Utilization of O-Rh-Negative Red Cells Kathryn Webert, MD, MSc, FRCPC Medical Director, Utilization Canadian Blood Services NAC Meeting November 2014

Objectives To describe the distribution of O-negative red cells To describe strategies to raise awareness of the demand on the O-Rh negative supply BloodBriefs Collection of hospital best practices

O-Negative Red Cell Units Issued Fiscal Period Source: CBS internal distribution data. Represents ~75% of Canadian supply

O-Negative Red Cell Units Issued (% of total RBC Issues) Fiscal Period Source: CBS internal distribution data. Represents ~75% of Canadian supply

O-Neg Issues by Hospital Type

bloodbriefs

September 2013 April 2014 December 2013 September 2014 Logo: Virginia Gaffney, Product Brand and Creative Development

Issue a ‘status report’ to top 50 hospital users: 3 years of issue data O neg or AB plasma issues as % of: All blood groups Total group O blood Ranking (1st, 2nd, 3rd etc)

All tables of data are anonymized. A is customized for each receiving hospital with hospital specific data identified. Slide from Cheryl Doncaster

Effectiveness and Impact Electronic survey sent January 2013 to 64 hospitals Both O-neg / AB plasma = 36 O-neg = 14 AB plasma = 14 25 survey respondents representing 30 hospital sites Doncaster et al. CSTM Abstract 2013 Slide from Cheryl Doncaster

Survey Results 68% indicated the BloodBrief highlighted data or information that was new 84% were influenced to review transfusion practice/blood component demand 48% anticipated revision or development of new policy Most hospitals with no planned change cited issue data below national average or already strict specific transfusion policy in place Doncaster et al. CSTM Abstract 2013

Summary Effective in promoting optimal utilization of blood components/products Heightens hospital awareness of issue trends over time Comparisons within hospital peer groups influences hospital transfusion practice / policy. Doncaster et al. CSTM Abstract 2013 Slide from Cheryl Doncaster

Collection of hospital best practices

Top 20 Hospitals % O Neg: National Avg =11.8%

Top 20 Hospitals continued

BloodBrief – O Neg RBCs Of the top 50 hospitals in the 2013-2014 list, 47 received an O Rh Neg BloodBrief last year. 25 of 47 decreased O Rh Neg as a % of all blood groups (0.02 to 3.34%) 31 of 47 decreased total O Rh Neg issues 32 of 47 decreased total RBC (all blood groups) issues

Peer Support Top 20 users - We need your assistance We’re looking for your adult* hospital O Rh negative RBC Utilization “best practices” Don’t assume that what your hospital does is what everyone else is doing! * We will explore pediatric hospital best practices at a later date

Peer Support Provide your HLS with 4-6 practices that you think contribute to your hospital’s effective O Rh Neg utilization management We will compile and share 4-6 best practices that hospitals can employ to improve their Rh Neg RBC utilization

Develop and implement a policy for hemorrhaging patients whose blood group is not known Develop and implement policies for optimal inventory management

Develop and implement a policy for hemorrhaging patients whose blood group is not known Immediately collect a blood sample for ABO/Rh from all trauma patients upon admission to the Emergency Department. Transfuse male trauma or hemorrhaging patients regardless of age with group O Rh positive red blood cells until their blood group can be determined or unless known to have anti-D. Determine the optimal maternal age restriction for women served by your hospital, and transfuse female trauma or hemorrhaging patients above the optimal child bearing age with group O Rh positive red blood cells until their blood group can be determined or unless known to have anti-D.

Have a policy to switch patients to their own blood group once known. Develop and implement a policy for hemorrhaging patients whose blood group is not known Have a policy to switch patients to their own blood group once known. Have a policy for switching known Rh negative hemorrhaging patients to Rh positive red blood cells unless known to have anti-D. Define the trigger at which point the patient will be switched, and if medical director consultation is required each time.

Develop and implement policies for optimal inventory management Small rural hospitals should stock a mix of O Rh positive and Rh negative red blood cells. Revaluate optimal inventory levels on a regular basis, or after hospital organizational/clinical program changes, especially those that will reduce red blood cells demand. Promptly notify your local Canadian Blood Services of any adjustments. Transfuse oldest units first unless there are other clinical considerations.

Develop and implement policies for optimal inventory management Always request group specific units for patients with red blood cell antibodies. Only use Rh negative substitutions if group specific is not available for the scheduled transfusion date. Notify your local Canadian Blood Services immediately for any difficult to fill antigen negative requests, especially those that will require ongoing transfusions. Reduce inventory tagged for specific patient use, using strategies such as crossmatch on demand/electronic crossmatch, type and screen, and a maximum surgical blood order schedule (MSBOS).

Develop and implement policies for optimal inventory management Cancel inventory tagged for specific patients after 24 hours or immediately after imminent need has passed, and make allowances for patients with red blood cell antibodies. Share inventory between affiliated hospital sites. Track Rh negative transfusions to Rh positive patients. Monitor soon to outdate units and as a last resort, transfuse to Rh positive patients to avoid wastage or redistribute to larger nearby hospitals where they are less likely to expire. Track and review redistribution data, and adjust ordering practices from Canadian Blood Services if redistribution frequency is excessive.

Acknowledgements Cheryl Doncaster Dan Shavrnoch Rob Romans Virginia Gaffney Lise Bourque CBS Hospital Liaison Specialists