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.

 

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