March 2022

In This Issue

CSTM Standards Version 5: What to expect in this version

Danielle Watson-Kinney CSTM Standards Committee (Chair),
Dr. Elaine Leung Haematopathologist; Division of Haematology and Transfusion Medicine Children’s Hospital of Eastern Ontario (CHEO)

The CSTM Standards for Hospital Transfusion Services, Version 5 were released December 2021, and reflects evidence based best practice in Canada. This bilingual document is compliant with the CAN/CSA-Z902-20, National Standard of Canada Blood and blood components and the Health Canada Blood Regulations. This user-friendly document is meant to support safe transfusion practice in hospitals and assist in meeting accreditation requirements in some jurisdictions.

A great deal of gratitude is to be given to the CSTM standards committee members for providing their expertise and sacrifice of their personal time in providing these standards. The CSTM standards committee is a group of 10 volunteers from regional, community, and rural transfusion services and from both pediatric and adult academic centers across Canada. The committee is a diverse group of professionals consisting of Medical Laboratory Technologists, Registered Nurses, Physicians, and one Quality Systems specialist.

Work on the current version started in January 2020 with all meetings held virtually. Under normal circumstances our team would meet in person at the annual CSTM conference to develop a working plan that aligns with Health Canada Regulations and CSA Z902-20 revisions, but unfortunately the pandemic prevented these face-to-face meetings. As this is a volunteer committee, we were at times challenged with coordinating meetings as members have full time jobs and family commitments.

There were numerous minor changes and updates made to Version 5, many of which were intended to clarify the existing standard. There were also some significant changes which include:

  • the application of the requirement for confirmatory ABO testing of all recipients prior to transfusion of non-group O red cell units to all crossmatches, not just computer crossmatches
  • addition of separate sections and expansion of the clauses related to the Health Canada requirements for errors and accidents and adverse transfusion reactions
  • addition of a “general” section with respect to modification of blood components and blood products to provide guidance with respect to Health Canada expectations
  • inclusion of x-ray irradiators
  • recommendation for people 45 years or younger of childbearing potential to be transfused with K negative red cell units
  • addition of the requirement for temperature monitoring of blood component and blood product shipments
  • recommending that a policy for return of blood components and blood products to the Transfusion Service to include consideration for infection control

Guidance Statement Additions

  • 3.1.2 Equipment 
  •  5.4.3.1 Selection for Transfusion of ABO Compatible Plasma 
  •  5.3.7.1.2 (formerly 5.3.7.3.3 Serological Testing Positive Patient Identification PPID)

The CSTM Standards for Hospital Transfusion Services are not meant to serve as an operating procedure manual but to provide standards for the development of policies, processes and procedures, which should be included in the institution’s policy and procedure manual. The CSTM guidance statements are developed for our hospitals nationally and come from your “Ask the Standards” questions and comments to our committee. Please continue to submit your questions and feedback so we can continue to thrive and make Canadian healthcare a place where quality and best practice comes first in all our transfusion facilities.
Lastly, ORBCoN will be purchasing the CSTM Standards version 5, 2021 for all hospitals in Ontario. CSTM Standards are protected under copyright laws and are not to be copied or redistributed. Your CSTM individual memberships provides you with access to the online copy. CSTM is a non-profit society, and you are encouraged to become involved in CSTM. Go to the website www.transfusion.ca for details on how to become an individual or institutional member. Please consider serving as a volunteer on one of the many committees – it’s a great way to meet others in the Canadian transfusion community. Without volunteers we wouldn’t be where we are today!

