O RhD Negative Red Cells: Trends in distribution, hospital perspectives and best practices Kathryn Webert Medical Director, Utilization, Canadian Blood Services NAC Meeting, April 16-17, 2015

Trends in the distribution of bood components

RBC units issued (per 1,000 pop) Trends in utilization of blood components RBC units issued (per 1,000 pop) There has been a slight yet steady decline in Canadian demand for blood products as health-care systems adopt more efficient approaches to utilization, and blood conservation and surgical techniques. At the same time, we must keep pace with emerging expectations about how blood products are selected and deployed – for example, the increased demand from hospitals for platelets that have undergone HLA (human leukocyte antigen) typing. The diminishing need for many fresh blood components is in contrast to the growing demand for specialized plasma products. We have seen an average annual increase of 6.5 per cent in use of the latter over the past several years, despite new utilization measures introduced by some provincial health ministries. Of particular concern is the growing off-label use of these expensive products, sometimes in the absence of compelling medical evidence that they support effective treatment. The resulting pressure on our traditional sources of supply has obliged us to begin evaluating alternatives Present US/UK numbers:

RBC units issued (and growth rates) There has been a slight yet steady decline in Canadian demand for blood products as health-care systems adopt more efficient approaches to utilization, and blood conservation and surgical techniques. At the same time, we must keep pace with emerging expectations about how blood products are selected and deployed – for example, the increased demand from hospitals for platelets that have undergone HLA (human leukocyte antigen) typing. The diminishing need for many fresh blood components is in contrast to the growing demand for specialized plasma products. We have seen an average annual increase of 6.5 per cent in use of the latter over the past several years, despite new utilization measures introduced by some provincial health ministries. Of particular concern is the growing off-label use of these expensive products, sometimes in the absence of compelling medical evidence that they support effective treatment. The resulting pressure on our traditional sources of supply has obliged us to begin evaluating alternatives Present US/UK numbers:

Trends in the collection and issues of group O RhD-negative blood components

O-neg RBC units issued (% total RBC issues) Trends in collections and issues of group O RhD negative blood components O-neg RBC units issued (% total RBC issues) There has been a slight yet steady decline in Canadian demand for blood products as health-care systems adopt more efficient approaches to utilization, and blood conservation and surgical techniques. At the same time, we must keep pace with emerging expectations about how blood products are selected and deployed – for example, the increased demand from hospitals for platelets that have undergone HLA (human leukocyte antigen) typing. The diminishing need for many fresh blood components is in contrast to the growing demand for specialized plasma products. We have seen an average annual increase of 6.5 per cent in use of the latter over the past several years, despite new utilization measures introduced by some provincial health ministries. Of particular concern is the growing off-label use of these expensive products, sometimes in the absence of compelling medical evidence that they support effective treatment. The resulting pressure on our traditional sources of supply has obliged us to begin evaluating alternatives Present US/UK numbers:

O negative collections, orders, and issues

O negative active whole blood donors Trends in collections and issues of group O RhD negative blood components O negative active whole blood donors O-negative whole blood donors represent ~10.6% of all donors

~12.4% of red cells (and increasing!) O-neg issues ~12.4% of red cells (and increasing!) CBS O-neg donors ~10% General population ~6-7% The problem… So….based on the information just presented…here is the problem summarized. While only 6-7% of the general population in most areas of Canada is O-negative….O-negative issues have increased to approximately 12% of red cells.

Aging and Blood Donation Trends in collection and issues of group O RhD negative blood components Aging and Blood Donation Aging population may result in substantial increase in blood demand Aging blood donor population may result in decreased blood donation Growing gap between blood demand and blood donation could have severe implications for future medical care Canada’s aging population may result in a substantial increase in blood demand In addition, an aging blood donor population may result in decreased blood donation The growing gap between blood demand and blood donation could have severe implications for future medical care

70-80 year olds have 8X greater RBC consumption than 20-40 year olds Trends in collection and issues of group O RhD negative blood components 70-80 year olds have 8X greater RBC consumption than 20-40 year olds The Finnish registry data suggest that RBC consumption increases dramatically with increasing age, beginning at around age 50. In fact, it has been demonstrated that 70 to 80 year olds have an 8 times greater RBC consumption than 20 to 40 year olds. Ali et al., Transfusion 2010

Trends in collection and issues of group O RhD negative blood components Donation patterns Only about 2-3% of the Canadian population are regular blood donors Very small segment of the population supports our blood transfusion needs Emphasizes the need to recruit new donors and to retain the existing ones Only about 2-3% of the Canadian population are regular blood donors. This means that a very small segment of the population supports our blood transfusion needs and emphasizes the need to recruit new donors and to retain the existing ones.

Age and Donation Frequency (CBS) Trends in collection and issues of group O RhD negative blood components Age and Donation Frequency (CBS) This slide emphasizes the importance of our older donors even more. This slide looks at the donor’s frequency of donation based on age. The red bars reflect the number of donors in each age category. The green bars reflect the total number of donations given by the group and the blue line illustrates the donation frequency or the number of donations given, on average by the age group per year. As you can see, there are a large number of younger donors, but these donors tend to give far less frequently than other blood donors. As discussed previously, often these donors are students at either university or high school and blood donation occurs sporadically. In contrast, in the older age groups, many of these donors are highly committed donors, with the oldest donors giving, on average more than 3 times per year. This further underscores the fact that older donors are extremely valuable donors to the blood system.

