National Advisory Committee on Blood and Blood Products (NAC)

The National Advisory Committee on Blood and Blood Products (NAC) is an interprovincial medical and technical advisory body which provides professional leadership in assisting, identifying, designing, and implementing cost-effective blood and blood product utilization management initiatives for the optimization of patient care throughout Canada.

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In This Issue

  • Experience of MHP Implementation in 16 small rural hospitals
  • Massive Hemorrhage Protocol Implementation at Small Hospitals: Challenges, Possible Solutions, and Opportunities
  • Featured Resources
    • 19th Annual TM Education Web Symposium (Archive)
    • Ontario MHP: Guidance for small/remote hospitals
    • Implementation Checklist (MHP Toolkit) – Adult
    • Patient Transport (MHP Toolkit)
    • MHP Quality Metrics Portal
  • Upcoming Events
    • CSTM 2024
    • Transfusionists Talks
    • U of T Rounds

Experience of MHP Implementation in 16 small rural hospitals 

Dr. J. Radigan, FRCPC, Pam Vansteelandt, MLT, BSc., CLQM, MBA, Tasha Vandervliet, RN, BScN, Deanna Wright MBA, BSc, MRT(T) 
Stratford General Hospital-Interhospital Laboratory program, Stratford, ON 

The Interhospital Laboratory Partnership (IHLP) is a lab-partnership of 16 small, rural community hospitals in Southwestern Ontario. We have one blood bank hub site that does antibody identification, 8 sites that do basic blood banking and crossmatching, and 7 dispensary sites which only carry emergency O PRBCs onsite. 

Since the release of the MHP Toolkit in 2020, we have been transitioning from a lab-based Massive Transfusion Procedure to a Hospital-based Protocol. After some delays due to COVID and Health-human resource shortages, our sites have been either refining existing processes, or actively developing their Hospital/Alliance-specific MHPs. 

A multidisciplinary team including nursing, nurse educators, lab staff, pharmacy, and maintenance have contributed their expertise and experience to make implementation successful.  We have utilized the resources from the provincial MHPs. We have utilized the resources from the provincial MHP toolkit, and have attempted to optimize plans for unique local conditions.  Small rural sites have specific challenges that were not clearly addressed in the MHP Toolkit such as, the types and quantity of blood products available on site, staffing levels, and availability of transport.

Given the limited lab staffing at rural sites, we have opted to utilize prothrombin complex concentrates (PCC), instead of plasma. This enables nursing to remove the product from the lab and reconstitute; avoiding ABO incompatibility issues, thawing requirements and product ratio tracking. For similar reasons, we have also implemented the use of fibrinogen concentrate (FC) across the region as a replacement for cryoprecipitate.

To validate the proposed MHP processes before finalizing them, Mock Code Transfusions were held in various rural EDs and key care areas. This not only garnered stakeholder buy-in but also enabled the multidisciplinary team to assess necessary process changes at each level to align with protocol goals. These simulations underscored the importance of prioritizing transfers to larger centers and provided valuable practice opportunities for nursing staff in reconstituting and administering PCCs and FCs, as well as utilizing blood warmers and warming blankets.

Physician education is continuous. Given the diverse care provided by our medical staff, training for less common protocols competes with other priorities. The MHP undergoes review by the Medical Advisory Committee before approval. Transfusion training is integrated into Grand Rounds and other educational opportunities for medical staff.

We have been successful in consistent early administration of Tranexamic acid (TXA). We have recently involved local paramedics, with the objective to incorporate pre-hospital TXA administration, where possible.

Knowing the expectation for quality metrics has been helpful in the process, thus we took the approach of evaluating MHPs in terms of these quality metrics.  Quality data will be useful in both process improvement and optimizing future blood product inventory levels.

With guidance and data provided by ORBCoN and CBS, we envision walking this fine line of balancing responsible resource management while still ensuring effective MHPs at all our rural hospital sites.

Massive Hemorrhage Protocol Implementation at Small Hospitals: Challenges, Possible Solutions, and Opportunities 

Talal Mahdi, MD, FRCPC 
Hematopathologist, Eastern Ontario Regional Laboratory Association, The Ottawa Hospital 

Massive hemorrhage protocols (MHPs) are vital tools designed to expedite the provision of blood components in emergent situations based on best practices for the management of massively bleeding patients. These best practices include early identification of the massively bleeding patient, rapid provision of blood components and products, and a coordinated human resource response aimed at rapid identification of and control of bleeding. 