An Ethics Review of the Ontario Contingency Plan for the Management of Blood Shortages

Wendy Owens, Rebecca Barty, Troy Thompson Ontario Regional Blood Coordinating Network (ORBCoN)

Following a debrief of a blood shortage simulation exercise in Ontario held in 2018 (1), a recommendation was made that there should be a review done of the provincial blood shortage plan to ensure it meets ethical guidelines. In 2021, ORBCoN contacted an ethicist to request such a review be initiated. This article highlights the purpose of an ethical review and the recommendations put forth by the ethicist after a review of the provincial blood shortage plan was completed.
What is an ethical review?
An ethical review of a document or process is done to ensure if meets ethical standards meaning that decisions will be made based on certain values and principles. A good decision-making process helps to build trust, to increase legitimacy and acceptability of decisions, and to effectively implement them. Its hallmarks are:

Accountability: decision makers are answerable to the public for the type and quality of decisions made or actions taken.
Openness and transparency: decisions are made in such a way that stakeholders know, in a full, accurate and timely manner, what decisions are being made, for which reasons, and what criteria were applied, and have the opportunity to provide input.
Inclusiveness: groups and individuals who are most likely to be affected by a decision are engaged in the decision-making and planning processes to the greatest extent possible.
Responsiveness: decisions are revisited and revised as new information emerges.
Intersectionality: an intersectional lens is applied to deliberation and decision making. (2)

When decisions need to be made in healthcare under circumstances where resources are in short supply, basing decisions within an ethical framework can help ensure care will be provided in an equitable manner that can be understood and accepted by all those affected.
The review of the plan included seeking feedback from stakeholders in healthcare that would need to apply the plan if a blood shortage occurs (clinical decision makers) or those that might be affected by the decisions made as potential recipients of blood products during a supply shortage event.
Strengths of the Ontario Plan included the fact that is harmonized with the National Plan for the Management of Shortages of Labile Blood Components, (3) and the fact that it defines a clear and consistent staged process of steps to follow dependent on the severity of the shortage. Another strength identified was that step wise mitigation steps are listed to help avoid an actual shortage occurring and having to make decisions to restrict access to blood.
In addition to these strengths, the plan was complemented on the focus of preparedness and the simulation exercises that have been held to ‘test’ it out and to raise awareness amongst stakeholders. It was suggested that the participants in any future simulation exercises should be expanded to include more clinical decision-makers as well as representation from recipient groups, especially those that are from vulnerable populations. Through the review process it was clear that prescribers and clinically decision-makers have confidence and trust in the blood system which will be an advantage should supply constraints occur and allocation decisions need to be made.
The review included some recommendations for improving the Ontario Plan. These included:

  • Improving inclusiveness and ensuring groups that have been marginalized in the past and excluded from decision making be consulted on any future iterations of the plan and be included in future simulation exercises. It was further suggested that adding training tools to help address awareness around these issues could improve the management of blood shortages within the province.
  • Improving transparency through making the plan more available publicly to aid in awareness of how hard decisions may need to be made and that they will be based on ethical principles. One of these principles is to ensure a patient, even if they are assessed to not receive the resource that is in short supply, will not be abandoned and will continue to receive every other alternative treatment available.
  • More preparation of clinical staff and hospital management will help ensure the decisions made in a blood shortage will be fair and just. Training of clinicians in their residency stage of education as well as development of tools and educational modules to support decision making would add value to the plan.

“The truth is, there will never be an easy or even distinctly ‘right way’ to make these decisions. Uncertainties will remain no matter what guidance is in place. However, some planning, support and other interventions can help mitigate primarily the moral harms faced by patients and secondly the effects of these hard decisions on decision-makers.” (4)

References:

  1. Ontario 2018 Blood Shortage Exercise Report http://transfusionontario.org/wp-content/uploads/2020/06/Ontario-2018-Blood-Shortage-Exercise-Report_Accessible.pdf 
  2. https://www.canada.ca/en/public-health/services/diseases/2019-novel-coronavirus-infection/canadas-reponse/ethics-framework-guide-use-response-covid-19-pandemic.html 
  3. National Plan for the Management of Shortages of Labile Blood Components Jan 2022. https://www.nacblood.ca/resources/shortages-plan/index.html 
  4. Ethics review for the Ontario Contingency Plan for Management of Blood Shortages. Schwartz L; Dec 2021.

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Upcoming Event: University of Toronto Transfusion Medicine Rounds

March 24th, 2022 @ 12:00 pm – 1:00 pm
RhIG administration in early Pregnancy Now and Moving Forward presented by Dr. Dustin Costescu