Tackling Ontario Transfusion Quality Improvement Plan Indicator Audits:
It May be Easier than You Think!
Danielle Watson, Charge Technologist, Grey Bruce Health Services
Lisa Ruston, Director, Quality, Risk and Medical Affairs, Peterborough Regional Health Centre
Yulia Lin MD, FRCPC, Transfusion Medicine Specialist, Sunnybrook Health Sciences Centre
Christine Cserti-Gazdewich MD, FRCPC, FASCP, Transfusion Medicine Specialist & Consultant Hematologist, University Health Network
Allison Collins MD FRCPC, ORBCoN Physician Clinical Coordinator
The Ontario Transfusion Quality Improvement Plan (OTQIP) was launched in 2015, with a goal of reducing unnecessary patient harm by improving the appropriate use of red cell transfusions. An important component of the program is the collection of indicator data for two quality indicators: the percentage of transfusions that occur with a pre-transfusion hemoglobin (Hb) of less than 80 g/L, and the percentage of single unit transfusions (defined as measurement of the Hb after the first unit is transfused and before the transfusion of subsequent units). The benchmark for each indicator is 80%, based on the results of an Ontario red cell utilisation audit performed in 2013. Indicator audit data can be entered into an online tool which allows a hospital to chart performance over time. So far, twelve Ontario hospitals are entering data into the audit tool. This article is intended to help other hospitals get involved in the OTQIP by gathering indicator data and entering it in the audit tool.
There seems to be some confusion about the data to be gathered by the indicator audits. These are not “appropriateness” audits, in which data on the patient’s signs, symptoms, co-morbidities, medical history, ordering physician, etc. are entered into the audit tool. Rather, the indicator audits are intended to provide a simple snapshot in time of transfusion practice. It is more important to track performance over time than to do large and complicated audits. So, rather than auditing 50 transfusions every quarter, measure 10 every six months, or something in between. Audit just one of the indicators if you can demonstrate that your hospital is performing reasonably well on the other one. Audit inpatients, outpatients, or ‘all-comers’ if you wish. Do not attempt to exclude bleeding patients or patients in specific inpatient locations unless you wish. The idea here is to keep things simple and make incremental change. We are trying to ‘eat the elephant’ just one bite at a time so we don’t choke on it. Every time you make a positive practice change, even if it is based on a small audit, you are making care safer for patients. In the end, that’s the goal!
There are several different approaches to doing these audits, and a few are presented here.
Method 1: Collecting audit data in real time as red cell orders are processed in the transfusion medicine laboratory (Grey Bruce Health Services):
In this corporation the technologists screen all transfusion orders for different time periods predetermined by site. When each transfusion order is received the technologist receiving the order would document 2 patient identifiers (MRN and initials), the pretransfusion hemoglobin (defined as within 12 hours of transfusion) and the number of units ordered. The next day a technologist working in Transfusion Medicine would follow up with the post-transfusion hemoglobin and document it (Note: the post-transfusion hemoglobin is not required for the OTQIP audit but is done at this corporation). The data would be recorded on an Excel spreadsheet or manually on a paper record, depending on the site. At the end of the data collection period all technologists share the responsibility for reporting into the QIP database, so that all become experienced with the use of the E-tool.
Method 2: Leveraging the power of your laboratory information system to gather audit data (University Health Network and Sunnybrook Health Sciences Centre):
At UHN, the blood bank information system (HCLL) is interfaced with the electronic patient record. For a given RBC transfusion, the most recent hemoglobin pre-transfusion is captured at the time of issue. The issue location of the patient is also captured. Thus, a report can be pulled generating the most recent Hb for RBC transfusion as well as the specific issue location. This report can be downloaded to generate the percent of pre-transfusion Hb < 80 g/L and can be broken down by location. For single unit transfusions using this same report, single units are defined as one transfusion given on one day.
At Sunnybrook, the report is done manually. A transfusion report is obtained for 5 days of transfusion which is about 75-100 RBC transfusions. For the first transfusion for each patient, the pre-transfusion hemoglobin is obtained. If there is more than one transfusion on the same day for a patient, the post-transfusion hemoglobin is also obtained. A single unit transfusion is defined as one unit given on a single calendar day or if more than one unit given on a day, then a single unit transfusion would have a pre and post-transfusion hemoglobin before the next transfusion. The report can then be separated into an inpatient and outpatient report based on location.