While all hospitals that contain emergency departments, operating rooms, and/or obstetrical services should have MHPs, there are certainly challenges that may come with their implementation. These can include engaging and educating clinical partners, staffing limitations, limited inventories of blood components and products, limited laboratory test variety, and the ability, or rather, the inability to offer definitive hemorrhage control. However, amidst these obstacles lie potential solutions to optimize MHP implementation and efficacy, and ultimately, improve patient care.  

Potentially the most significant obstacle to effective MHP implementation at small hospitals is the engagement and education of clinical colleagues. It is crucial that all individuals involved in carrying out the MHPs are engaged throughout the process, and all educated to be on the same page, as the MHPs require a rapid, coordinated team response. This can be done through the creation of specialized subcommittees as well as holding regular education and review sessions for all those who may be involved in the implementation.  

At the heart of MHP efficacy lies the timely identification of massively bleeding patients and the rapid provision of necessary blood components or products. However, staffing limitations pose a significant hurdle in this process. To address this, hospitals can implement after-hours working policies and procedures. By empowering physicians and nurses to obtain blood units with appropriate documentation outside regular hours, hospitals can bolster their ability to respond promptly to hemorrhage cases. 

Moreover, tailoring blood tests to match available resources during after-hours shifts can further streamline the process. Utilizing point-of-care instruments for this allows for efficient testing, enabling swift decision-making regarding blood component provision.  

If patient transfer is necessary, proactively preparing for such events can be accomplished by establishing clear criteria for MHP activation. Additionally, due to the scarcity of MHP activation in most centers, running regular mock MHP activities can help maintain staff competency and ensure readiness to execute protocols effectively when the need arises.  

Retrospective learning is a valuable tool as well, and implementing regular audits provides valuable insights from previous MHP activations, facilitating compliance with regulations and driving continuous quality improvement. 

Lastly, when faced with unavoidable blood components and product inventory limitations, it is important to foster communication and collaboration with nearby hospitals. This can bolster support during blood component and product shortages and patient transfers, forming a network of assistance in times of need.  

While challenges in implementing MHPs persist, proactive measures and innovative strategies offer pathways to surmount these obstacles. By leveraging adaptive solutions, maintaining a network of support with one another, and fostering a culture of continuous improvement, hospitals can enhance their capacity to respond swiftly and effectively to cases of massive hemorrhage, ultimately improving patient care. 

Featured Resources

19th Annual TM Education Web Symposium

Ontario’s MHP: Guidance for small/remote hospitals

Implementation Checklist (MHP Toolkit) – Adult

Patient Transport (MHP Toolkit)

MHP Quality Metrics Portal

Note: Each Ontario hospital will need to determine where the data for the metrics is housed within their facility and who will be responsible for gathering and entering the data.

Capture MHP Quality Metrics data, Auto-generate reports, Assess and improve specific metrics. Get more info at transfusionontario@gmail.com

Upcoming Events

Transfusionists Talk

CSTM 2024

U of T

June 20, 2024 @12pm-1pm

MLT Session – Interesting serology cases

Subscribe to U of T Transfusion Medicine Rounds mailing list to get registration details

Attachment(s)

Mystery in a Test Tube April 11, 2024

Tier 1

Tier 2

Tier 3

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Presented by: Sunitha Vege 

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The Blueprint for Massive Hemorrhage Protocol: Development, Implementation, and Optimization for Rural Hospitals

April 11, 2024

PresentationSpeaker
A practical approach to updating the Massive Hemorrhage Protocol (MHP) at your community hospital: What we have done and what we have learnedDr. Laura Stone , MD CCFP-EM
Emergency Physician

Sault Area Hospital
Chair, Sault Area Hospital Transfusion Committee
Assistant Professor, Northern Ontario School of Medicine

Manda Willette RN
ICU Nurse Educator and Collaborative Practice Specialist
Bringing your MHP to life: the roll out, the logistics and the trainingDr. Andrew Petrosoniak 
MD, MSc, FRCPC, Emergency Physician & Trauma Team Leader at St. Michael’s Hospital, Assistant Professor at the University of Toronto, Co-Founder of Advanced Performance Healthcare Design 
Transfusion in the pre-hospital and inter-facility transport systemDr. Michael Peddle 
FRCPC DRCPSC
Associate Medical Officer
Transport Medicine Physician 

