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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the wide variation in red blood cell (RBC) and frozen plasma (FP) utilization (includes transfused, discarded and outdated) rates across 62 community hospitals in Ontario.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 www.transfusionontario.org 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); https://doi.org/10.1111/trf.15070
  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); https://doi.org/10.1111/trf.13848
  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; http://doi.org/10.1111/trf.13718

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 www.blood.ca). 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 (www.choosingwisely.org and www.choosingwiselycanada.org), and the National Advisory Committee on Blood and Blood Products (www.nacblood.ca) 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 (www.cihi.ca). 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 www.transfusionontario.org under the “Blood Utilization” tab.