCoN): Looking Back on 10 years of Collaboration and Networking

By: ORBCoN 
Just like in the word team, there is also no “I” in ORBCoN—although we do know individuals who pronounce it as such! In other words, the quality and volume of work that ORBCoN produces could not be accomplished without the collaboration and dedicated volunteerism of the entire “network” of transfusion stakeholders (regionally, provincially and nationally). This includes the continued support of the Ministry of Health and Long-Term Care.

  

In 2006, the three ORBCoN offices were born:

  • The Northern and Eastern Office housed at The Ottawa Hospital
  • The Central Office located at Sunnybrook Health Sciences Centre
  • The Southwest Office situated at McMaster University

  
ORBCoN’s mission, vision and values were established in a strategic planning session in 2007. Our five goals evolved from this strategy: 
   
Figure 1 ORBCoN Goals

  

For utilization improvement, ORBCoN has continually supported the proof of concept for a provincial data strategy, conducted and produced many audits and audit tools for utilization of FP, IVIG, RBC and platelets and of bedside administration of blood and specimen collection. Recommendations and guidelines for utilization and administration of these blood components/products encourage standardized progress towards best practice for appropriate and safe transfusion.

   

The educational tools and toolkits ORBCoN has produced over the past decade are numerous and support a wide variety of health professionals, patients and their families. We are particularly well known for our Bloody Easy series and the numerous provincial educational events we plan and host.

   

Following the use of inventory calculators and benchmarking and the implementation of a provincial redistribution network, hospital RBC outdate rates in Ontario have been greatly improved over the past 10 years (see figure 2).

  

Figure 2 RBC Outdate Rates in Ontario Hospitals

  

The Ontario Contingency Plan for Blood Shortages first released in 2008, helped to ensure that Ontario hospitals developed a standardized approach to blood shortage management that aligns with the National Emergency Blood Management Plan. Testing the Ontario plan through blood shortage simulation exercises helps to continually update and improve hospital plans on a provincial level.

  

For communication, ORBCoN is fortunate to have the ability to meet with our hospitals in partnership with colleagues at Canadian Blood Services (CBS) on an annual basis at our joint CBS-ORBCoN site visits. Over the past 10 years, we have built relationships with our hospital partners and developed a network that crosses regional boundaries and helps to continually improve the quality of our transfusion medicine community. Our website is a helpful communication resource that is used widely and frequently along with our regular newsletter, The ORBCoN Report. We also regularly meet with hospital peer/networking groups, our Regional Advisory, Steering and Ontario Blood Advisory Committees to stay tuned in to the current issues and challenges we face in transfusion medicine in Ontario.

  

Although quality is our foundational cornerstone, we also have initiatives contained within this goal such as our Ontario Transfusion Quality Improvement Plan and specific educators for our hospitals’ nurses and physicians.

  

In addition to partnering with CBS and hospitals, ORBCoN also forges relationships with our sister blood programs like the Ontario Transfusion Transmitted Injuries Surveillance System (ON-TTISS), Factor Concentrate Redistribution Program (FCRP) and Ontario Transfusion Coordinators (ONTraC) making us truly a provincial transfusion network.

  

Over the past decade, ORBCoN has evolved into a robust network that provides support through communication, education and networking to hospital transfusion services in the province of Ontario. We act to connect the Ministry of Health and Long-Term Care with the transfusion medicine community by identifying issues, advocating for hospital transfusion laboratories and by developing supporting resources to ensure Ontario transfusion services are complying with current standards, encouraging best practices and minimizing waste to ultimately ensure the best possible care for all patients in the province with respect to blood transfusion.


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March 2017 Newsletter


March Newsletter

The ORBCoN Report Newsletter:
Introduction to New Format 

By: Denise Evanovitch, ORBCoN Regional Manager, SW Ontario
As the world of technology evolves, ORBCoN endeavours to change with it. In the early days of ORBCoN, we issued a paper-based newsletter twice a year (The ORBCoN Report) and shipped paper copies to each of our 158 Ontario hospitals with transfusion services.

  

Later, we heard from some of our hospital contacts and our Steering Committee that we should consider being less paper based, and focus more on electronic technology. The reasons were two-fold: environmental reasons (less paper and a reduction in our carbon footprint) and many customers actually prefer an electronic format. A hospital survey demonstrated that there were no strong objections to this new format, so ORBCoN began issuing their newsletter electronically twice a year.

  

In today’s world, the rapid rate of change and the need to provide more timely information continues to accelerate. In order to meet this need and be flexible in sharing information with our hospitals, ORBCoN’s newsletter format is evolving once again. We will be issuing short articles on a monthly basis. The name of our newsletter remains the same and you can locate it on www.transfusionontario.org.

  

If you do not wish to subscribe, please select 'unsubscribe from this list' at the bottom of this newsletter. You will still be able to access our newsletter on our website even if you do not receive our reminders.

  

If there are topics of interest you would like to hear more about, feel free to contact your local ORBCoN office by email or telephone.

  
We hope you enjoy our more timely delivery of the most current transfusion information.


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Taking Stock: Platelets, Plugs and Pods

By: Lisa Mantifel, ORBCoN NE
Platelets are an important component of blood that help with clotting and deserve special attention. In healthy people platelets circulate and are also stored in organs such as the spleen for bleeding emergencies. Patients who experience prolonged bleeding or platelet destruction may require large quantities of platelets. Platelets can be challenging to manage due to the short shelf life and being stored at room temperature.  

  

The ORBCoN Provincial Platelet Audit project is a key activity of the provincial blood utilization strategy to improve blood management. ORBCoN launched the audit on January 9th of this year and it will run until April 7th, 2017. A web-based audit tool has been created to capture the data of the audit results by hospital sites. If your site is a part of this audit, then congratulations are in order! You are moving Ontario forward in the management of a critical blood component that is often in short supply. The goal of this audit and subsequent data analysis is to create a strategy for Ontario to ensure patients have access to platelets when they need them and that they are only transfused when appropriate.

  

The International Collaboration for Transfusion Medicine Guidelines (ICTMG) has posted a three-part podcast series titled “Platelets Unplugged: The Sticky Truth”.  The series covers the introduction of two new platelet transfusion guidelines recently published by the AABB (formerly American Association of Blood Banks) and the ICTMG. The podcast series can be accessed through the ORBCoN website in a recently added section called “Interesting Podcasts”. You can access this section under the ORBCoN Resources tab at http://transfusionontario.org/en/documents/?cat=interesting-podcasts to listen in and hear more about platelets! 


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