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The ORBCoN Report, April 2024

In This Issue

  • ONIT Program Update
  • Needs Assessment Results: ORBCoN Bloody Easy Coagulation Simplified
  • Update Alert!
    • Blood Transfusion: Information for Patients
  • Featured Resources
    • Transfusionists Talk (archive)
  • Upcoming Events
    • CSTM 2024
    • 19th Annual Transfusion Medicine Education Web Symposium 
    • U of T Rounds

Program Update

Sarah Shehadeh1, Stephen Betschel2, Susan Waserman3, Danny Hill4, Donald William Cameron1,5, Juthaporn Cowan1,5*

1The Ottawa Hospital Research Institute, Ottawa, Ontario
2Department of Medicine, University of Toronto, Toronto, Ontario
3Deparmtnet of Medicine, McMaster University, Hamilton, Ontario
4Hematology Clinic, Ambulatory Care Unit, Sault Area Hospital, Sault Ste. Marie, Ontario
5Department of Medicine, University of Ottawa, Ottawa, Ontario
*Corresponding author

The Ontario Immunoglobulin Treatment (ONIT) Program is an Ontario government-approved and funded initiative designed to facilitate and manage home-based self-administered subcutaneous immunoglobulin (SCIG) treatment. The program provides care through hospital-embedded outpatient clinics, with nursing coordination, education, and follow-up, and medical oversight for indication, dosage titration, health outcomes and therapeutic re-evaluation.

We first introduced the program for ORBCoN members in the newsletter published in May 2020. The program was fully implemented at three centers (The Ottawa Hospital, St. Michael’s Hospital and McMaster University Medical Center) by the end of 2020. We also created a patient-consented case registry to collect data at the point-of-care. At present, there are close to one thousand patients enrolled in the registry, reflecting the program’s significant reach and impact. This database plays a crucial role in facilitating research, quality improvement initiatives, standardize care, and ensuring the continued effectiveness and safety of immunoglobulin therapy. Through the ONIT registry, we published an article on the clinical outcomes of immunoglobulin therapy in individuals with secondary antibody deficiency (PLoS One. 2023 Nov 16;18(11):e0294408. doi: 10.1371/journal.pone.0294408). We reported that immunoglobulin treatment reduced the average annual number of infections by 82.6%, emergency room (ER) visits by 84.6%, and hospitalizations by 83.3%. Overall, 84.6% of patients reported their health as better compared to before immunoglobulin treatment. Among those patients who switched from intravenous immunoglobulin (IVIG) to SCIG, 33.3% reported their health as the same, and 62.9% reported their health as better. This study demonstrated that immunoglobulin treatment significantly improved clinical outcomes and patient-reported general health state in patients with secondary antibody deficiency. The study also further supports the use of SCIG in patients with secondary antibody deficiency.

Additionally, we have developed an internal dashboard tailored for individuals involved in the program. Discussions are underway regarding the potential external availability of this dashboard, which would provide valuable insights and transparency into program operations and patient outcomes. Since 2023, the program has expanded to include Sault-area Hospital as the fourth center. We are evaluating the program expansion implementation process with the aim to enhance effective future program implementation to other sites through the continual support from the Ministry of Health.

Needs Assessment Results: ORBCoN Bloody Easy Coagulation Simplified

Troy Thompson ORBCoN Program Manager

Dr. Rita Selby Hematologist & Medical Director, Coagulation Laboratories, University Health Network & Sunnybrook HSC, Bloody Easy Coagulation Author

The Bloody Easy Coagulation: Simplified handbook provides practical information on coagulation. It is designed to enhance the knowledge of physicians, nurses and medical laboratory technologists about the basics of coagulation from laboratory testing to anticoagulant drugs and management of bleeding disorders.  ORBCoN has distributed over 15,000 handbooks to hospitals/facilities nationwide since Oct 2013 and had approximately 1000 views/downloads from our website annually.

In partnership with the Institute for Quality Management in Healthcare (IQMH), a needs assessment was conducted to gather information on the use of coagulation educational resources, especially the ORBCoN handbook, Bloody Easy: Coagulation Simplified (second edition) and its educational value to laboratory professionals in Ontario.

