Presented by: Sunitha Vege 

Attachment(s)

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

April 11, 2024

Attachment(s)

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 Cameron^1,5, Juthaporn Cowan^1,5*

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)

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 use^4,5,6.

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).  

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

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

Attachment(s)

In This Issue

• Highlights from the ORBCoN/FCRP Redistribution Summit
• Redistribution Summit 2023: Charting the Future Course for Ontario’s Redistribution Program Optimization through Collaborative Vision
• Featured Resources
  • MHP Podcast
• Upcoming Events
  • 19th Annual Transfusion Medicine Education Symposium 
  • CSTM 2024
  • Transfusionists Talk
  • U of T Rounds

Overview of the Provincial Factor Concentrate Redistribution Program

Sarah Crymble, Hemophilia Provincial Coordinator, St. Michael’s Hospital

We’re thrilled to bring you the latest updates from the Factor Concentrate Redistribution Program (FCRP), as showcased in the recent ORBCoN/FCRP Redistribution Summit. The FCRP program is on a mission to efficiently distribute short-dated Plasma Protein and Related Products (PPRPs) to patients across Ontario, with St. Mikes at the forefront due to its high patient volume and remarkable home care program, making them an ideal site to receive over 80% of all product.

Key Highlights

1. Efficient Redistribution:
   Our commitment to efficiently redistribute short-dated PPRPs is a cornerstone of the FCRP program. By optimizing the distribution process, we ensure that these crucial products reach patients in need across Ontario promptly.
2. Product Availability:
   We’re calling on all stakeholders to join hands in ensuring timely redistribution. If you have PPRPs available for redistribution, please notify us as soon as possible. The more time the better! Giving us the maximum amount of time will ensure we can get the product and used before expiry.
   The introduction of Hemlibra means there are less patients to use redistributed PPRPs. Another reason to give us as much time as possible to find a hospital to take short dating product.
   Finally, when restocking PPRPs, please make sure that you do not receive the same lot number that you are trying to redistribute. If you are ordering more stock, please check with CBS first to ensure that you are getting long-dated products.
3. Secure Packaging and Shipping:
   Maintaining the highest standards is paramount. We emphasize the secure packaging and shipping of all products, following protocols set by ORBCoN and Canadian Blood Services (CBS) based on precondition parameters. This commitment ensures the integrity of our products and, most importantly, upholds patient safety throughout the entire redistribution process….and as always, remember to seal the box!
4. Our successes over the years:
   The FCRP has been a beacon of efficiency and resourcefulness since its inception in 2007. It’s truly heartening to see how we have all managed to prevent millions of IUs from going to waste. Over the past 16 years, FCRP has impressively redistributed nearly 17,000,000 IUs of PPRPs and 8352mg of product. This translates into an astounding savings of approximately $25,000,000 CDN – a testament to the program’s effectiveness. All these remarkable achievements have been realized at a modest cost of $360,000 for running the program.

A Heartfelt Thank You:
To our partners, contributors, and advocates – thank you for your unwavering support. Your commitment plays a pivotal role in making a positive impact on health care across Ontario. Together, we’re creating a network of care and support that reaches every corner of the community.
If you have any questions or want to learn more about the Factor Concentrate Redistribution Program, please reach out to us at sarah.crymble@unityhealth.to
Let’s continue making a difference together!
Warm regards, Sarah and Antonette

Redistribution Summit 2023: Charting the Future Course for Ontario’s Redistribution Program Optimization through Collaborative Vision

Valérie Rhéaume, MLT
Project Coordinator for the Ontario Regional Blood Coordinating Network (ORBCoN)

An in-person meeting was held on December 11th, 2023 to discuss the Ontario redistribution program. This was a pivotal gathering that brought together key stakeholders from hospital laboratories primarily focusing on the collaboration between ORBCoN, FCRP, CBS and laboratories. The event aimed to address existing challenges, share insights, and strategize for future improvements for Ontario’s redistribution program.