Method 3: Retrospective review of red cell transfusion data (Northumberland Hills Hospital).
This method is described for Meditech users. Periodically, print off a report of all red cell issues for a month, a quarter, or whatever time period will allow you to capture 10-50 transfusions, counting only the first transfusion for each patient. For example, the “BBK unit final disposition report” will do. Make up a worksheet with 5 columns labelled: Name, Date, Time, Hb and Number of Units. Look up a patient by name in the PCI module, go to the “Blood Bank Products” entries, select the first red cell unit issued for the time period being audited, and note the date and time of issue. In this screen, you can also see the patient location and choose not to include them in the audit if they are from, for example, the oncology clinic. Then go to the “Hematology” list, and note the pre-transfusion hemoglobin value. If there are multiple units transfused, select the first transfusion only, and determine if it’s a multi-unit transfusion if there is no Hb measurement between the time of the first and subsequent unit(s). Note the number of units transfused (either 1 or more than 1; the actual number beyond 1 doesn’t matter) and go on to the next patient. You can use patient ID number instead of name, of course, but it may be helpful to keep a list of chronically transfused patients so that they can be skipped whenever their name appears on the unit disposition report. This can take 1-3 hours per audit, depending on how many transfusions are audited. The data is easily summarized, either by hand or in a spreadsheet, then entered in the OTQIP audit tool.
Choose one of these auditing methods or develop your own and, remember, the best way to get something done is to get it started! The OTQIP and tools are available at www.transfusionontario.org. If your hospital is already gathering indicator data, please consider entering it into the OTQIP online audit tool if you are not already doing so.
The Ontario Transfusion Quality Improvement Plan and Choosing Wisely Canada:
It’s time for Medical Laboratory Technologist Choosing Wisely Statements
By: Denise Evanovitch, Regional Manager, SW ORBCoN
The Choosing Wisely movement began in the USA in 2012 and was physician driven. Choosing Wisely Canada (CWC) was launched in 2014 by a small group from the University of Toronto, the Canadian Medical Association and St. Michael’s hospital. It is now a global program that includes 20 different countries across 5 continents.
The purpose of the Choosing Wisely campaign is to bring attention to and reduce unnecessary tests, treatments, and procedures that do not add any value and worse, may cause patient harm.
If these processes are unnecessary, then why do they occur? There are many reasons. A few of them are:
- Practice habits are difficult to change, even when faced with new evidence
- Patients and their families can be misinformed and demand extra tests
- Lack of time for shared decision making between health care professionals and their patients/families
- Outdated computer and decision support systems that encourage over ordering
- Fear of malpractice
- Payment systems for clinicians that reward “doing something” rather than nothing
The Ontario Transfusion Quality Improvement Plan (OTQIP) Committee, ORBCoN and its working groups collaborated on developing the “Why Give Two When One will Do” OTQIP toolkit: https://transfusionontario.org/en/documents/?cat=quality-improvement-plan
Physicians and their professional associations have developed a myriad of Choosing Wisely statements. Transfusion Choosing Wisely statements were developed by AABB https://www.aabb.org/pbm/Documents/Choosing-Wisely-Five-Things-Physicians-and-Patients-Should-Question.PDF and the Canadian Society for Transfusion Medicine: http://www.transfusion.ca/Education/Choosing-Wisely
Some of the CWC recommendation statements related to transfusions include:
- Don’t transfuse more than one red cell unit at a time when transfusion is required in stable, non-bleeding patients
- Don’t order unnecessary pretransfusion testing for all preoperative patients
- Don’t routinely order preoperative autologous and directed donations
Nurses in Canada have developed their own profession’s Choosing Wisely statements: https://choosingwiselycanada.org/nursing/
At LABCON (the annual Canadian Society for Medical Laboratory Science-CSMLS conference) this year, I will be facilitating a session to begin the process of developing Choosing Wisely statements from a medical laboratory technologist’s point of view. Some statements will include transfusion but we will also be looking to the different specialties attending the session to broadly cover all laboratory aspects. Each statement must be backed by current literature. The ideas generated at the conference session will be collated and submitted for publication to share with the wider laboratory community and to generate even further interest among the technologists across Canada.
Do you have ideas for Choosing Wisely statements for technologists and other laboratory professionals? Please send your ideas and references to me at firstname.lastname@example.org
When health care professionals work together in quality improvement, our patients are the beneficiaries of improved healthcare. Isn’t that why we selected our profession in the first place?