March 2020

Measles post exposure prophylaxis (PEP): IVIG versus other IG products. Which one should we use?

Authors: Dr. Juthaporn Cowan and Dr. Bill Cameron, Infectious Diseases, The Ottawa Hospital


Measles cases occur sporadically throughout Canada. Post exposure prophylactic (PEP) treatment with immunoglobulin (IG) offers protection to susceptible individuals if IG is given within an appropriate time frame. Due to changing knowledge of IG products and formulations, and changing recommendations, there has been some confusion regarding which IG products can and should be used.


Anti-measles antibody levels in IG products have been declining over the years, due to control of natural measles infection and declining re-exposure in the plasma donor pool. IG PEP is a passive immunization with the expectation that there is an adequate anti-measles antibody level in the IG products to ensure a protective trough level of neutralising antibody in recipient serum above 120 mIU (or 0.12 IU) /mL. It is reassuring that all IG preparations have to meet a regulatory standard requirement of anti-measles antibodies of 25 IU/mL minimum concentration, which is enough to deliver a trough titre well above the protective level.


GamaSTAN S/D, which is an intramuscular (IM) formulation, has long been recommended for measles and hepatitis A PEP. However, this product can only be given at a small volume not exceeding 15 mL. Provided that the recommended dosage is 0.5 mL/kg, an individual whose weight is greater than 30 kg may not get adequate protection due to the limited maximum dose. Intravenous formulation of IG such as Gammunex, IGIVnex, Gammagard, and Privigen can be given without a low maximum dosage, therefore, it can provide better seroprotection to individuals who weigh greater than 30 kg. For this reason, IVIG at 400 mg/kg is now recommended for use in measles outbreak or exposure situations. The downside of IVIG is a need for an active monitoring over several hours of infusion by trained personnel.  Currently, subcutaneous formulations such as Hizentra, Cuvitru or Cutaquig have not been evaluated for measles PEP.


Take home messages:

Both IM and IV formulations of IG products can be used for measles PEP
IMIG may not provide full protection to susceptible individuals who weigh greater than 30 kg
IVIG is preferred in susceptible individuals who weigh ³ 30 kg


Tunis MC, Salvadori MI, Dubey V, Baclic O. Updated NACI recommendations for measles post-exposure prophylaxis. Can Commun Dis Rep 2018;44(9):226-30.


Vandeberg P et al., Measles antibody trough levels after treatment with immunoglobulin products and predicted levels assuming lower measles antibody specifications.  TRANSFUSION Volume 58, p 3072, December 2018



High-dose intravenous immunoglobulin (IVIG) for treatment of heparin-induced thrombocytopenia (HIT)

Author: Theodore (Ted) E. Warkentin, MD


Professor, Dept. of Pathology and Molecular Medicine, and Dept of Medicine, McMaster University; Regional Director, Transfusion Medicine, Hamilton Regional Laboratory Medicine Program; Hematologist, Service of Clinical Hematologist, Hamilton General Hospital; Core Member, McMaster Centre for Transfusion Research, Hamilton, Ontario, Canada.


Heparin-induced thrombocytopenia (HIT) is an immune-mediated prothrombotic drug reaction that is usually triggered by exposure to heparin, either unfractionated or low-molecular-weight. HIT pathogenesis is driven by antibodies that target a cationic platelet-derived protein, platelet factor 4 (PF4), when it forms multimolecular complexes with (polyanionic) heparin. The pathogenic antibodies, which are predominantly of immunoglobulin G (IgG) class, produce strong platelet activation by forming PF4/heparin/IgG immune complexes that cross-link platelet surface IgG Fc receptors. HIT is one of the most prothrombotic disorders in medicine: affected patients have approximately 15-fold greater risk of thrombosis than expected for the clinical situation. Moreover, patients often develop unusually severe thrombotic events (e.g., limb loss secondary to limb artery thrombosis or venous limb gangrene; thrombotic stroke; adrenal necrosis secondary to adrenal vein thrombosis).


HIT has traditionally been viewed as a disorder of heparin-dependent platelet-activating antibodies. However, there is growing recognition of an important subset of HIT—recently named autoimmune HIT (aHIT)—in which the patient’s HIT antibodies cause both heparin-dependent and heparin-independent platelet activation. Clinical correlates of aHIT antibodies include: delayed-onset HIT (thrombocytopenia that begins or worsens after stopping heparin); persisting (refractory) HIT (thrombocytopenia that continues for >1 week after stopping heparin); heparin “flush” HIT (HIT triggered by exposure to small amounts of heparin); and “spontaneous HIT syndrome” (a disorder clinically and serologically indistinguishable from HIT but where there is no plausible preceding exposure to heparin). Further, most patients with severe HIT (platelet count <20 × 109/L with overt disseminated intravascular coagulation; HIT with multiple venous and arterial thromboses) have associated aHIT antibodies.


Treatment of HIT has traditionally focused on timely discontinuation of heparin plus initiation of an alternative non-heparin anticoagulant, such as a factor Xa inhibitor (danaparoid, fondaparinux, rivaroxaban, apixaban) or a direct thrombin inhibitor (argatroban, bivalirudin, dabigatran). A novel and increasingly utilized treatment adjunct is administration of high-dose intravenous immunoglobulin (IVIG), most often dosed as 2 g/kg (usually given as 1g/kg over 2 consecutive days). The biological rationale is dose-dependent inhibition by IVIG of HIT antibody-induced platelet activation through platelet Fc receptor blockade. A recent narrative review (Warkentin TE. Exp Rev Hematol 2019;12:685-698) of 36 HIT patients treated with high-dose IVIG concluded that most patients developed rapid platelet count recovery, without a prothrombotic signal.


Given that HIT is highly prothrombotic and that IVIG itself can trigger thrombotic events, the apparent low frequency of thrombosis in IVIG-treated HIT patients is consistent with the hypothesis that high-dose IVIG helps to rapidly deescalate HIT hypercoagulability, thus reducing subsequent risk of thrombosis and related sequelae. Moreover, in vitro data indicate that high-dose IVIG is especially effective at inhibiting heparin-independent platelet activation by HIT antibodies, suggesting that this novel treatment should be considered in patients whose clinical picture suggests an aHIT syndrome.


Ontario Transfusion Quality Improvement Plan Outline Red Blood Cell Utilization Results at Cornwall Community Hospital

Author: Patty Hebert, Eastern Ontario Regional Laboratory Association (EORLA), Interim Laboratory Manager, Queensway-Carleton Hospital


In 2018, Cornwall Community Hospital (CCH) initiated an improvement plan for RBC utilization.  A baseline retrospective audit of RBC utilization was performed using the Ontario Transfusion Quality Improvement Plan (OTQIP) Guidance Document for Institutional Implementation. The data from the audit was used to compare how the current hospital transfusion practices aligned with the recommended Choosing Wisely Recommendations and to assess any inappropriate transfusions.


Fifty consecutive transfusion orders were audited during the months of February and March 2018. Surgical patients, outpatient transfusion clinics, and any bleeding patients were excluded from the audit. A total of 91 RBC units were transfused to the 50 patients. Forty-three of fifty or 86% had a pre-transfusion hemoglobin of less than 80 g/L and 15 or 30% out of these total transfusions were single unit transfusions.  Forty-six RBCs or 51% of these units transfused could have potentially been saved. The transfusion target of 80% for patients with a pre-transfusion hemoglobin of less than 80 g/L was being met but the target of 80% being single unit transfusions was not. The data highlighted the need to improve on single unit transfusions.


Another retrospective audit of 50 consecutive transfusion orders during February and March 2019 was performed following the same criteria.  A total of 86 RBC units were transfused to the 50 patients. Forty-seven of fifty (94%) had a pre-transfusion hemoglobin of less than 80 g/L and 18/50 or 36% were single unit transfusions.


Dr Scharf, Chief of Staff at CCH initiated a Quality Improvement Plan (QIP) in 2019 for CCH using the Choosing Wisely Recommendations to reduce unnecessary patient testing, treatment and procedures to ultimately improve patient care. The QIP included the recommended transfusion medicine guidelines for transfusing single units and for transfusing patients with a pre-transfusion hemoglobin less than 80 g/L. A goal of a 10% increase in single unit transfusions per year was set until reaching the target of 80%. In order to improve the rate of single unit transfusions, it was agreed with Dr Scharf to screen all RBC transfusion orders received in the Transfusion Medicine department for multiple unit requests. Dr. Giulivi, EORLA Hematopathologist for CCH, guided and aided the transfusion lab MLTs with the screening process. The screening excluded bleeding patients, outpatient clinics and surgical units. Mohammed Sheheen, CIO of CCH, would also be implementing changes in the LIS to reflect the Choosing Wisely Recommendations for transfusions, to aid physicians when placing a transfusion order.


The physicians at CCH were informed by Dr. Scharf about the transfusion QIP project and the screening began on the 1st of June 2019.  A mini audit to track progress was performed for RBC transfusions during September 2019.  Thirty-one of 37 (31/37) or 84% of the transfusions were single unit transfusions, exceeding the expectations and the target. A further audit will be performed for 50 transfusion orders in February and March 2020 to determine if the improvement to the use of single unit RBC transfusions has been sustained.


February 2020

Choosing Wisely at Georgian Bay General Hospital

Author: Jessie Clelland, MLT, CQM

Charge Technologist/Quality Leader, Georgian Bay General Hospital Laboratory


Georgian Bay General Hospital (GBGH) enrolled in the Choosing Wisely program to take a second look at overuse in testing, as 30% of tests and treatments have been deemed unnecessary (according to a 2017 report Choosing Wisely also provides our hospital with an opportunity to pause, question long-standing practices and take a leadership role in making the necessary changes for improving quality and safety, which in many cases, can also reduce costs.


We launched Phase 1 of the program on July 2, 2019 and it included “5 Quick Wins” which were successfully implemented:


  1. Uncoupling PT/INR and aPTT tests and revising the Emergency Department order sets
  2. Using troponin instead of CK, as it has greater specificity and sensitivity
  3. Removing “Daily lab” options from order sets
  4. Removing folate testing from our ordering systems
  5. Stop ordering of routine chest X-rays in the ICU, except to answer specific clinical questions

In October of 2019, only a short three months after the implementation of Phase 1, GBGH was deemed a Choosing Wisely Level 1 hospital. We have seen a reduction in CK testing by 84% and a reduction in aPTT testing by 87%.