The following questions were added to the IQMH Proficiency Testing COAG-2308 survey.

A total of 178 laboratories participated in this survey. Results are shared below:

Question: How are the coagulation educational resources (e.g., published materials, online resources etc.) used in your laboratory? (Select all that apply*) (n=189)

*Multiple responses submitted

Question: Does your laboratory use Bloody Easy: Coagulation Simplified handbook / the online version? (n=184)

 Question: Please indicate the ways in which you use ‘Bloody Easy: Coagulation Simplified (Select all that apply*) (n=121)

*Multiple responses submitted

Question: What do you like most about the current version? (Select all that apply*)  (n=413)

*Multiple responses submitted

Question: How could the current edition be improved? (Please list up to 2)

Some of the suggested improvements:

  • Add multimer gel results for Von Willebrand Factor
  • Add case studies
  • Explain how HIL interferes with testing
  • Explain interference from prescription drugs
  • Flow charts to evaluate abnormal coagulation tests
  • Ways to assess competency
  • Slightly larger print
  • More details on treatments

The results of this needs assessment survey will be used to guide the revision process for the next version of the Bloody Easy: Coagulation Simplified Handbook. 

We would like to thank all the participating laboratories for their responses to this survey. To order the Bloody Easy: Coagulation Simplified handbook or other ORBCoN resources please visit:  transfusionontario.org/order-resources

📣 Update Alert

Blood Transfusion: Information for Patients

Risks of Transfusion Table has been corrected in the Blood Transfusion: Information for Patients document. Please discard and replace any previous versions you may have with this version

Featured Resources

Transfusionists Talk

Bedside Audit of Blood Administration Version 2

Upcoming Events

CSTM 2024

U of T

April 18, 2024 @12pm-1pm

Exploring the relevance of race and ethnicity in transfusion medicine by Sunitha Vege

Subscribe to U of T Transfusion Medicine Rounds mailing list to get registration details

Attachment(s)

Donna Berta, RN, BScN

Access version with interactive patient case learning opportunities here

Attachment(s)

https://transfusionontario.org/wp-content/uploads/2024/04/Transfusionists-Talk-2024-Mar-The-Elephant-in-the-Transfusionists-Skill-Set.pdf

In This Issue

  • Ministry of Health / ORBCoN Immune Globulin Quality Improvement Project
  • ORBCoN Immune Globulin Resources – 2024 Update
  • Upcoming Events
    • CSTM 2024
    • 19th Annual Transfusion Medicine Education Web Symposium 
    • Transfusionists Talk
    • U of T Rounds

Ministry of Health / ORBCoN Immune Globulin Quality Improvement Project

Laura Aseltine, ORBCoN Regional Project Coordinator, SW Office

In December 2020, the Office of the Auditor General of Ontario released the Value for Money Audit on Blood Management and Safety. The audit identified 13 recommendations for the Ministry of Health (MOH) to support an ongoing safe and stable supply of blood and blood products for Ontarians provided within a cost-effective and evidence-based context. Recommendation three spoke to management of supply and demand of immunoglobulins (IG) in Ontario, making sure they are available to those who need them most and avoiding the costs of wasted product, specifically “collect more complete data from hospitals on how immunoglobulins are being used and identify emerging conditions that may warrant inclusion in the provincial utilization guidelines.” 1

Currently in Ontario, paper request forms detailing the MOH approved IG indications are available for prescriber use when submitting requests to the Transfusion Medicine Laboratory (TML). Although all paper request forms must be submitted to TML for review and approval2 none of the stakeholders, including Canadian Blood Services (CBS), the MOH or the Ontario Regional Blood Coordinating Network (ORBCoN), collect comprehensive electronic data on how IG products are prescribed in hospitals (e.g., labelled medical indication for use, assessment of appropriate dose, or to what extent IG is being utilized to treat conditions for which there is limited/no evidence to support their use3). The lack of this data challenges investigation of the expanding IG utilization and the rate of guideline compliance. In the past, ORBCoN performed audits to evaluate practice and prepared formal reports to increase awareness of appropriate use4,5,6.