Participants included 4 members from ORBCoN, 2 Ministry of Health representatives, 2 members of the FCRP program, a Hospital Liaison Specialist from CBS and 9 laboratory leaders that represented medium, regional, and large-sized hospitals that offer varying levels of transfusion medicine services. All participants were able to actively contribute to the discussions. Representatives from small-sized hospitals were invited, but none were unable to attend.

The summit featured five presentations, covering topics such a review of the FCRP program, a review of the results from the environmental scan survey, a review of the challenges encountered, the current redistribution processes for blood component and plasma protein and related products (PPRP), the challenges encountered with the redistribution program processes, as well as challenges with reporting and definitions of dispositions for blood components and PPRP from CBS. Round-table discussions with participants were facilitated by ORBCoN that focused on logistics and shipping container issues, troubleshooting the patient transfer process, and suggested improvements for the redistribution toolkit. The summit concluded with the identification of participants willing to form a provincial working group, signalling a commitment to collaboratively drive future improvements for Ontario’s redistribution program.

Key points that the group identified as next step deliverables were:

1. Perform an in-depth review of the redistribution toolkit, incorporating suggestions to enhance the process for patient transfers and implementing standardized definitions for reporting disposition.
2. The establishment of a dedicated working group tasked with the ongoing improvement of the redistribution processes, ready to address emerging challenges collaboratively.

This strategic approach would bolster the efficiency and effectiveness of the redistribution program to ensure successful redistribution in the province of Ontario.

The summit served as a platform for constructive discussions and collaborative problem-solving and was overall received as a success. One of our participant’s shared with us the following comment: “As always, very well done!” The active participation of diverse stakeholders ensured a comprehensive and inclusive approach towards addressing the challenges, and strategized on enhancing the redistribution program. Stay informed about the upcoming enhancements to our redistribution toolkit by visiting our website, following us on social media, or joining our annual site visits for an exclusive look at the exciting changes that will take place.

Featured Resource

Memorandum of Understanding

Has your lab signed theirs? Find the list here.

7 Ts of Massive Hemorrhage Protocol Podcast

In this episode – The 7 Ts of Massive Hemorrhage Protocols, Dr. Jeannie Callum, Dr. Andrew Petrosoniak and Dr. Barbara Haas join Anton in answering the questions related to MHP

Upcoming Events

19th Annual Transfusion Medicine Education Web Symposium

CSTM 2024

Transfusionists Talk

U of T

February 22, 2024 @12pm-1pm

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

Attachment(s)

Presented by: Cassandra D. Josephson, MD

January 25, 2024

U of T Evaluation Survey Link

Attachment(s)

Attachment(s)

In This Issue

• Bloody Easy Blood Administration eLearning course- 2 Year Anniversary!
• MHP 2.0 – An Educational Symposium
• Small-Volume Tubes to Reduce Anemia and Transfusion (STRATUS) Clinical Trial
• Featured Resources
  • MHP 2.0 Archive
• Upcoming Events
  • Transfusionists Talk (Save the Dates)
  • U of T Rounds

Bloody Easy Blood Administration eLearning course- 2 Year Anniversary!

Transfusionist Education and Competency Assessment: Bloody Easy
Troy Thompson- ORBCoN Program Manager and Donna Berta- ORBCoN Clinical Project Coordinator

The Canadian Transfusion Medicine standards mandate that all individuals performing activities related to blood transfusion participate in training and competency assessment programs^1,2. The skills, theoretical and practical knowledge, essential to their role responsibilities must be addressed^1,2.  The Ontario Regional Blood Coordinating Network’s (ORBCoN) mission is “inspiring and facilitating best transfusion practices in Ontario”³.

The Bloody Easy Blood Administration eLearning course was re-developed/launched in December 2021. The course was developed to help hospitals with standards and accreditation requirements.  Revisions to the BEBA eLearning module (figure 1) were based on principles of adult learning, recognizing transfusionists as mature learners with an abundance of prior learning experiences^4,5. Module content is organized to align with the procedural steps for blood administration. Interactive activities are a strategic design element to inform learning (figure 2). The assessment quiz incorporates scenario-based questions and provides immediate explanation for the correct responses. For successful completion, 80 percent correct responses are required (multiple attempts are permitted). Expertise in clinical content and innovative use of software simulation tools supported the module development process. The material is reinforced by the BEBA handbook, a widely used clinical practice reference.