It is anticipated our Phase 2 implementation will take place over the next 6-12 months. In preparation, we will be reviewing data throughout the hospital to determine where further improvements can be made. One opportunity on our radar is Transfusion Medicine and unnecessary transfusions. Over the next few months, we will be gathering data to look at our current transfusion state and determine areas where we can improve. Some of the data to be reviewed will include:


  1. Hemoglobin level prior to transfusion
  2. Diagnosis/ reason for transfusion
  3. Hemoglobin level after transfusion of one unit of packed RBC
  4. Hemoglobin level after transfusion of a second unit of packed RBC
  5. Platelet counts in patients prior to receiving a transfusion of platelets
  6. The number of Type and Screens performed unnecessarily due to panels used in the Emergency Department

From this data, GBGH will look to answer the following questions:


  1. Was the transfusion necessary?
  2. Was the patient transfused more than one unit of blood?
  3. If so, was the hemoglobin checked prior to the transfusion of each additional unit?
  4. Are platelets being transfused appropriately?
  5. Are we properly using our Emergency Department panels?

From the data gathered, we will also look at the percent of transfusions with a pre-transfusion hemoglobin less than 80 g/L and the percent of single unit red blood cell transfusions.
Once we fully understand our current state, we will explore if we should implement the following initiatives:


  1. Prospective MLT screening.
  2. Why give two when one will do?
  3. Education surrounding the proper use of panels in the Emergency Department.

In conclusion, Choosing Wisely has helped to improve the quality and safety for patients and employees at GBGH. After seeing the positive impact that Choosing Wisely has had with Phase 1, we will be moving towards Phase 2 with confidence knowing that more improvements are on their way.



Vanessa’s Law: New mandatory Health Canada reporting requirements for hospitals

Author: Amanda Pape, BHA, BSc, MLT

Charge Technologist | Team Leader Transfusion Medicine and Hematology

Halton Healthcare, Oakville, ON


Adverse drug reactions are one of Canada’s most serious and under-reported causes of health problemsThe introduction of Vanessa’s Law, Bill C-17: Protecting Canadians from Unsafe Drugs Act, which came into effect on December 16, 2019, is the first amendment to the Food and Drugs Act in 50 years. Aimed at strengthening the safety of therapeutic products and its regulation, Vanessa’s Law will require hospitals to provide Health Canada with a report of a serious adverse drug reaction (ADR) or medical device incident (MDI) within 30 days of its documentation within their institution. Named after Vanessa Young, a 15-year-old girl from Oakville, Ontario, who died in March 2000 of a heart attack after taking cisapride as prescribed; a prescription drug known to have serious side effects causing death and later removed from the US and Canadian markets by May 2000. 


 The intent of Vanessa’s Law is to: 

  • increase the quantity of reporting of serious ADRs and MDIs; 
  • improve the quality of these reports; 
  • support Health Canada’s ability to take action when a serious risk to health is identified.

What does Vanessa’s Law mean for hospitals and healthcare professionals? 


All hospitals are required to report serious ADRs and MDIs to Health Canada. Healthcare professionals play an important role in recognizing and documenting serious ADRs and MDIs, however, it is the hospital that is responsible for: 

  • determining clear roles and responsibilities for its employees; 
  • developing and maintaining policies and procedures for reporting; 
  • identifying reportable events; 
  • reporting ADRs and MDIs in a timely fashion; 
  • developing and complying with follow-up requests from Health Canada; and
  • providing training to employees on compliance with mandatory reporting.

What does Vanessa’s Law mean for Transfusion and Diagnostic Laboratory Services? 


Vanessa’s Law does impact the reporting of serious ADRs, or cluster of minor ADRs, due to fractionated blood products (e.g. factor VIII concentrate) and plasma proteins (e.g. albumin) as stated under the Biologic Drugs section of the Act. In addition, hospitals are required to report MDIs due to medical laboratory diagnostic instruments, test kits for diagnosis, and tubing as stated under the Medical Devices section. It is the responsibility of the hospital to report these types of ADRs and MDIs to the manufacturer and Health Canada. 


Vanessa’s Law does not change how hospitals currently report adverse recipient reactions (ARRs) due to blood and blood components. Mandatory reporting of ARRs related to the safety or quality of blood and blood components is mandated under Blood Regulations (pursuant to Section 30 of the Food and Drugs Act). The process for reporting remains the same and Transfusion Services should continue to report these ARRs as usual. 


For a complete list of therapeutic products included and excluded from the mandatory reporting requirements under Vanessa’s Law, see Table 1 and 2. For a summary of required documentation and who to report to, see Table 3. 


 All therapeutic products have benefits and risks. Even though these products are carefully evaluated before they are licensed in Canada, ADRs and MDIs may become evident after a product is in use by consumers. Complying with the mandatory reporting requirements of Vanessa’s Law, shows a shared commitment to product safety among all healthcare professionals and manufacturers.


 Submitting ADR and MDI Reports to Health Canada 


 There are three ways to submit a report of an ADR or MDI to Health Canada. 

 1. Fax or Mail

  • Fillable PDF documents are available for download from Health Canada (see Resources below for direct links). 
  • Download the applicable PDF form. 
  • Complete all the required information and print the form. 
  • Fax or email the completed form to Health Canada. A fax number and mailing address are located on each form.

 2. Online

  • A fillable form is available at 
  • Click on ‘Report an adverse reaction or side effect’ and follow the prompts. 
  • Complete all the required information and click ‘Submit’. 

 3. Electronic Secure File Transfer Protocol (sFTP) 

  • A system-to-system exchange of data from the hospital’s information system to Health Canada. 
  • To setup an account, contact the Canada Vigilance Program at 


Table 1: Therapeutic products subject to the mandatory reporting requirements for hospitals under Vanessa’s Law

Table 2: Therapeutic products not subject to the mandatory reporting requirements for hospitals under Vanessa’s Law

Table 3: Summary of applicable forms and where to report (CBS=Canadian Blood Services, CTAERF=Canadian Transfusion Adverse Event Reporting Form, TTISS-ON=Ontario Transfusion Transmitted Injuries Surveillance System)



Health Canada, 2019. Guidance Document – Mandatory reporting of serious adverse drug reactions and medical device incidents by hospitals


Serious Adverse Drug Reaction Reporting Form for Hospitals


Medical Device Problem Report Form for Health Care Professionals


Canadian Patient Safety Institute – Educational Support Materials


For questions related to mandatory reporting for hospitals, contact the Canada Vigilance Program:

To enroll in the TTISS-ON database for reporting ARRs, complete the contact information form here:


Survey Results of Quality Improvement Initiatives in Transfusion Medicine

Author: Troy Thompson MLT, BAHSc (Hons)

Regional Manager, ORBCoN CE Region


The Ontario Transfusion Quality Improvement Plan (OTQIP) was developed in order to help hospitals reduce inappropriate red cell transfusions. In a recent audit in Ontario, approximately 25% of RBC units transfused were deemed inappropriate1. Similar findings have been demonstrated worldwide.


In order to improve appropriate red cell utilization, the OTQIP was developed in collaboration with the Choosing Wisely Canada campaign to support quality improvement initiatives at Ontario hospitals.


To assess uptake of various quality improvement initiatives in Transfusion Medicine, a recent survey was sent to Ontario hospitals. This article will highlight the results of the 2019 survey and the expansion of quality improvement initiatives in relation to blood product utilization in Ontario.


For the 2019 survey a total of 56 responses were received representing 76 hospital sites. The following results highlight the 2019 survey questions and the associated results.


Are you interested in adopting the OTQIP?

The OTQIP adoption rate was 91% for those hospitals that responded to the survey; 37% of respondents have already adopted the OTQIP and 54% of respondents are planning to adopt the OTQIP.


For those that have adopted or are planning to adopt the OTQIP, the results below highlight which aspects of the QIP have been or will be adopted.


Which part(s) of the OTQIP are being implemented?

Are you entering your data into the ORBCoN RBC eTracker tool? (Pre-transfusion hemoglobin <80 g/L and single unit transfusions)?


33% of respondents who have adopted the OTQIP are entering their data into the eTracker tool and 33% of respondents who will be adopting the OTQIP are planning to enter their data into the eTracker tool in the future.


Results of Audits entered into the ORBCoN eTracker tool (31 hospital sites)

Of the sites currently entering data into the eTracker tool, the average for all repeat audits for pre-transfusion Hb<80 g/L and single unit transfusions was 75% and 56% respectively.


Baseline audit results for pre-transfusion Hb levels <80 g/L were similar to repeat or subsequent audit results (74% vs 75%), highlighting the fact that clinicians at most sites have a good grasp of pretransfusion hemoglobin trigger levels. Baseline audits for single unit transfusions averaged 41% and on repeat 56% which represented a 37% increase in single unit transfusions over baseline.


Hospitals continue to promote quality improvement initiatives to increase appropriate blood utilization. However, some survey respondents have acknowledged that site specific barriers have limited the uptake of quality improvement initiatives for blood utilization. These include staffing levels and limited opportunities for physician education. Liberal blood transfusions have been associated with worse patient outcomes2-4 and blood products are in finite supply. Improving appropriate utilization will help to reduce adverse reactions and ensure that blood products are available to those patients who truly need them.



1. Spradbrow J, Cohen R, Lin Y, et al. Evaluating appropriate red blood cell transfusions: a

quality audit at 10 Ontario hospitals to determine the optimal measure for assessing

appropriateness. Transfusion. 2016 Jul 27.

2. Vincent JL, Baron JF, Reinhart K, et al. Anemia and blood transfusion in critically ill

patients. JAMA. 2002 Sept 25; 288(12):1499-507.

3. Corwin HL, Gettinger A, Pearl RG, et al. The CRIT study: anemia and blood transfusion

in the critically ill-current clinical practice in the United States. Crit Care Med. 2004


4. Goodnough LT, Maggio P, Hadhazy E, et al. Restrictive blood transfusion practices are

associated with improved patient outcomes. Transfusion. 2014 Oct;54(10 pt 2): 2753-9.


