Manitoba Report for NAC October 15,16 2015 Debra Lane, MD FRCPC

The Manitoba Innovation Awards for the 2015 Health Innovation Conference / LEAN Congress Recognizes leadership in innovation and to celebrate excellence in quality improvement. Award nominations were submitted for Program Teams and/or Individuals in five categories. The Knowledge Transference and Training Award recognized initiatives that have enhanced knowledge transference Knowledge Transference and Training Award for 2015 was awarded to the submission for the  Best Blood Manitoba website – Diagnostic Services Manitoba The Manitoba Innovation Awards for the 2015 Health Innovation Conference / LEAN Congress recognize leadership in innovation and to celebrate excellence in quality improvement.  Award nominations were submitted for Program Teams and/or Individuals in five categories. The Knowledge Transference and Trainingrecognizes initiatives that have enhanced knowledge transference and training within or across organizations and health care professions to improve access to care, scheduling, service availability, accessibility, accommodation, affordability, acceptability and reduced time between health care events. Manitoba is proud to share that the Knowledge Transference and Training Award for 2015 was awarded to the submission for  Best Blood Manitoba – Diagnostic Services Manitoba

Choosing Wisely Canada Transfusion Medicine 10 Recommendations

Choosing Wisely for Transfusion Medicine 1. Don’t transfuse blood if other non-transfusion therapies or observation would be just as effective. Blood Conservation Service is available to assist physicians and their patients on the use of alternatives to transfusion. See www.bestbloodmanitoba.ca 2. Don’t transfuse more than one Red Cell unit at a time when transfusion is required in stable, non-bleeding patients. Blood Management Rounds and the Manitoba Nursing Working Group have discussed this. Additional education information available on the Provincial Transfusion Practices endorsed poster “Transfuse Safely”

5. Don’t routinely use plasma or prothrombin complex concentrates for non-emergent reversal of vitamin K antagonists. Education currently being provided to Community sites and hub sites around reversal of vitamin K antagonists. Additional information and educational videos are available on Best Blood Manitoba. 6. Don’t use immunoglobulin therapy for recurrent infections unless impaired antibody responses to vaccines are demonstrated. Information on the utilization of IVIG by diagnosis and physician has occurred. Additional resources required to take further action on this project.

7. Don’t order unnecessary pre-transfusion testing (type and screen) for all pre-operative patients. Current guidelines are set by Clinical programs. Abuse has not been identified. 8. Don’t routinely order perioperative autologous and directed blood collection. Use of Autologous and Directed blood is very rare. No Directive donation for 7 years. Only done for rare blood types. Autologous was 25 a day and now 25 a year.

9. Don’t transfuse O negative blood except to O negative patients and in emergencies for female patients of child-bearing potential of unknown blood group. Manitoba has had this policy in place for many years. Compliance is excellent. 10. Don’t transfuse group AB plasma to non-group AB patients unless in emergency situations where the ABO group is unknown. Rural sites now have additional groups of plasma in stock to ensure this recommendation is followed.

Choosing Wisely Recommendations not yet addressed 3. Don’t Transfuse plasma to correct a mildly elevated (<1.8) international normalized ration (INR) or activated partial thromboplastin time (aPTT) before a procedure. 4. Don’t routinely transfuse platelets for patients with chemotherapy-induced thrombocytopenia if the platelet count is greater than 10 x 10⁹ (utilization of platelets in Manitoba requires further audits. Transfusion Medicine physicians on call are monitoring any order >2 doses)

WHY: Province-Wide Transfusion Medicine Laboratory Information System Patient Safety Inventory Management of Blood Components and Derivatives Utilization information Electronic traceability of products (vein to vein) Improve Turnaround times (samples came from Hospitals to CBS Crossmatch Laboratory for testing and issuing of red cells and platelets) Reduce red cell and platelet returns from Winnipeg hospitals to the CBS Crossmatch Laboratory Discontinue red blood cell in-date discards for rural Hospitals (blood was not returned from rural hospitals for re-issue) Sharing of perinatal database to manage Perinatal antibody cases.

Traceline Locations

Was Patient Safety Achieved? Centralized database Protocols visible to all sites Previous transfusion reactions identified 75% of patients have a blood group on file 90% of patient testing done on automated equipment to reduce technologist errors

Is There Better Inventory Management? Electronic traceability of products Interfaces to ePROGESA and SAP eliminated transcription errors related to recording donation/lot numbers received “Confirmation of Transfusion” is used as the official system of record to identify patients transfused Ability to provide patients with individual transfusion history records if required, without manually searching patient charts

Is There Better Inventory Management? Reduced number of returned products from Winnipeg Hospitals to CBS from 40,000/year to less than 1,000/year Accepting returns was a significant workload and inventory management issue at both CBS and Hospitals Improper documentation resulted in a significant number (1,000) of unnecessary discard of red cells which is now avoided.

Reductions in Discards Post-Traceline Name of site Date of implementation RBC Discarded units 6 months pre-implement RBC Discarded units 6 months post implement RBC Average monthly discards pre-implement RBC Average monthly discards post implement RBC Average units saved per month Selkirk 2012 October 122 21 20.3 3.5 16.8 Portage 2014 February 109 33 18.2 5.5 12.7 Steinbach 2014 December 68 11.3 7.8 Boundary Trails 42 24 7 4 1.3 Swan River 2014 June 75 59 12.5 9.8 2.7

Turnaround Time Changes Winnipeg 41% of requests are ordered STAT Brandon 49% of requests are ordered STAT >90% of all matches are now electronically matched at Hospital Trace Line sites TAT in Winnipeg has been reduced 35 minutes (78%) since 2011 (based on St. Boniface data) If there is an in-date crossmatch sample, TAT has been reduced to 15 minutes from 60 minutes (75%). TAT reduction for rural issuing sites not determined but thought to be as much as 24 hours Potential for additional reductions in TAT as “Hub and Spoke” model is implemented

Massive Transfusion Implemented at largest site –Health Sciences Centre Second largest site-St Boniface- to be implemented November 2015