The BEBA eLearning module is available to Ontario facilities via ORBCoN’s Sharable Content Object Reference Model (SCORM) files and through a Canadian health care focused Learning Management System (LMS) provider. The LMS provider enables ORBCoN to independently track eLearning utilization, specifically aggregate assessment quiz responses. These outcome metrics will endorse ongoing appraisal of the module and identification of knowledge gaps to be addressed.

Since December 2021, the inaugural year, there has been significant uptake of the eLearning course. Approximately 41 facilities accessed the SCORM files for their site.  Data from the LMS provider reported an additional 129 facilities (including 12 colleges/universities) and over 7500 individuals have utilized the module (figure 3).

The BEBA eLearning module was updated to reflect self-directed learning, current TM standards and best practices. There has been positive uptake of the module by hospitals as well as colleges and universities. Quiz outcome metrics will be analyzed to identify foci for further learning. The BEBA eLearning module serves to meets the mandate of the Canadian standards, while also informing clinical practice to enhance the safety of blood transfusion.  The current eLearning module and quiz will be further revised in 2024/25.

REFERENCES

1. National Standard of Canada Canadian Standards Association (CA) Blood and blood components. Toronto ON; 2020 Mar 24; cited 2023 Mar 10. 162 p. Report No.: CAN/CSA-902:20. Available from: https://community.csagroup.org/docs/DOC-126295
2. Canadian Society for Transfusion Medicine (CA) Standards for hospital transfusion services. Markham ON; 2021 Dec 1 [revised 2022 Dec cited 2023 Mar 10]. 114 p. Report No.: Version 5. Available from: https://www.transfusion.ca/Resources/Standards
3. Ontario Regional Blood Coordinating Network. About us [Internet]. [Place unknown]: Ontario Regional Blood Coordinating Network;  2006 [revised 2020 cited 2023 Mar 10]. Available from: https://transfusionontario.org/en/about/
4. Knowles MS. The modern practice of adult education: from pedagogy to andragogy. Rev. and updated. Wilton, Connecticut. Chicago:  Association Press; 1980. 400 p.
5. Hutchinson AM, Estabrooks CA. Educational theories. In: Straus SE, Tetroe J, Graham ID, editors. Knowledge translation in health care: moving from evidence to practice. 2nd ed. Hoboken, New Jersey: Wiley Blackwell BMJ Books; 2013. p. 298-307.

MHP 2.0 – An Educational Symposium

ORBCoN, Central Region

On November 9^th 2023, 109 multi-disciplinary healthcare professionals from across Ontario and beyond attended ORBCoN’s Massive Hemorrhage Protocol (MHP) 2.0 educational symposium. The goal of the symposium was to bring together stakeholders to present new topics relevant to the massively bleeding patient, provoke discussion and share the latest in evidence that may impact the current iteration of Ontario’s First Recommendations of Massive Hemorrhage Protocol.

The educational event focused on the following 3 fundamental questions:

1. What have we learned?

• data on provincial survey results and pilot data on quality metrics portal 

2. What can we expect?

• Impending changes due to new products, new trials and new publications   

3. What do we do next to update recommendations and improve current practice? 

• pre-hospital red blood cell transfusion; Tranexamic acid
• clinical event debrief
• addressing barriers to change

As illustrated in figure 1 below, a significant improvement in the number of hospitals with a formal MHP in place with a net increase of 25 hospitals since 2018.

47% (75) of hospitals have a formal MHP in place. A further 30% (47) indicated they were partially aligned with the Ontario Recommendations. 37% do not have an MHP in place however, 18% (29) of those who do not indicated that they were currently working towards a protocol and alignment with Ontario Recommendations. 7% (8) of hospitals (7 small and 1 large) in Ontario do not have an MHP in place and are not currently working towards one at the time of survey. 

We hear you!!  … but patients with massive hemorrhage can present to any hospital.