January 2020

An Update: Transfusion Transmitted Injuries Surveillance System

Author: Joanne Duncan, MSc, CCRP, HRM, TTISS- ON Coordinator


Transfusion Transmitted Injuries Surveillance System (TTISS) is a national hemovigilance system implemented by the Public Health Agency of Canada (PHAC) to report moderate to severe adverse transfusion events (ATEs) related to blood components and plasma derivatives. The Ministry of Health (MOH) in Ontario and the PHAC contracts the McMaster Centre for Transfusion Research at McMaster University to coordinate the TTISS activities in the Province of Ontario.  


The program is designed to capture ATEs related to all blood products comprised of blood components (red cells, plasma, platelets, cryoprecipitate) and plasma derivatives (immunoglobulin preparations, coagulation factors, and albumin).    


In Ontario, there are 159 hospitals that transfuse blood products. All TTISS participating hospitals submit reportable ATEs (moderate to severe). There were 1,234 reportable ATEs collected 2014-2018.

These reportable ATEs account for 20% of all ATEs in Ontario.  The other 80% consist of minor reactions (non-reportable to PHAC).  A subgroup of 28 hospitals, referred to as sentinel sites, report the non-reportable, minor ATEs (minor allergic, delayed serological and febrile non-hemolytic reactions) to Ontario TTISS.   

These sentinel sites reported 43.6% of all the ATEs and 1,982 non-reportable ATEs.    


Since Ontario TTISS obtains denominator data for blood components, comprehensive reporting by sentinel sites allows risk calculation for ATEs as a result of transfusions with blood components. 


 Red blood cells were implicated in 632 (72.2%) of the reactions to blood components.  ATEs associated with plasma derivatives were most frequently reported with IVIG (308; 87.5%). 


Overall, 590 (47.8%) of the 1,234 reportable ATEs were severe or life threatening; 462 (78.3%) were related to blood components and 121 (20.5%) were related to plasma derivatives. Fifty-six deaths were reported, of which 24 were related to transfusion. Twenty-one of these deaths were associated with blood components, 3 with plasma derivatives.  For more information please see our full 5 year report (2014-2020)  posted on the Ontario TTISS website under transfusion data. 


NEW Reporting requirements as of December 16, 2019: The impact of Vanessa’s Law, will not affect the regulatory requirements with respect to reporting ATEs from blood components. For plasma derivatives (plasma protein products) it is now mandatory to report serious reactions directly to the Canada Vigilance Program at Health Canada. For full details and rationale see the NEW Ontario Guide to Reporting Transfusions Reactions on the TTISS website located under resources or click here for more information.

Patient Blood Management

Authors: John Freedman, ONTraC Program Director and Alanna Howell RN, ONTraC Program Manager


In recent years we have seen the development of Patient Blood Management (PBM) programs. Ontario has been an early implementer and leader in the field. PBM is now seen as an international initiative in best practice as it is associated with appropriate transfusion practice as well as improving patient outcomes and reducing healthcare costs.


Patient Blood Management is “the timely application of evidence-based medical and surgical concepts designed to maintain hemoglobin concentration, optimize hemostasis and minimize blood loss in an effort to improve patient outcome”. The definition presented by the Society for the Advancement of Blood Management (SABM), as well as several other definitions of PBM, have moved away from placing the focus on reducing the use of blood components to the development of a multidisciplinary and multimodal strategy centered on patients’ outcome. Reducing transfusions might be a means, but it is certainly not an end. Thus, PBM has moved from a product-centered approach to a patient-centered approach.


Based on a growing body of evidence published over the years, clinicians have learnt to use the therapeutic options presented in the three pillars of PBM: optimizing hematopoiesis, minimizing bleeding and blood loss, and harnessing and optimizing physiological tolerance of anemia while it is treated appropriately. This has resulted in a tailored approach toward the clinical use of blood components, a limited resource that should be reserved for those patients who really need them. Using this strategy, the harms associated with inappropriate transfusions is avoided. Several clinical societies and scientific associations have published guidelines on the performance and content of PBM bundles for different populations of patients, such as those published by NATA, the Network for the Advancement of Transfusion Alternatives, for PBM, hemostasis and thrombosis in pediatric, cardiac surgery and obstetrics.


ONTraC (Ontario Transfusion Coordinators), the Ontario provincial patient blood management program, was established in 2002 with the support of the Ministry of Health. It is a network of nurse coordinators in 25 hospitals across the province, who are responsible for implementing and managing PBM programs within their institutions. The program focuses on joint replacement surgery, cardiac surgery and gynecological surgery, but other surgical procedures are included. Anemia in surgical patients is a common and serious problem that affects surgical outcomes. It is associated with increased morbidity and mortality. Approximately 30 – 70% of patients presenting for surgery will be anemic and pre-operative anemia has been a strong indicator for perioperative blood transfusion. All patients undergoing elective surgery in whom blood loss is expected to be >500ml should be evaluated for anemia at least 3 -4 weeks before the operative date. Iron deficiency is the most common cause and can be treated with oral iron, intravenous iron and +/- recombinant erythropoietin, the latter particularly for the anemia of chronic disease. Surgical and anesthesia techniques are important during surgery for minimizing blood loss. Post op initiatives include the utilization of restrictive transfusion triggers, single unit transfusions and reduced blood draws.


Using an algorithm developed by the ONTraC coordinators for preoperative hemoglobin optimization and anemia management each coordinator identifies patients with pre-operative anemia. Working with the patient and the multidisciplinary team the coordinator develops an individualized treatment plan for each patient.



The program has seen a significant reduction in provincial transfusion rates e.g. the mean provincial transfusion rate in knee surgery was 24.4% in 2002 and had decreased to 0.57% in 2018. For CABG surgery, the mean provincial transfusion rate has declined from 61% to 25%. The implementation of PBM has resulted in reduced length-of-stay and infections and significant cost-savings to the province and the healthcare system in Ontario overall.



More recently PBM has begun expanding into non-surgical areas such as oncology and internal medicine.


Information about the ONTraC program including a toolkit for PBM in hospitals can be found on the ONTraC website.


December 2019

Fibrinogen Replacement for Bleeding After Cardiac Surgery: The Results 0f the Canadian FIBRES Trial

Author: J. Callum1 , MD and K. Karkouti2 , MD on behalf of the FIBRES Research Group

1 Department of Laboratory Medicine and Molecular Diagnostics, Sunnybrook Health Sciences Centre and Department of Laboratory Medicine and Molecular Diagnostics, University of Toronto, Ontario

2 Department of Anesthesia and Pain Management, Sinai Health System, Women’s College Hospital, University Health Network, Toronto, Ontario; Department of Anesthesia and Institute of Health Policy, Management, and Evaluation, University of Toronto, Ontario; Peter Munk Cardiac Centre, University Health Network, Toronto, Ontario

Hemorrhage is a common complication after cardiac surgery and accounts for a large proportion of the blood products transfused across Ontario. An important cause of bleeding is hypofibrinogenemia (fibrinogen <1.5-2.0 g/L), for which international guidelines recommend fibrinogen replacement with cryoprecipitate or fibrinogen concentrate. The two products have important differences, but comparative clinical data is limited and large randomized trials have not been carried out. Cryoprecipitate is the most common product used in Ontario but it is not used in many other jurisdictions (e.g., European countries) due to the concerns regarding the risk of future emerging pathogens with a non-pathogen reduced product. Due to the lack of definitive clinical trials, the following are unknown: (1) the preferred product for fibrinogen replacement; (2) the optimal dose of the preferred product; and, (3) the right threshold for administration of fibrinogen when faced with a bleeding patient. The objective of the FIBRES study was to answer the first question and determine if fibrinogen concentrate is non-inferior to cryoprecipitate for the treatment of bleeding related to hypofibrinogenemia after cardiac surgery.


The study randomized patients at 11 Canadian hospitals. The study included adult patients experiencing clinically significant bleeding and low fibrinogen levels after cardiac surgery (the patients underwent surgery between February 10, 2017 and November 1, 2018). The patients were randomized to fibrinogen concentrate 4 g (N=415) or cryoprecipitate 10 units (N=412) for each ordered dose within 24-hours after cardiopulmonary bypass. Quality control data from Canadian Blood Services showed that 4 grams was the closest dose to the standard 10 U pooled cryoprecipitate dose. The fibrinogen concentrate was Fibryga provided by Octapharma (room temperature storage product with rapid reconstitution in <5 minutes and rapid infusion (4 grams over 5-10 minutes)). No other aspect of their care was modified. The primary outcome was blood components (red cells, platelets, plasma) administered during the 24-hours after bypass. A two-sample, one-sided test for the ratio of the mean number of units was conducted to evaluate non-inferiority (threshold for non-inferiority <1.2).


Overall, 735 patients (372 fibrinogen concentrate, 363 cryoprecipitate) were treated and included in the primary analysis. The patients represented approximately 6% of all patients undergoing cardiac surgery at these centres and therefore represent unusual patients with significant hemorrhage. The median (IQR) age was 64 (53–72) years, 30% were women, 71% underwent complex surgeries, 92% had moderate to severe post-operative bleeding, and pre-treatment fibrinogen level was 1.6 (1.3–1.9) g/L. The mean (95% CI) 24-hour post-bypass allogeneic transfusions were 16.3 (14.9 to 17.8) and 17.0 (15.6 to 18.6) units in the fibrinogen concentrate and cryoprecipitate groups, respectively (ratio 0.96; 1-sided 97.5% CI, -∞ to 1.09; p-value for non-inferiority <0.001; superiority 2-sided 95% CI, 0.84 to 1.09; p-value for superiority =0.5). Thromboembolic events occurred in 26 (7.0%) and 35 (9.6%) of patients in the fibrinogen concentrate and cryoprecipitate groups, respectively. No other outcomes differences for secondary outcomes or safety concerns were identified. The full trial results and supplementary appendix can be found at this link:


In conclusion, in the FIBRES study fibrinogen concentrate was found to be non-inferior to cryoprecipitate with regard to number of blood components transfused in a 24-hour period post-bypass. Use of fibrinogen concentrate should be considered for management of bleeding in patients with acquired hypofibrinogenemia after cardiac surgery to mitigate the risk of emerging pathogens. In addition, fibrinogen concentrates are logistically easier for the technologists to prepare, they are stored at room temperature, are easier to redistribute if not used before the expiration date, can be prepared at the bedside (may reduce wastage), and have no impact on the production of other components (platelets and plasma).


