Is Your Hospital Using Blood Wisely?

RNAO is a member of Choosing Wisely Canada and together we partner in both advancing RNAO’s best practice guidelines and helping reduce unnecessary tests and treatments in health care through Choosing Wisely initiatives. We appreciate their contribution of the following article with important recommendations for making our blood supply and hospital services more efficient and accessible.

Every day, countless Canadians roll up their sleeves to donate blood. The generosity of donors from across the country has created a robust national blood supply that is essential for everyday medical procedures.

Yet, as seen at the height of the COVID-19 pandemic, hospitals across the country faced increasing pressures to avoid blood shortages. The postponement of elective surgeries and subsequent resumption in June caused additional concerns about the availability of blood products. While Ontario hospitals were able to avoid critical shortages, the challenges of managing the demand and supply of blood, especially in a crisis, reinforced the importance of using finite health care resources wisely.

Choosing Wisely Canada is the national voice for reducing unnecessary tests and treatments in health care—things that do not add value for patients, potentially expose them to harm, and consume precious time and resources. Since 2014, Choosing Wisely Canada has worked with professional societies and associations, including those representing nursing, to publish over 380 specific practices that should be stopped, with patient groups to increase awareness about the risks and benefits of tests and procedures, and with provider organizations to re-engineer their internal processes to be more evidence-based.

A number of Choosing Wisely Canada’s recommendations zero in on how we use blood. For example: “Don’t transfuse more than one red cell unit at a time when transfusion is required in stable, non-bleeding patients.” Current science says that in a stable, non-bleeding patient, often a single unit of blood is adequate to relieve patient symptoms or to raise the hemoglobin to an acceptable level. Transfusing two units at a time is common practice in many hospitals, but should no longer be the default. Yet, a recent province-wide audit of Ontario hospitals showed a 10-fold difference in red blood cell transfusion rates between the highest and lowest users. Another audit of 10 hospitals in Ontario found 1 in 5 red cell transfusions may be unnecessary.

This September, Choosing Wisely Canada and Canadian Blood Services is launching Using Blood Wisely, a national campaign to decrease inappropriate red blood cell transfusion practices in Canada. The campaign challenges hospitals across Canada to conduct a spot audit of recent red blood cell transfusions to see how they compare to national appropriateness benchmarks. These benchmarks are:

• At least 65% of red blood cell transfusion episodes are single unit transfusions
• At least 80% of inpatient red blood cell transfusions have a pre-transfusion Hb 80 g/L or less

Hospitals that meet these benchmarks will get designated as a “Using Blood Wisely Hospital” and be recognized nationally. Those that do not can enrol in a quality improvement program proven to reduce inappropriate transfusions and qualify for designation upon meeting the benchmarks.

Nursing plays a critical role in ensuring that evidence-based transfusion practices are followed. Nurses are an important part of the transfusion team that includes the ordering clinicians (including NPs) and the medical laboratory technologists in the blood bank. Often, the nurse may be the individual who follows up on abnormal hemoglobin results and is also aware of whether the patient is symptomatic or bleeding. The nurse will also be the first point of contact for the medical laboratory technologists calling the floor to inquire about the patient’s status, and the first to notice most of the acute adverse events related to transfusion.

The Registered Nurses’ Association of Ontario (RNAO) is an active member of the Choosing Wisely Ontario steering committee. The steering committee has made improving transfusion appropriateness a major priority and will be working with a variety of health sector partners to encourage hospital participation in the Using Blood Wisely campaign. You can learn about how to get involved by visiting: UsingBloodWisely.ca

This week, Choosing Wisely Canada also released a report called “Not Necessary: Policy Ideas for Limiting Low-value Care in Canada.” In addition to ways health system decision-makers can reduce inappropriate use of blood components and products, the report offers four other big ideas to thoughtfully affect the state of low-value care across Canada during the pandemic and beyond. The ideas are:

Idea 1: Streamline the perioperative pathway for scheduled surgeries and procedures to reduce wasteful practices and manage increasing demands for surgery. This includes reducing unnecessary pre-operative testing, redesigning surgical queues, and investing in virtual care to improve efficiency and minimize physical contact across the perioperative journey.

Idea 2: Reduce low-value laboratory testing that lead to additional downstream testing and tie up resources that could otherwise be used to provide high-value services.  This includes retooling lab requisition processes at the provincial and organizational levels with built in appropriateness considerations, as well as investing in audit and feedback strategies.

Idea 3: Reduce low-value imaging that increases wait times and can expose patients to unnecessary harm. This includes investing in interprofessional programs to assess and manage imaging- intensive conditions such as back pain and implementing appropriateness criteria for common imaging requisitions.

Idea 4: Reduce overly aggressive life-sustaining measures at the end of life. This includes a concerted and adequately resourced approach to advance care planning, as well as improved palliative care capacity in the community.

Idea 5: Sustain the national supply of blood components and products.  This includes establishing national appropriateness benchmarks and directing hospitals to measure their performance against benchmarks, as well as exploring whether alternative funding models that could strengthen incentives for hospital blood conservation efforts.

You can read the report at https://choosingwiselycanada.org/perspective/not-necessary/.