Results of audits

ORBCoN 2014 O neg Utilisation Survey 5.5% MTP, no ABO group on file, or only 1 ABO group on file ORBCoN data from 2014 O neg audit Slide from Dr. A Collins, ORBCoN

Results of audits CBS Hospital Disposition Data: % RBC transfused reported by ABO group (Dec 2014) 25.7%

Results of audits CBS Hospital Disposition Data: # O-neg units discard by hospitals (FY 14/15) Dec 2014 - 25.7% of RBC transfused reported by ABO *BC data included in outdates only

Results of audits CBS Hospital Disposition Data: #O-neg units transfused to non-Oneg patients Sample of what could be possible as more hospitals report (and report by ABO) Denominator currently difficult Complicated by units not requested as O-neg by hospitals (i.e. phenotyped units)

What can we do to fix this?

The Solutions Increase supply of O-negative red cells Best practices The Solutions Increase supply of O-negative red cells Decrease demand for O-negative red cells The solutions to this problem are to further increase the supply of o-negative red cells and to decrease the demand for O-negative red cells.

Best practices Don’t transfuse O negative blood except to O negative patients and in emergencies for women of child bearing potential with unknown blood group. O negative blood units are in chronic short supply due in part to overutilization for patients who are not O-negative. O negative red blood cells should be restricted to: (1) O negative patients; or (2) women of childbearing potential with unknown blood group who require emergency transfusion before blood group testing can be performed.

Best practices A new standard of transfusion care: appropriate use of O-negative red blood cells. http://hospitals.unitedbloodservices.org/

Best practices http://hospitals.unitedbloodservices.org/

Best practices Indications for appropriate and necessary use of O-negative red blood cells Group O-negative patients with anti-D Group O-negative females of reproductive potential Unknown blood group females of reproductive potential in emergent transfusions. Switch patients to type-specific red blood cell support as soon as the blood type is determined Group O-negative neonates and children (males and females < 18 year of age) All intrauterine transfusions http://hospitals.unitedbloodservices.org/

Best practices Indications for appropriate and necessary use of O-negative red blood cells Any patient with antibodies when the only phenotype-compatible blood available is group O-negative. Type-specific phenotype- compatible products should be used whenever possible. Group O-negative patients in non-emergent, lower volume (less than 6 units in any 24 hour period) transfusion. Switch patients other than females of reproductive potential and neonates/children to O-positive red blood cells when there is the expectation of larger volume transfusions (greater than 6 units in any 24 hour period) http://hospitals.unitedbloodservices.org/

O-Negative Red Cells: General Principles/Recommendations (NHS) Best practices O-Negative Red Cells: General Principles/Recommendations (NHS) Hospitals should regularly review policies for use of O-neg RBC for emergencies and investigate incidences where use is considered inappropriate Hospitals should regularly review practice of emergency transfusion of O-negative red cells to non-O-neg patients UK: in some cases patients being unnecessarily transfused with >3 units Hospitals must provide group specific red cells rapidly to avoid unnecessary use of emergency group O-neg RBC The following are principles and or key recommendations regarding the use of O-negative red cells, based heavily on those recommendations arising from the audits performed by the NHS Blood and Transplant committee for the use of group O RhD Negative red cells. Hospitals should regularly review their policies for the use of O-negative red cells for emergencies Hospitals should regularly review practice of emergency transfusion of O-negative red cells to non-O-negative patients AND Hospitals must provide group specific red cells rapidly to avoid unnecessary use of emergency group O-negative red cells NHS Blood and Transplant. 2010 Re-audit of the Use of Group O RhD Negative Red Cells

O-Negative Red Cells: General Principles/Recommendations (NHS) Best practices O-Negative Red Cells: General Principles/Recommendations (NHS) For group O-pos recipients with alloantibodies, all efforts must be made to identify phenotypically matched group specific blood The blood supplier should provide a sufficient number of extensively phenotyped O-pos units of blood in order to enable the appropriate selection of group specific blood for patients with alloantibodies For group O-positive recipients with alloantibodies, all efforts must be made to identify phenotypically matched group specific blood The blood supplier should provide a sufficient number of extensively phenotyped O-positive units of blood in order to enable the appropriate selection of group specific blood for patients with alloantibodies NHS Blood and Transplant. 2010 Re-audit of the Use of Group O RhD Negative Red Cells

O-Negative Red Cells: General Principles/Recommendations (NHS) Best practices O-Negative Red Cells: General Principles/Recommendations (NHS) Adequate inventory policies should be in place to minimize wastage of O-neg RBC (UK: reduce stockholding level to <10.5%) Avoid wastage due to: Expiration Electively transfused to non-group O recipients Appropriate policies which guide use of O-neg RBC should be introduced in order to reduce unnecessary high stockholding levels Adequate inventory policies should be in place to minimize wastage of O-negative red cells through expiration or elective transfusion to non-group O recipients Appropriate policies which guide the use of O-negative RBC should be introduced in order to reduce unnecessarily high stockholding levels NHS Blood and Transplant. 2010 Re-audit of the Use of Group O RhD Negative Red Cells

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

Best practices 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. CBS Customer Letter #2014-14

Best practices 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. CBS Customer Letter #2014-14

Develop and implement policies for optimal inventory management Best practices 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. CBS Customer Letter #2014-14

Develop and implement policies for optimal inventory management Best practices 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). CBS Customer Letter #2014-14

Develop and implement policies for optimal inventory management Best practices 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. CBS Customer Letter #2014-14

Conclusions

Conclusions Conclusions Appropriate utilization of blood products group O RhD negative blood products is important Current trends in issues can not continue Next steps to consider/discuss O-neg working group Best practices developed and/or endorsed by NAC

Acknowledgements Dan Shavrnoch CBS Hospital Liaison Specialists Cheryl Doncaster Rob Romans Hospital blood banks ORBCoN