Fibrinogen Concentrate (Human) (Riastap®)– Frequently Asked Questions for Physicians

University Health Network, Version 3: March 7, 2018

1. What are fibrinogen concentrates?

Fibrinogen concentrate is a blood product/ plasma derivative (from pooled human plasma) containing fibrinogen (1 gram per vial).


2. When should this product be used?

This product is indicated for the treatment of congenital fibrinogen deficiency (i.e. congenital afibrinogenemia and hypofibrinogenemia). Off label use may be considered for replacement of fibrinogen in urgent situations (e.g. hemorrhage post CV surgery, severe trauma, postpartum hemorrhage, and tPA-related intracranial hemorrhage)


3. Is it a blood product?

Yes. This product is derived from human plasma. As with blood transfusion, the donors have been screened for viral infections such as Human Immunodeficiency Virus (HIV), Hepatitis C (HCV) and Hepatitis B (HBV). In addition, virus inactivation and virus removal steps which are part of the manufacturing process, are considered effective for enveloped viruses such as HIV, HCV, HBV, and for the non-enveloped Hepatitis A virus (HAV). The measures taken may be of limited value against non-enveloped viruses such as parvovirus B19, and theoretically, Creutzfeldt-Jakob disease (CJD) and variant-CJD.


4. Is consent required?

Yes. Patients should be informed that it is a blood product and that the risk of viral transmission is exceptionally low, but not zero, because the product is derived from blood donors. They should also be informed of the risk of allergic reactions.


5. What Blood Bank testing is required?

None. A group and screen is NOT required before use.


6. Are there patients who should not receive this product?

Exercise caution when administering to patients with a history of deep vein thrombosis, pulmonary embolism, arterial thrombosis or liver disease as there is a risk of thrombosis


For complete information please refer to the product monograph.


7. What are the common side effects that my patient could experience?

Hives, generalized urticaria, tightness of the chest, wheezing, hypotension, and anaphylaxis.


8. What is the typical adult emergency dose?

4grams of Fibrinogen concentrate is equivalent to 1 adult pool of cryoprecipitate (~10U)


9. What do I do if the patient refuses fibrinogen concentrate?

Some Jehovah’s Witness patients may decline the use of fibrinogen concentrate – this should be discussed with the patient on a case by case basis.


Document in the patient’s chart and communicate the reason to the Blood Bank so we can put a comment in the electronic blood bank record.


The form Transfusion and Alternative Options as Selected by Patient, available from Blood Bank, should be used to document the patient’s wishes.


References 1. Riastap® product monograph



November 2019

Code Orange: Simulation to Real Life

Authors: D. Neurath, Manager, Transfusion Medicine, EORLA The Ottawa Hospital sites
M. Tokessy, Regional Discipline Manager for Transfusion Medicine, Tissue Typing and Molecular Diagnostics

On January 11, 2019 in Ottawa, a double decker city bus collided with the shelter of a busy commuter bus station. On impact, the second level of the bus crumpled towards its middle, pinning passengers in their seats. Three passengers were killed, another 23 sustained major blunt force trauma injuries.


In anticipation of the incoming casualties, a Code Orange was declared at the trauma center of The Ottawa Hospital (TOH) Civic Campus.


The Code Orange procedure for Transfusion Medicine (TM) at TOH includes the process of packing 2 validated cold boxes; one box with 10 group O Rh negative red blood cells (RBC) and one with 10 group O Rh positive RBC. Two technologists, wearing red TM vests, bring the two blood boxes to the Emergency Department (ED) and dispense uncrossmatched blood as needed.


Just two months earlier, in November 2018, TM participated in a Code Orange simulation exercise among all other required medical and support services. The scenario simulated casualties of a mass shooting and took place in the ED over a span of three hours. It was the largest simulation ever performed at TOH. Dedicated staff were assigned to observe and evaluate the processes of the exercise. Post-exercise debriefing with the multi-disciplinary team identified gaps in many processes requiring improvements. While the TM support was very effective, there were a few minor changes to be made: identifying a dedicated desk with phone for TM strategically located within the ED, ensuring two technologists to be stationed in the ED (as staffing in the lab permits) and providing a dedicated porter assigned solely to the TM service for transporting additional blood products as needed from the lab. Based on this new information, the Code Orange procedure was revised and signed off by all TM staff within a week of the mock exercise.


Two months later, on that devastating Friday evening, two technologists wearing the red TM vests and equipped with two boxes of RBC set up their station in the ED. It was recognized early on that RBC units weren’t the only urgently needed blood product: and a cold box with thawed group AB plasma was quickly brought to the ED. The two technologists worked tirelessly dispensing RBC and plasma while ordering replacement products from the lab. Most of the female patients were of child-bearing potential (<45-years of age) therefore used many group O Rh negative RBC. Meanwhile in the lab, technologists were performing stat type and screen, thawing plasma, packing blood boxes and ordering additional product from Canadian Blood Services (CBS) to replenish the RBC inventory.


By the end of the evening, 12 patients had been transfused. There were 96 RBC, 58 units of plasma and 10 pools of platelets transfused. Once the Code Orange was over, the TM staff continued support to the OR and ICU patients.


What we learned:


While the Code Orange simulation had provided the team with invaluable improvements to the TM procedure, the real-life casualty response identified additional opportunities for enhancing the process which were included in a newly revised Code Orange procedure:
  1. We recognized the importance of AB plasma being immediately available during the Code Orange process. The procedure has been changed to include a box of 10 thawed AB plasma.
  2. Uncrossmatched group O RBC will continue to be dispensed until the patients’ proper identification is available; only then will group specific blood be issued to avoid any potential errors in wrong blood to patient.
  3. For more timely and effective replacement of the blood inventory during Code Orange, the decision was made to request blood from the General Campus of TOH instead of the local CBS. The transportation time is shorter and the incoming RBC units will already have ABO confirmed in the shared LIS.
  4. Reconciliation is an important aspect of the process to ensure accurate documentation of patient transfusion history.

Our preparedness and past Code Orange exercises aided in developing competency in responding to mass casualties. The simulation exercise was very useful, but nothing can prepare you more than real life situations.


We are fortunate to have dedicated and knowledgeable staff that contributed to the support of the bus crash victims. In the post Code Orange debriefing staff expressed how they felt there is a great sense of pride and accomplishment when you can do what you are trained to do in a manner where it directly impacts the health and survival of another human being.

On the road to a massive hemorrhage protocol (MHP): Updated October, 2019.

Author:Stephanie Cope, Regional Project Coordinator, ORBCoN CE Region

 On September 20, 2019 ORBCoN released Ontario’s first recommendations for massive hemorrhage.  A modified Delphi technique was used by a multi-disciplinary panel of experts to reach consensus. For additional information regarding background, methods and results, refer to the article just published in CMAJ Open.


This unique approach resulted in 42 recommendation statements and 8 quality indicators which will form the basis of one provincial standardized protocol for all Ontario hospitals to follow, a process that has not been done before.


Currently we are in the process of developing the toolkit – which will aid hospitals in the implementation of these recommendations and quality metrics. We have twelve different working groups and one Steering Committee hard at work on this initiative. Resources to include: pretransport care, facilitation of early transfer, activation/termination criteria, determination of team, communication, lab testing, temperature requirements, blood and blood products, training materials, pediatrics, patient/family support and quality reporting. The toolkit will also address obstetrical patients, various hospital sizes and hospitals with limited resources.


The target completion date for the MHP toolkit is spring 2020. ORBCoN’s bi-annual Transfusion Committee Forum (2020) will be dedicated to the release of the MHP toolkit. Stay tuned for more information coming soon.


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


Question – Cryo and Fibrinogen Dosing in MHP for Adult vs Pediatric
We are trying to implement our MHP protocol and some questions have arisen regarding our proposed procedure. Regarding a pediatric MHP, should platelets and cryoprecipitate be included in the “pack”? Is fibrinogen concentrate an acceptable substitute for cryoprecipitate in an MHP situation?




The final Ontario Massive Hemorrhage Protocol (MHP) Toolkit is currently in development and is expected to be available in the Spring of 2020.  It will contain recommendations for both large and small hospitals as well a special section addressing management of pediatric patients.


This toolkit will have guidance on the use of blood components and products as well as tranexamic acid, maintaining temperature (keep patient warm), Ca, minimizing blood loss from hemorrhaging sites, etc.


Here’s some information and references that may help you in the meantime:


Cryoprecipitate and fibrinogen concentrate dosing for MHP


For recommendations on the use and dosing of cryoprecipitate and fibrinogen concentrate for replacement of fibrinogen refer to the most recent statement released by the National Advisory Committee on Blood and Blood Products


Is there a need for a standardized protocol which can help in the management of patients who are massively bleeding?


To find out, watch this U of T rounds presentation by Drs. Jeannie Callum and Katerina Pavenski, posted on ORBCoN’s website.


For expert recommendations on what should be included in a Massive Hemorrhage Protocol go to:


October 2019

Principal Findings in ORBCoN Platelet Utilization Audit

Author: Troy Thompson MLT, BAHSc (Hons), Regional Manager, ORBCoN CE Region


Platelet transfusions are used for the treatment or prevention of hemorrhage in patients with deficiency in total numbers and/or function of platelets, whether as a direct or indirect result of disease or as a consequence of medical treatment such as chemotherapy, massive transfusion or use of platelet inhibitors.


Numerous audits of platelet transfusion practice world-wide have revealed highly variable rates of inappropriate platelet transfusions with non-conformance rates commonly estimated in excess of 30%.


A voluntary platelet utilization audit was conducted in Ontario with 69 participating hospitals of which 57 reported platelet orders made during the audit period. (41 community and 16 teaching hospitals) The audit was conducted between January 9th and April 7th, 2017.


Data were collected using a web-based audit tool and included: Hospital Site, Patient Care Area, Date of Transfusion, Patient Age and Sex, Number of Platelet Doses Ordered and Transfused, Ordering Physician Specialty, Indication for Transfusion, Administration of Antiplatelet Therapies, Patient Bleeding Status [“minor” (WHO grade 1 and 2) or “major” (WHO grade 3 and 4)] and Pre- and Post-Transfusion Platelet Counts. Data for patients aged over 18 years (“Adults”) and 18 years and under (“Pediatric”) were analysed separately.


