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.