Upon release of the Value for Money Audit, ORBCoN set to work on the Immune Globulin Quality Improvement Project (IG QIP) to develop an IG request form electronic database to collect the rich information that is currently gathered on the paper MOH IG Request Forms. The team’s aim was to ensure that this process was mutually beneficial to both the MOH, as well as the hospital users choosing to share their IG data. Utilizing the Research Electronic Data Capture (REDCap®)7 platform (familiar to Ontario TMLs based on previous ORBCoN projects), a database was designed. The following beneficial features were implemented:

  • Organizing the REDCap electronic record form to mirror the information collected on the paper MOH IG Request Form would limit TMLs searching sources/systems for the essential data.
  • Embedding the IG “Dosing Using Adjusted Body Weight” calculator within the REDCap electronic record form facilitates real time data entry by end users, limiting the need to link to additional web-based programs.
  • End users with established sophisticated electronic data sets in their Laboratory Information Systems can electronically upload IG data into REDCap, avoiding people resource intensive manual data entry.
  • Site specific electronic alerts are generated when an IG request has reached its 6-month or one year renewal date, saving TMLs time (an alternative to manually searching paper MOH IG Request Forms) when determining requests requiring prescriber review.
  • Providing templated reports for users who wish to download their IG data and present it to their transfusion committee or quality improvement teams to evaluate hospital utilization and workflow.

The MOH, via ORBCoN, has launched the IG QIP in response to recommendations within the Value for Money Audit, Blood Management and Safety1. Furthermore, to endorse best practice for hospitals and their patients, ORBCoN has developed an efficient means to delineate IG utilization based on current provincial guidelines and evolving evidence-based indications. At present, hospital participation is voluntary. As the benefits are realized, it is anticipated that adoption of the IG QIP process will grow.

If your hospital would like more information about the IG QIP, please reach out to Laura Aseltine (ORBCoN IG QIP project lead) at aseltinl@mcmaster.ca.

References

  1. Value-for-Money Audit: Blood Management and Safety (2020) [Internet]. Office of the Auditor General of Ontario. 2020. p. 1–68. Available from: Value-for-Money Audit: Blood Management and Safety (2020) (auditor.on.ca)
  2. The Ontario Regional Blood Coordinating Network. Ordering IG in Ontario [Internet]. 2018. Available from: https://transfusionontario.org/en/category/ivig-scig/ordering-igin-ontario/  
  3. Shih AW, Jamula E, Diep C, Lin Y, Armali C, Heddle NM, et al. Audit of provincial IVIG Request Forms and efficacy documentation in four Ontario tertiary care centres. Transfus Med. 2017;27(2):122–31.
  4. ORBCON (Ontario Regional Blood Coordinating Network). Intravenous Immune Globulin (IVIG) 2012 Audit Report [Internet]. 2012. Available from: https://www.mendeley.com/catalogue/intravenous-immune-globulin-ivig-2012-audit-report/
  5. The Ontario Regional Blood Coordinating Network. Audit of Intravenous Immune Globulin (IVIG) Indications and Effectiveness in Ontario Tertiary Care Centres [Internet]. 2015. Available from: https://transfusionontario.org/wp-content/uploads/2020/05/Audit-of-Intravenous-Globulin-IVIG-Indications-and-Effectiveness-in-Ontario-Tertiary-Care-Centres-2015.pdf
  6. The Ontario Regional Blood Coordinating Network. IG QIP Project Protocol [Internet]. 2023. Available from: IG QIP – Transfusion Ontario
  7. PA Harris, R Taylor, BL Minor, V Elliott, M Fernandez, L O’Neal, L McLeod, G Delacqua, F Delacqua, J Kirby, SN Duda, REDCap Consortium, The REDCap consortium: Building an international community of software partners, J Biomed Inform. 2019 May 9 [doi: 10.1016/j.jbi.2019.103208]

ORBCoN Immune Globulin Resources – 2024 Update

Donna Berta, ORBCoN, Clinical Project Coordinator Nursing

Immune Globulin (IG), both intravenous (IVIG) and subcutaneous (SCIG), is an extensively used blood product. To fulfill the Ontario Regional Blood Coordinating Network’s (ORBCoN) mission, “inspiring and facilitating best transfusion practices in Ontario”1 a wealth of IG resources are available on the ORBCoN website.

The IG landing page was introduced to streamline and simplify navigating ORBCoN’s website. From the ORBCoN website, https://transfusionontario.org/en/, select the Resources tab, and then click the heading “IVIG/SCIG” to explore the landing page (refer to Figure 1).  