The audit was intended to assess the current state of the clinical practice of platelet transfusion in Ontario in respect of:

  • Determining the proportion of platelet transfusions deemed inappropriate against defined, validated criteria
  • Identifying the patient and provider factors associated with inappropriate platelet transfusion
  • Providing guidance in the way of remediation efforts that could lead to improvements in the clinical practice of platelet transfusion

For the purposes of this audit, the criteria used were derived from recent guideline recommendations published by the AABB (Kaufman et al., 2015a) and the International Collaboration for Transfusion Medicine Guidelines (Nahirniak et al., 2015), and validated in a preliminary pilot study (Etchells et al. 2018).


Principal Finding Highlights


  • Of the total of 1903 platelet transfusion orders audited, 834 (43.8%) did not meet criteria and were deemed “inappropriate”.
  • Of the 1693 transfusion orders for “Adult” patients, 701 (41.4%) were deemed inappropriate (266 [40.3%] of 660 in academic centres and 435 [42.1%] of 1033 in community hospitals).
  • Of the 210 orders for “Pediatric” patients, 133 (63.3%) orders were deemed inappropriate (119 of 181 [65.7%] orders in academic centres and 14 of 29 [48.3%] orders in community hospitals).
  • In adult patients, the highest number of platelet transfusion orders and the lowest rate of “inappropriate” orders, at 24.1%, were for oncology patients. The highest rates of inappropriate platelet transfusion orders were for patients in acute care settings – intensive care units, emergency departments, operating rooms and acute care in-patient bed units.
  • 60% of platelet transfusion orders were for prophylaxis in non-bleeding patients and 40% were either for management of bleeding or in anticipation of surgery or other invasive procedure.
  • In pediatric patients, the highest number of orders were in hematology/oncology patients but inappropriate platelet transfusion order rates were in the range of 56-71% regardless of patient service identified (minimum ≥ 10 platelet orders).
  • 31 of the 57 (54%) participating hospitals reported the presence of guidelines for platelet transfusion at their facility.
  • The presence of guidelines in an institution did not appear to significantly improve platelet transfusion appropriateness; however the use of pre-printed order sets and pretransfusion order screening resulted in lower rates of “inappropriate” orders for platelet transfusion.

Inappropriate platelet transfusions accounted for 44% of the total platelet orders audited, a figure in keeping with the results of similar audits world-wide. A variety of strategies should be employed to improve appropriate platelet utilization including mechanisms to understand the reasons for non-compliance and focusing on the “specialities” having a higher rate of inappropriate platelet transfusions. With this knowledge, educational content can be developed and directed to improve appropriateness of platelet transfusions. Additionally, other practice improvement initiatives founded on evidence-based guidelines, including the use of pre-printed order sets and implementation of an effective pre-transfusion screening process by technologists with sufficient Medical Director support, show promise as effective strategies for reducing inappropriate transfusions.


In spite of advances in improving the inherent safety of blood and blood products, the transfusion of blood and blood products remains potentially hazardous. Adverse reactions including allo-immunization, febrile and allergic reactions, Transfusion Associated Circulatory Overload (TACO) and Transfusion Related Acute Lung Injury (TRALI) remain important, often serious, patient outcomes. The prevention and reduction of these types of adverse events comes first with recognizing when a transfusion should or should not be prescribed in compliance with evidence based transfusion guidelines. Furthermore, the costs of transfusion are considerable (estimated at approximately $60 million per year in Ontario for platelets alone) and the supplies are not without limitation. Reducing inappropriate transfusions will help to prevent adverse reactions but also ensure that these blood and blood products are available to those patients that legitimately require them, while respecting the financial sources of support.


More detailed information for the Provincial Platelet audit will be available shortly on


  1. Etchells M, Spradbrow J, Cohen R et al. Audit of appropriate use of platelet transfusions: Validation of adjudication criteria. Vox Sang 2018; 113:  40-50.
  2. Kaufman RM, Djulbegovic B, Gernsheimer T et al. Platelet transfusion: a clinical practice guideline from the  AABB. Ann Intern Med 2015a; 162: 205-213.
  3. Nahirniak S, Slichter SJ, Tanael S et al. Guidance on platelet transfusion for patients with hypoproliferative thrombocytopenia. Transfus Med Rev 2015; 29: 3-13.


Report: 2019 Annual Videoconference “Platelets – The Sticky Truth and why it matters to you!”

Author: Tracy Cameron, Regional Project Coordinator, ORBCoN NE Region


ORBCoN and CBS provided another great educational opportunity for medical laboratory technologists, nurses, physicians and other allied health professionals on April 10th, 2019. This year’s Platelet themed videoconference symposium was well attended with a total of 1006 attendees, from over 100 sites within Ontario and 5 other provinces.


The symposium was offered through videoconference and by webcast. The majority attended by videoconference, while 40% attended via webcasting. There were 28 in attendance at the host site at Thunder Bay Regional Health Sciences Centre.


This educational symposium is primarily designed for community and small hospitals who don’t have as much opportunity to attend educational events as staff in larger teaching hospitals. The primary focus is to provide up-to-date information on a variety of topics that  community primary care physicians, nurses and lab staff may not encounter on a regular basis.



99% of attendees indicated they felt the overall symposium objectives and the objectives of each speaker were met and that they were satisfied with the overall symposium. Each presentation was rated favorably.


The recorded webcast is available through the ORBCoN archived webcasting centre  .The PowerPoint presentations can also be found on the ORBCoN website or by clicking on each of the presentations below.



All attendees were eligible to win a prize for attending the symposium and the draw was held on June 13th once all attendance records were received. We would like to send out congratulations to the following winners:


Planning for the 2020 Videoconference symposium will begin in September. A “Save the Date” will be sent out in early fall so that you can secure videoconference rooms. We encourage everyone involved in the circle of care  whose patients may require a transfusion to attend.


The organizing team would like to thank you again for attending this year’s videoconference symposium and making it another successful event. We look forward to bringing you next year’s event.


If you attended this years symposium and did not receive your certificate of attendance, have any suggestions for topics to present on, or if your site is interested in hosting this annual event, please contact


September 2019

Should Group A Plasma Be Used in Massive Hemorrhage Protocols Instead of Group AB Plasma?

Author: Michelle P. Zeller MD FRCPC MHPE DRCPSC, Assistant Professor; McMaster University, Program Director Transfusion Medicine AFC Diploma; McMaster University, Director Operations, Transfusion Medicine; Hamilton Regional Laboratory Medicine Program, Medical Officer; Canadian Blood Services


Group AB plasma is the universal plasma group with 73% transfused to non-AB recipients.1 A survey of blood centres in the United States showed a 27% increase in demand for AB plasma in 2011 when compared to 2006 data; the increase was disproportionate relative to other plasma groups.2 Canadian data shows the same disproportionate increase in AB plasma use (Figure 1). Only 3-4% of Canadian and American donors are group AB making Group AB plasma a scarce resource of increasing demand.


What accounts for the increase in demand?


Implementation of massive hemorrhage protocols (MHPs) is becoming the standard of care across many jurisdictions with improved delivery and reduced wastage of blood products and beneficial impact to patient survival.3–5 With increased MHP adoption there has been concurrent, disproportionate increase in AB plasma use compared to other plasma groups. In an international multicentre study, plasma transfused in the Emergency Department accounted for the highest percentage of group AB plasma units transfused to non-AB recipients.1 As a means of conserving Group AB plasma, there has been a move towards provision of Group A plasma in MHPs instead of Group AB plasma.6


What are the risks of transfusing Group A plasma to an ABO incompatible recipient?


Group A plasma contains anti-B antibodies; if given to a group B or group AB patient there is potential for an acute hemolytic transfusion reaction (AHTR). Donor antibodies bind host RBCs, activate the complement cascade leading to anemia, and in severe cases can result in disseminated intravascular coagulation, acute renal failure, and death. In Canada, a transition to Group A plasma from Group AB plasma in MHPs has potential to negatively impact ~12% of the population who are Group B and AB.


Why would we consider incompatible plasma transfusion if there is risk?


Incompatible plasma is transfused routinely, as it is common practice to transfuse platelets to recipients without matching for ABO group. Studies on ABO incompatible platelet transfusions report an extremely low risk of hemolytic reactions.7–10 All reports of hemolytic reactions were caused by products containing Group O plasma, while there were no documented cases of hemolysis from products containing Group A plasma.7,8,10 As an added protective effect, trauma patients can develop acquired immunosuppression. 11 Furthermore, use of group O whole blood in trauma patients of unknown ABO group did not show hemolysis or renal failure among non–group O recipients.12


What have others found in using Group A plasma for MHPs?


A single centre retrospective review of all trauma patients receiving emergency release plasma (Group A) from 2008 to 2011 reported no significant differences in outcomes for 254 patients: 35 (14%) received ABO-incompatible and 219 (86%) received ABO-compatible plasma transfusions.8 A multicentre retrospective study of 8 trauma centres in the US (2012-2016) compared compatible to incompatible (A plasma to Group B and AB patients) plasma transfusion in the context of MHP activation. They included 1573 patients; 92% compatible vs 8% (120) incompatible and found no hemolytic transfusion reactions, no significant difference in acute respiratory distress syndrome, thrombotic events, sepsis, acute renal failure and no significant difference in mortality at 6 or 24 hours, nor at 28 days.13


A survey on use of Group A plasma in trauma of 61 trauma centers (mostly Level 1) found that most maintain an inventory of immediately available Group A plasma.14 The majority (63%) use Group A plasma in the initial phase of the resuscitation of trauma patients of unknown ABO group; 50% of group A plasma usage is a relatively new practice having started in 2015; 62% do not limit amount of group A plasma administered to trauma patients; and, only 21% consider anti-B titer when choosing group A plasma units.14


A large multicentre study, Safety of the use of group A plasma in Trauma (STAT Study) retrospectively collected data on consecutive injured group A, B, and AB patients admitted to adult Level 1 or 2 trauma centers.6 Results from 17 trauma centers (16 US and 1 UK) from 2008 to 2015 reported on 1163 trauma patients: 809 (70%) group A patients in the identical group, 354 (30%) group B or AB patients in the incompatible group. They found no significant difference in in-hospital mortality and no AHTR were reported (though hemolytic markers were not specifically collected).