• Ensure you have a policy to transfer the patient out for definitive damage control.
• Leverage the resources you have. Consider a regional policy or learn how others with similar size and services manage or check out the non-definitive setting checklist available to you.

Although huge strives have been made in the province over the last five years to standardize the care of the massively bleeding patient, there remains room for improvement. As we work on MHP 2.0 in 2024 we will look to continue to reduce policy variability, increase inclusion of pediatric provisions for those hospitals that care for children (only 56 hospitals out of 101 who indicated they care for patients under the age of 18 include provisions for population) and continue to ensure quality assurance and adherence.  

Presentations have been archived and can be found here

Small-Volume Tubes to Reduce Anemia and Transfusion (STRATUS) Clinical Trial

Dr. Deborah Siegal, MD MSc FCRPC, Hematologist (Thrombosis), The Ottawa Hospital
Associate Professor, Department of Medicine, University of Ottawa
Scientist, Clinical Epidemiology Program, Ottawa Hospital Research Institute

Patients with critical illness in the intensive care unit (ICU) are at high risk for anemia which affects 90% after only 3 days in ICU. About 40% of ICU patients receive at least one red blood cell (RBC) transfusion to correct anemia, half of which are given in the absence of active bleeding. Both anemia and RBC transfusion are associated with adverse outcomes including higher mortality, and longer ICU and hospital admission.

Although anemia is multifactorial, blood sampling for laboratory testing is substantial with volumes of 41 mL/day or more than 200 mL during ICU admission. This is like donating a unit of blood after 8 days in ICU. For each additional 150 mL drawn, the risk of RBC transfusion is increased 2-fold.

However, unlike healthy blood donors, ICU patients are unable to increase the production of RBCs to compensate for blood loss. Reducing RBC transfusion, a scarce and costly treatment with well-described risks, is viewed widely as a clinical priority for ICU patients.

Laboratory testing, a modifiable contributor to anemia and RBC transfusion, is an ideal target because only 10% of the blood collected is required for testing and the remainder is discarded. However, there have been legitimate concerns about negative effects on laboratory testing, especially specimen sufficiency.

We conducted the Small-Volume Tubes to Reduce Anemia and Transfusion (STRATUS) Trial to test the hypothesis that switching to tubes that “automatically” collect less blood for lab testing (so called small-volume or low-vacuum tubes) reduces RBC transfusion in ICU patients (https://jamanetwork.com/journals/jama/fullarticle/2810758). These tubes have the same cost and size as the standard-volume tubes so are compatible with lab equipment, but they have lower vacuum and fill to a lower predetermined volume.

We used an innovative stepped wedge cluster randomized trial design in which ICUs switched from standard- to small-volume tubes according to a randomized schedule. STRATUS involved 25 academic and community ICUs in Canada with data collected from over 27,000 patients admitted to ICU for 48 hours or longer. Implementation of small-volume tubes reduced RBC transfusion during ICU admission by about 10 units per 100 patients. After switching to small-volume tubes, the decrease in hemoglobin during ICU admission was lower. Importantly, there was no negative effect on blood sample sufficiency. Although the COVID-19 pandemic affected study conduct and analyses, taken together, the findings support implementation of small-volume tubes.

Small-volume tubes were ordered using existing hospital infrastructure and implemented by hospital staff with brief targeted education. An important limitation is that non-ICU hospitalized patients were not included. However, reducing blood loss is expected to have broad benefit, as excess volume does not add value to care and may be harmful. Implementation strategies may be different in other settings.

While transition to small-volume tubes had a small effect on individual patients, if implemented widely, they have potential for significant impact on health systems and the blood supply. In STRATUS, over 36,000 RBC transfusions were given in less than 2 years; use of small-volume tubes saved about 1500 units of blood. Efforts to sustain the supply of blood products are critical to ensure they are available when needed especially during ongoing shortages in Canada.

Featured Resources

MHP 2.0

Upcoming Events

Transfusionists Talk

U of T Rounds

January 25, 2024 @12pm-1pm

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

Attachment(s)