Figure 1: ORBCoN Website: IVIG/SCIG Landing Page

The landing page identifies each of ORBCoN’s IG resources on a card. A synopsis and time stamp of each of these IG resources is presented (refer to Table 1).

One page summary regarding using the MOHLTC IG Request Form.
Ontario MOHLTC IG Request Form Neurology and
Ontario MOHLTC IG Request Form Non-Neurology
(including fillable formats).
Version January 31, 2018.
Recommended IG indications (with additional information) as well as dose and frequency of administration are listed by clinical service. Some indications where IG is not recommended for routine use are also detailed.
Seven IG utilization strategies for all hospitals where IG is prescribed.
Version January 31, 2018
The patient’s sex, height, and weight are entered to calculate:
Ideal body weight and dosing weight
IVIG dose (select dose) and rounded dose
Body mass index (BMI).
A mobile app is available with these calculations as well as the recommended IG indications information.
Version January 31, 2018
Centralized repository for IG utilization data to endorse continuous audit and feedback for IG stewardship (voluntary participation). Includes protocol, user guide, tracking log, survey for registration to participate link, and REDCap repository log on link. 
Version September 2023
MOH/ORBCoN IVIG audit reports 2012 and 2015.
Incorporates six resources in one document:
Ordering IG in Ontario, Utilization Management Guidelines,
Dosing Using Adjusted Body Weight, Facts for Patients,
Travelling with IG and Infusion Guide and Adverse Events.
Version January 31, 2018
Downloadable and print ready IG information (what, why, how, risks, and side effects) for outpatients who are being treated with IVIG.
Version October 31, 2015
This resource is being revised; an updated version is anticipated April 2024.
Information regarding receiving infusion of IVIG outside of Ontario, with IVIG supplied by an Ontario hospital (participation agreement/ patient responsibilities, letter from treating physician to travel destination health care prescriber, and IVIG travel letter for the patient regarding their IVIG vials and ancillary supplies).
Version January 2018
Reviews general practices when administering IVIG (pre, during, and post infusion), infusion rate increment tables (IVIG brand specific, adults, five-kilogram weight range categories), and an adverse reaction chart listing signs and symptoms, possible etiology, as well as suggested treatment/actions and strategies to mitigate.
Version March 10, 2022
Table 1: Description of ORBCoN’s IG Resources

Resources specific to SCIG are structured within the ORBCoN Home Infusion Toolkit. This toolkit outlines the requirements for hospitals that issue home infusion products to patients. Example documents to support and manage such programs are also provided.

ORBCoN has developed IG resources to assist hospital Transfusion Medicine laboratories and health care providers to treat patients following best practice, evidence-based standards. The Utilization Management Guidelines (as well as Ordering IG in Ontario, which is informed by the Utilization Management Guidelines) are currently being evaluated for additional evidence-based information. To learn more about the newest resource, the IG Quality Improvement Project (IG QIP), refer to that article in this March 2024 Newsletter.

Feedback regarding these resources or suggestions for alternate resources that would be of benefit is most appreciated. Reach out to your regional ORBCoN office (contact details found at https://transfusionontario.org/en/contact/).


References

  1. Ontario Regional Blood Coordinating Network. About us [Internet]. Toronto ON; Ontario Regional Blood Coordinating Network; 2006 [revised 2020 cited 2024 Jan 23]. Available from: https://transfusionontario.org/en/about/
  2. Ontario Regional Blood Coordinating Network. IVIG/SCIG [Internet]. Toronto ON; Ontario Regional Blood Coordinating Network; 2023 Dec [cited 2024 Jan 23]. Available from: https://transfusionontario.org/en/category/ivig-scig/
  3. Ontario Regional Blood Coordinating Network. Home Infusion Toolkit [Internet]. Toronto ON; Ontario Regional Blood Coordinating Network; 2019 Dec [cited 2024 Jan 23]. Available from: https://transfusionontario.org/en/category/toolkits/home-infusion-toolkit/

Upcoming Events

CSTM 2024

Transfusionists Talk

19th Annual Transfusion Medicine Education Web Symposium

U of T

March 28, 2024 @12pm-1pm

Subscribe to U of T Transfusion Medicine Rounds mailing list to get registration details

Attachment(s)

Presented by: Dr. Deborah Siegal and Dr. Jeffrey Carson 

U of T Evaluation Survey Link

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