What happens at your centre? Will you make the switch?


Some Canadian trauma centres have already transitioned to use of Group A plasma in their MHPs while others continue to use Group AB plasma. Use of Group A plasma in MHPs is not yet standard of care and evidence remains retrospective and observational; however, it is an important strategy to keep in mind in the event of Group AB plasma shortage.


Figure 1. Fresh Blood Components Distribution Trends Q4 2017/18 (Source: Canadian Blood Services)


    1. Zeller MP, Barty R, Dunbar NM, et al. An international investigation into AB plasma administration in hospitals: How many AB plaSma units Were INfused? The HABSWIN study. Transfusion. 2018;58(1):151–157
    2. Yazer M, Eder AF, Land KJ. How we manage AB plasma inventory in the blood center and transfusion service. Transfusion. 2013;53(8):1627–1633.
    3. Cotton BA, Au BK, Nunez TC, et al. Predefined massive transfusion protocols are associated with a reduction in organ failure and postinjury complications. J. Trauma – Inj. Infect. Crit. Care. 2009;66(1):41–48.
    4. Cotton BA, Reddy N, Hatch QM, et al. Improvement in Survival in 390 Damage Control. Ann. Surg. 2013;254(4):1–15.
    5. Khan S, Allard S, Weaver A, et al. A major haemorrhage protocol improves the delivery of blood component therapy and reduces waste in trauma massive transfusion. Inj. Int. J. Care Inj. 2013;44(5):587–92.
    6. Dunbar NM, Yazer MH, Carey PM, et al. Safety of the use of group A plasma in trauma: the STAT study. Transfusion. 2017;57(8):1879–1884.
    7. Mair B, Benson K. Evaluation of changes in hemoglobin levels associated with ABO-incompatible plasma in apheresis platelets. Transfusion. 1998;38:51–55.
    8. Zielinski MD, Johnson PM, Jenkins D, Goussous N, Stubbs JR. Emergency use of prethawed Group A plasma in trauma patients. J. Trauma Acute Care Surg. 2013;74(1):69–74; discussion 74-5.
    9. Cooling L. Going from A to B: The safety of incompatible group A plasma for emergency release in trauma and massive transfusion patients. Transfusion. 2014;54(7):1695–1697.
    10. Cooling L. ABO and platelet transfusion therapy. Immunohematology. 2007;23(1):20–33.
    11. Kimura F, Shimizu H, Yoshidome H, Ohtsuka M, Miyazaki M. Immunosuppression following surgical and traumatic injury. Surg. Today. 2010;40(9):793–808.
    12. Seheult JN, Triulzi DJ, Alarcon LH, et al. Measurement of haemolysis markers following transfusion of uncrossmatched, low-titre, group O+ whole blood in civilian trauma patients: initial experience at a level 1 trauma centre. Transfus. Med. 2017;27(1):30–35.
    13. Stevens WT, Morse BC, Bernard A, et al. Incompatible type A plasma transfusion in patients requiring massive transfusion protocol: Outcomes of an Eastern Association for the Surgery of Trauma multicenter study. J. Trauma Acute Care Surg. 2017;83(1):25–29.
    14. Dunbar NM, Yazer MH. A possible new paradigm? A survey-based assessment of the use of thawed group A plasma for trauma resuscitation in the United States. Transfusion. 2016;56(1):125–129.



Evening Symposium: Choosing Plasma Wisely: When and When Not to Use Plasma

Author: Stephanie Cope, Regional Project Coordinator, ORBCoN Central Region, Allison Collins MD FRDPC, Physician Clinical Project Coordinator, Ontario Regional Blood Coordinating Network


The Spring Symposium is a collaborative event held by the Ontario Regional Blood Coordinating Network (ORBCoN) and Canadian Blood Services (CBS) which began in 2007. This is an accredited, continuing medical education opportunity for those in the field or with an interest in Transfusion Medicine, and for clinicians who prescribe blood and blood products.


The theme of the event, frozen plasma utilization was selected as provincial frozen plasma audits (conducted by ORBCoN in 2008 and 2013) identified a high rate of inappropriate plasma use, even after the introduction of recommendations and tools aimed at improving the appropriate use of plasma were created and disseminated to Ontario hospitals (via licensed laboratories) following each audit. The top five inappropriate uses of plasma based on the 2013 audit results were reviewed and formed the basis for the symposium. In an attempt to increase our reach, we approached Choosing Wisely Canada who agreed to collaborate with us. Choosing Wisely Canada has created a campaign aimed at promoting the avoidance of unnecessary tests, treatments and procedures which includes the unnecessary utilization of blood and blood products.


Top 5 inappropriate uses of plasma (ORBCoN, 2013)

  1. Reversal of warfarin or vitamin K deficiency in the absence of bleeding or urgent major invasive procedure (within 6 hours)
  2. Treatment for trivial abnormalities of laboratory test results that are not associated with an increased risk of bleeding
  3. Reversal of coagulation defect with elevated INR in the absence of bleeding or urgent invasive procedure
  4. Heparin reversal
  5. Rapid reversal of anticoagulant therapy

Given the fact that recommendations and tools were made available in 2013 with relatively no positive change in the inappropriate usage of plasma, the planning committee decided to include a small knowledge retention exercise to ensure the needs of our stakeholders were being met. Case-based clinical scenarios, using the five categories above, were included in a pre and post survey sent to registrants of the symposium.


Example of a case-based clinical scenario

Patients with liver failure have a rebalanced hemostatic system, and are at risk of either bleeding or thrombosis as a result. The INR does not predict the risk of bleeding in these patients. Prophylactic plasma transfusion is of unproven benefit in the setting of minor invasive procedures, such as central line insertion, paracentesis, and thoracentesis, all of which carry a very low risk of bleeding. Because plasma transfusion is not without adverse effects, it is prudent to reserve plasma transfusion for the rare patient who bleeds during or after a procedure. The risks of prophylactic plasma transfusion in this setting include transfusion-associated circulatory overload (TACO), elevation of portal venous pressure (which may cause or exacerbate bleeding), and the risks associated with delaying the procedure itself. For further details, see Dr. Callum’s presentation in the ORBCoN Presentation Library Here.


ORBCoN will continue to promote and support utilization improvement activities and will use auditing as a means to highlight opportunities to improve appropriate utilization of blood and blood products. The formats of our spring symposiums have changed throughout the years as we conform to our target audience and the needs of our community. Did you attend this event? We value any feedback regarding this event, past events and welcome any suggestions for future events!


Contact Us today!


June 2019

The Second Sample – Blood Group Checks So You Can Catch Some ZZZZs

Author: Connie Colavecchia, BSc, MLT, Manager, Transfusion Medicine and Tissue Bank, Sunnybrook Health Science Centre

The transfusion of an ABO incompatible red cell is every Blood Banker’s nightmare. Countless studies have identified that “wrong blood in tube” (the blood drawn into the tube does not belong to the patient whose identification label is affixed on the tube), affectionately known as WBIT, has the potential to be a catastrophic event causing morbidity or death. Patient identification processes, supported by standards and industry requirements, are paramount in preventing such events. In early 2018, CSA Z902-15 Blood and Blood Components was revised as follows:


Clause states: To provide ABO group compatible red blood cells, there shall be at least two determinations of the recipient’s blood group on record:


a. One from a current sample and the second from the recipient’s previous records:
b. Testing of a separate sample collection or
c. Retesting of the same sample where positive patient identification technology was used at the time of sample collection.


The original clause referred specifically to electronic crossmatch only. The revised clause applies to all compatibility testing.


Sunnybrook Health Sciences Centre is no stranger to these strategies. In 2004, positive patient identification technology was implemented in two high volume transfusion areas of the hospital, the outpatient transfusion clinic and the inpatient oncology ward. With this technology in place, the risk of a WBIT was virtually zero. However, this technology was not available institution wide. In late 2005, several near miss WBIT events from the Emergency Department (ED) occurred in a short period of time which led to an immediate policy change. Non group O patients from the ED would be provided with group specific blood only if two concordant blood groups were on file. Prior to transfusion, if there was no historical blood group on file, a new group and screen sample was required to confirm the ABO of the first sample. Not in place at the time, CSA Clause b) now provides for this safety check. The intent, although obvious to some, was to ensure that the patient’s group and screen was confirmed on two independent occasions. For some time, this process appeared to be working until the blood bank became aware that the clinical team, in an effort to be efficient, collected two tubes from the same draw and held one back “just in case” the blood bank requested a second sample for the blood group check. This process circumvented the patient safety initiative of confirming that the first group and screen sample and the second group and screen sample had been collected following patient identification checks as per hospital policy on separate occasions. To ensure that the blood group check sample was being collected independently of the first group and screen (Pink top tube), a process was implemented in January 2011 across the institution for all blood groups whereby a special tube, the Royal Blue top tube, available only from the blood bank was accepted as the blood group check. The Royal Blue top tube could not be purchased by anyone else in the institution nor stored anywhere else, only in the blood bank. If a blood group check was required for a patient, the blood bank would request that the Royal Blue tube be retrieved from the blood bank and used only for that specific patient. The process worked well until the blood bank was notified that the Royal Blue top tube was required for a specific test in biochemistry. The resolution was to source another tube to be used only for the blood group check. The Tan top tube was found and replaced the Royal Blue top tube. The blood group check requirement is specific to those patients who may require transfusion and whose only group and screen on record is less than 24 hours old. The 24 hour criteria is in place to discourage the collection of more than one Pink top tube when the first group and screen is collected. A bag containing the Tan top tube is prepared with the patient’s name on the outside of the bag along with instructions (see Figure 1). Following the 24 hours of the first group and screen on record, a Pink top tube is required.

The implementation of the blood group check has decreased the risk of ABO incompatible transfusions and serves as an effective solution until positive patient identification technology is rolled out institution wide. As for me, I sleep better knowing that our institution has taken these added patient safety steps.


The Top Ten Hospital Issues Identified at Annual ORBCoN/CBS Hospital Site Visits from 2018-19

Authors: Sheena Scheuermann MLT BTech, Regional Project Coordinator ; Wendy Owens ART B Comm Program Manager ; Susan White MLT Hospital Liaison Specialist¥, Amanda Nowry MLT BSc Hospital Liaison Specialist¥


Ontario Regional Blood Coordinating Network, ¥Canadian Blood Services.


Each year, staff from the Ontario Regional Blood Coordinating Network (ORBCoN) and from Canadian Blood Services (CBS) plan site meetings with all hospitals in Ontario to discuss blood utilization. The purpose of these meetings is to:

  • Build and maintain relationships
  • Encourage continuing improvement in inventory management
  • Communicate evidence based best practices in the field of transfusion medicine
  • Communicate messages from the Ministry of Health and Long-Term Care (MOHLTC) regarding the provincial Blood Utilization Strategy
  • Discuss hospital issues related to transfusion to bring forward to CBS and MOHLTC

Hospital issues are tracked through minutes of the meetings. In 2018-19 we also captured issues through a meeting evaluation survey sent out following the meeting. Issues were analyzed and the ten most common were identified.


Top Ten Hospital Issues as Reported to ORBCoN/CBS during 2018-19:


1. Second sample requirement for ABO group confirmation for patients without historical group on file
This issue was most frequently cited by hospitals this year during our site visits. The logistics of implementing this process was challenging for many hospitals. In January 2018, CSA released a revision to their Z902-15 Standards that introduced the need for a second sample to confirm ABO group for any compatibility testing (was previously only required for computer or electronic crossmatch).1 Several hospitals reported pushback from clinical staff as this requirement for an additional blood draw appeared to be contradictory to policies around minimizing phlebotomy. It is important to note that this standard relates to ABO group only (not Rh) and to red cells only (not other components). More hospitals reported they are considering implementing Positive Patient Identification (PPID) technology for sample procurement which removes the need for a separate sample draw.


2. Lack of engagement by physicians and nurses around hospital transfusion related issues
While many hospitals have been reporting improvements in this, many are still reporting it is a challenge for them. Implementation of policies on managing blood shortages, informed consent, the need for the second sample for group confirmation all involve and require clinical staff to ensure they are implemented. Physician and nurse attendance and participation on Transfusion Committees is also an issue for several sites. Sites also reported there is still some difficulty screening inappropriate orders for products if there is a lack of medical backup.


3. Lack of engagement of Senior Administrators with transfusion related issues within the hospital
Many laboratory professionals report that it is often difficult to raise transfusion related issues with Senior Management and, as a result, they struggle to implement real change. This is a longstanding issue and could possibly be related to the fact that hospital administrators do not have to ‘pay’ for blood. There is some reality to the fact that if you don’t pay for something, it will not receive as much attention, particularly from Senior Administrators who may be primarily concerned about issues that affect the budget of the hospital.


4. Transitioning to new Plasma Protein Products as a result of the new CBS contracts
Hospitals reported several issues that made it challenging to proceed with transitioning patients to the new products. Some of those raised during the site visits were:

  • Lack of availability of requested vial sizes
  • Backorders of products or product vial sizes
  • Storage temperature restrictions for shelf-life, limiting available product and available storage space if refrigerated environment required
  • Time and logistics to re-train all patients currently using Sub Cutaneous Immune Globulin (SCIG)
  • Concerns around increased risk of reactions moving to a product not currently in use


5. Limitations around transport options in Northern Ontario
Transportation options have always been a challenge in the Northern parts of our province. Generally, there are fewer service providers and distances are longer. Earlier this year, Greyhound Bus announced they were discontinuing service in Northern Ontario west of Sudbury. Many hospitals depended on Greyhound to provide their blood components and products if not for regular delivery, as an alternative to their regular provider. Without access to this option, the ability to request STAT orders or to redistribute products has become more challenging.


6. Platelet related issues
Some reported issues related to platelets include:

  • Receiving short dated platelets from CBS – with the introduction of platelets with a 7 day expiry, there may have been a misunderstanding of the expectations for additional shelf-life. In general, the shelf-life gained was approximately 24 hours due to additional testing and ‘holding’ time required to allow for the extension of the expiry date
  • Related to the above extension of shelf-life, a reduction in the outdate rate of platelets was seen at many hospitals and overall availability of platelets improved
  • Sites that rarely stock platelets need to order in each time a physician requests them. Some physicians may not understand they will likely need to be discarded if the order is changed. This can lead to increased wastage rates. It is important to communicate to CBS, when ordering a platelet in this situation, if there is no order to transfuse. CBS may then be able to issue a platelet with longer remaining shelf-life. This increases the chance to redistribute the platelet if not used which would prevent discarding it due to outdating. Hospitals are encouraged to make use of ORBCoN’s platelet web application to facilitate redistribution

7. Scarcity of available Medical Laboratory Technologists (MLTs)
Several small rural hospitals reported they were having difficulty filling available positions and one small site had to shut down temporarily until staffing could be found. As many technologists are retiring or nearing retirement age, there are heightened concerns over looming shortages of certified MLTs. With the increase of core laboratories, it is also difficult for technologists to develop expertise in the field of transfusion. Another challenge related to this issue is that fewer technologists are electing to apply for supervisory or managerial roles. This has left several sites without this much needed position for extended periods of time.


8. Increased workload for MLTs
Two main issues were raised related to an increase in ‘non-measurable or non-billable’ workload for MLTs:

    • Implementing prospective screening by technologists as part of the Ontario Transfusion Quality Improvement Plan. Sites that have introduced prospective screening of blood orders to improve the appropriateness of blood components and products ordered by clinicians have noticed an increased workload. There is no argument that it is very time consuming in the beginning when this practice/policy is first introduced. However, many sites that introduced this policy report that their requests for blood have actually decreased which, in the long run, saves technologist time.
    • A number of hospitals indicated that Sub-cutaneous Immune Globulin (SCIG) use was increasing and placing an additional workload burden on their departments. Preparing and issuing SCIG is not recognized as measurable laboratory workload, therefore, hospital managers have difficulty in increasing FTE levels to accommodate this. Both CBS and ORBCoN have been asked to advocate on their behalf.


9. Slow transition to Fibrinogen concentrate (FC)
Many sites report they were waiting to hear more evidence to support use of FC for acquired hypofibrinogenemia. With the recent release of the revised statement on fibrinogen from the National Advisory Committee on Blood and Blood Products (NAC)2 perhaps this issue may resolve over the next six to twelve months. Additional information about the efficacy of FC will be available after results from the FIBRES (FIBrinogen REplenishment in Surgery) study are published. As a result of a cryoprecipitate shortage early in 2019, hospitals are being encouraged to put policies and procedures in place to enable them to stock and use fibrinogen concentrate in the event of a similar future shortage of cryoprecipitate.


10. Increased component wastage related to activations of Massive Hemorrhage Protocols (MHP)
A few sites continue to hold an inventory of thawed AB plasma and a large portion of these are not used in an MHP. This was confirmed in an ORBCoN provincial audit of AB plasma completed in 20183. During site visits this past year, ORBCoN and CBS were also told that cryoprecipitate or plasma is often thawed when the protocol is activated but then not used. Improving the definition of when an MHP should be activated could help improve this issue. For sites that do not have a high number of MHP activations, it may be more prudent to thaw and prepare plasma and/or cryoprecipitate upon activation or when the product is requested. Use of fibrinogen concentrate for massively bleeding patients may also prevent wastage of cryoprecipitate.Platelets may also be pre-emptively ordered in but then not be required. Platelets are generally issued in a later ‘pack’ or ‘box’. Many sites expressed interest in the work that is being done on the development of a provincial MHP and are looking forward to the release of the recommendations as well as the toolkit.


Platelets may also be pre-emptively ordered in but then not be required. Platelets are generally issued in a later ‘pack’ or ‘box’. Many sites expressed interest in the work that is being done on the development of a provincial MHP and are looking forward to the release of the recommendations as well as the toolkit.



  1. Canadian Standards Association. CSA Z902-15 Standards on Blood and Blood Components. October 2015. rev Jan 2018.
  2. National Advisory Committee on Blood and Blood Products. NAC Statement on Fibrinogen Concentrate. July 2018.
  3. Ontario Regional Blood Coordinating Network. [Online].; Ontario 2018 AB Plasma Audit Report [cited 2019 April]. Available from:

ORBCoN’s patient pamphlet is now a one-pager designed for patients and families to provide basic information on blood transfusion and to help patients make informed decisions regarding their treatment options. This resource was pared down in size and volume to focus on key messages important to patients and health professionals. In conjunction with the revised one-pager, ORBCoN developed a Questions to Ask Your Doctor sheet as a tool for patients to prepare for their visits with clinicians.


Previously the Blood Transfusion: Information for Patients short version was a hard copy booklet that was ordered online. This resource is no longer available to order. The new version and the Questions to Ask Your Doctor sheet are easily accessible for download on our website at under the tab “For Patients” → “Patient Booklets”. The options for download are:

  • Blood Transfusion: Information for Patients, v3 Short Version PDF, and
  • Customizable Blood Transfusion: Information for Patients, v3 Short Version PDF with option to insert your hospital/site logo, and
  • Questions to Ask My Doctor PDF.


Please note that Blood Transfusion: Information for Patients, v2 Long Version will remain available and supported online at under the “For Patients” tab to provide additional information for those patients who are looking for a more detailed resource.



Provincial Redistribution Check-Up

Authors: Tracy Cameron MLT and Sheena Scheuermann MLT, BTech, Regional Project Coordinators, Ontario Regional Blood Coordinating Network

December 2018 marked the first anniversary of the launch of the revised Provincial Redistribution Program for Transfusion Services in Ontario Toolkit. The process for redistributing blood components and products was evaluated by a provincial working group in 2016 and the toolkit was revised with standardized procedures to ensure that the security and safety of the redistributed blood components and products are maintained during shipment. The process was validated to demonstrate that acceptable temperatures and traceability will be maintained when redistributing or transferring blood components or products between facilities within Ontario.


The program relies on 3 types of shipping containers. Hospitals can choose which container to use based on the blood component/product being shipped. The first type is the J82 container, the old Canadian Blood Services (CBS) shipping container which can be used to ship any products that need to be maintained between 1 and 10°C during shipment. The second container type is the E38 container, which again is the old CBS shipping container to ship any products that need to be maintained between 20 to 24°C during shipment. The third is the Pelican Biothermal Series 4 shipping container (formally known as MTS EMT or Golden Hour box) which is used to ship any products that need to be maintained between 1 and 10°C during shipment. The difference between the 3 shipping containers is the packing material used to maintain the required temperatures.

Each of these shipping containers have been validated using criteria defined by ORBCoN and in consultation with transfusion medicine service staff. The table below shows the validation results for each of the shipping containers using the established packing configuration to maintain the required acceptable shipping temperatures. If hospitals choose to use a different configuration for the shipping containers, then they must do their own validation and need to share their validation with any sites that they would ship product to if requested as part of the provincial redistribution program.

Hospitals are requested to indicate their agreement to participate in the provincial redistribution program by completing a memorandum of understanding (MOU) which states the hospital will follow a standardized process, use a validated packing configuration and acknowledge how they are pre-conditioning ice packs used in the J82 packing configuration. Once hospitals have submitted this MOU it is then stored on file at ORBCoN and can be provided to any hospital that receives components or products from that shipping hospital. This reassures the receiving sites that the products or components they are receiving have been stored, packed and shipped appropriately and can be accepted into their inventory for patient use. A list of all hospitals who have submitted their MOU can be found on ORBCoN’s Transfusion Ontario website here.


To aid in compliance with IQMH requirements (IQMH v 7.1 APR 2017: IV.2 TM 070) ORBCoN, along with participating hospitals, will perform ongoing temperature verifications on the shipping containers. Sites may be approached to help perform these verifications by adding data loggers (supplied by ORBCoN) to one of their redistribution shipments. The sites will follow the standard packing configurations and add the data loggers in the placement identified in the Standard Operating Procedure (SOP) provided. After the shipment is complete, the sites will send the data loggers back to ORBCoN with the supplied shipping labels. The results of these ongoing verifications are posted on ORBCoN looks forward to working with hospitals to ensure the ongoing temperature verification of these boxes and thanks those who have already assisted.


The redistribution program allows hospitals to send near to expiring components and products to other sites where they may be utilized before they expire. Hospital efforts to ensure that blood components and products provided by Canadian donors are not wasted are shown in the graph below.

May 2019

Platelet Inventory Management: A Quality Improvement Initiative to Reduce Platelet Outdates

Authors: Jeff Kinney, ART, Dr Ziad Solh, MD London Health Sciences Centre

The shelf life of platelet products makes it challenging for both blood suppliers and hospitals to manage inventory and avoid platelet outdates and wastage. London Health Sciences Centre (LHSC) is a large tertiary care hospital in London, Ontario, Canada which includes two separate hospital sites, University Hospital (415 beds) and Victoria Hospital (565 beds). Annual transfusion rates for both sites combined are approximately 22,000 red blood cell (RBC) units and 4,000 platelets over the past 3 years. Prior to Canadian Blood Services (CBS) consolidating services to the Brampton site in 2012, a CBS facility was located just outside the front doors of Victoria Hospital which allowed for quick access to many of the blood components CBS provides. Today, the travel distance between CBS distribution facility and the London hospitals is greater than 170 km which presents new challenges for inventory management. At the time of CBS consolidation, the hospital and CBS worked together to ensure blood product availability while minimizing STAT transportation costs. These priorities sometimes lead to platelet outdate rates as high as 30% which was not acceptable, so a new outdate goal of below 15% was set.


Factors leading to platelet outdates were identified with the intent to implement interventions that would reduce outdates. Hospital-based factors were pre-existing high inventory goals, lack of adherence to inventory levels by technologists, platelets expiring more often on a specific weekday, and inconsistent product redistribution between sites. Interventions included 1) adhering to the department policy of platelet redistribution to the busier Victoria site when units at the University site were in last 24 hours of shelf life, 2) ensuring that daily platelet product requests were not a fixed standing order Monday to Friday but a flexible number based on historical data for outdate each day of the week, and 3) re-evaluation of the ratio of irradiated to non-irradiated platelets stocked.


After implementation of these interventions, the percentage of expired units dropped below 10% for both sites combined and continued below this level for several months. In August 2017 CBS introduced 7 day storage of platelets which saw a further reduction in outdates to below 5%. Hospital inventory management strategies including redistribution of product and changes to inventory ordering practices had a large impact on reducing platelet wastage at our large centre which was additive to extension of storage duration. For a period of greater than 2 years LHSC has been able to maintain a platelet outdate well below its intended goal and we will continue to monitor our performance to ensure a sustained low platelet outdate rate.


The Ontario Immune Globulin Screening Pilot (IGSP) for Neurology

Authors: Denise Evanovitch, ART, Wendy Owens, ART, Laurie McLeod, MLT, ORBCoN and Lois Shepherd, MD, Kingston Health Sciences Centre/ Queen’s University


In 2015, the Ontario Ministry of Health and Long-Term Care (MOHLTC) and Immune Globulin Advisory Panel (IGAP) examined different order/request screening methodologies for immune globulin (IG) for several reasons:

  1. IG utilization and costs continue to grow
  2. Concerns regarding the sustainability of this growth
  3. A 2015 compliance audit demonstrated a need for improvement in appropriate IG utilization
  4. The need for patient reassessment for those on long-term therapy to determine if the treatment and dosage continued to achieve the expected clinical response
  5. The expertise to screen IG requests across all specialties is not available at every hospital
  6. An IG audit conducted in 2012 indicated that 11.6% of Ontario’s IG use was for unapproved conditions

A pilot project to review requests for IG and provide screening by specialist physicians was proposed to determine if this approach could potentially improve appropriate IG utilization. Requests for neurology indications were selected for the IGSP because provincial clinical champions were identified and were willing to support it.


The Exceptional Access Program (EAP) model, currently in use for screening some drug requests, was selected due to its availability at all hospitals that issue IG and the fact that most physicians are already familiar with the EAP.


The objectives of the IGSP were to:

  • reduce inappropriate use and wastage of IG
  • ensure the minimum effective dose was administered
  • improve patient outcomes by ensuring treatment was efficacious
  • gain an understanding of the increased utilization of IG
  • raise awareness of IG use and costs
  • ensure dose correction for obese patients
  • develop a screening model that may expand to requests from other specialties.

As the EAP electronic request technology was not available for this pilot, a paper-based, faxing system was developed to fill this gap. The pilot ran from May 30th, 2016 to January 31st, 2017.

All IG neurology requests were initially screened by an IGSP assessor (pharmacist). The order was approved within 24 hours if the order met established guidelines. The requests not meeting the guidelines were forwarded to an anonymous neurologist reviewer for approval or rejection. An urgent process was developed for critical patients and an appeal process was available.

All IG orders for renewal were required to have an Outcome Questionnaire completed and submitted with the new request form to ensure that the treatment continued to be effective and that a minimally effective dose had been applied.


Ninety-two (92) hospitals submitted 1,478 requests which represented 1,167 patients. Eleven (11) requests were rejected, 1,187 requests were approved and 187 requests had adjustments, either through dosing, frequency or duration of treatment.

When the baseline data were compared to the post-IGSP data, the pilot did not appear to affect physician IG ordering practices.

The pilot potentially conserved 72,848 g of IG at a cost saving of $4.5M (CAN). A compliance assessment determined that only 51% of cases had the IGSP-approved dose administered by the hospital. The final cost saving was $2.2M (CAN) when this compliance rate was applied along with factoring in EAP costs.



The pilot was a partial success as it provided:

  • A uniform, expert screening process
  • A mechanism to deny inappropriate requests or adjust frequency, duration or dose of IG
  • Awareness of the extent of IG treatment and the cost
  • A monitoring process for patient outcomes
  • Cost savings were realized
  • The means for all transfusion services to have access to neurology expertise

A limitation of the pilot was the manual nature of the process, which was tedious and unsustainable for the ordering clinicians, the IGSP screeners and reviewers, and the hospitals. An IG screening model can reduce inappropriate utilization and have a positive effect on patient outcomes, but the requisite technology must be available to support it.


The IGSP for Neurology Report

For those stakeholders who are interested in a copy of the IGSP for Neurology Report, it is available upon request, through the MOHLTC. Please click on this link to request one.


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:



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



  1. Canadian Blood Services [Internet]. Toronto: Blood Brief;2018.An Update on AB Plasma;Aug.2018[cited 2019 March 11]; Available from:
  2. Canadian Standards Association. CSA-Z902-15 Blood and Blood Components. 2015 edition. Toronto (ON): Canadian Standards Association; 2015:,,
  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 and look under the Quality Improvement tab for tools and resources.*


  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);
  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);
  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;

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 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 ( and, and the National Advisory Committee on Blood and Blood Products ( 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 ( 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 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.


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.



  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. [Online].; 2018 [cited 2019 January 15. Available from:
  4. Ontario Regional Blood Coordinating Network. [Online].; 2018 [cited 2019 January 15. Available from:

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



  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?



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?



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 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)



  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. 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 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 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



  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; 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)


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.



  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
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


  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 in the near future!



  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 and


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.



  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



  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
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


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:



May 2018

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

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 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:


Physicians and their professional associations have developed a myriad of Choosing Wisely statements. Transfusion Choosing Wisely statements were developed by AABB and the Canadian Society for Transfusion Medicine:


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:


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


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: 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




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:


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 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


March 2018

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

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)?

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.



  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 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.



  • 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. (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 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.



  • 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)


  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
  2. Clinical Guide to Transfusion, Chapter 15. Canadian Blood Services, 2017. Available at
  3. National Advisory Committee on Blood and Blood Products, draft Recommendations for use of Irradiated Blood Components in Canada. Available at
  4. National Advisory Committee on Blood and Blood Products
  5. Guide to the preparation, use and quality assurance of blood components. Council of Europe, 2017, pages 188 and 274. Available at
  6. Kopolovic I et al. A systematic review of transfusion-associated graft-versus-host disease. Blood 2015;126(3):406. Available at


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



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 ( or Dr. Russell MacDonald (



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.



  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 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.



  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

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


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 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


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).


  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
  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





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

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


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.

BE 4 Available Upcoming Events

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 to listen in and hear more about platelets! 

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