Nova Scotia Update NAC Meeting October 15-16, 2015

IVIG/SCIG In Nova Scotia, 3.0% decrease in the use of IVIG/SCIG is estimated for 2015/2016 based on the 5 months of available distribution data. This is a marked improvement from last year’s growth rate of +7.0% The decline in the estimated growth rate of the use of IVIG/SCIG for 2015/2016 is likely due to the implementation of dosing by body weight using IVIG/SCIG dose calculations in Nova Scotia.

Red Blood Cells Nova Scotia is the only province in Canada that exhibited an increase in the growth rate of red blood cells. 3.8% in 2014-2015. NSPBCP conducted an audit of RBC use in March 2014 through out NS, which showed that there were 322.8 total units requested using 199 RBC requests. 5.7% of the total transfusion requests (for 7.1% of the total transfused units) in NS were inappropriate. This provided the evidence for the need of RBC guidelines.

Red Blood Cells The NSPBCP with the advice of clinical experts in Nova Scotia has developed red blood cell guidelines based on the AABB Guidelines (based on the NAC’s recommendation), for adult and pediatric indications for transfusion. The Nova Scotia red blood cell Transfusion pathway exhibiting transfusions triggers for “one unit of RBC at a time” is developed to enhance the compliance with the guidelines and support their implementation in Nova Scotia A 4.4% decrease in the distribution of RBCs is estimated for 2015-16 based on the 5 months of actual data. This is a marked improvement from the figures of 2014-2015.

Red Blood Cells Determining hospitals daily red cell use by ABO/Rh has led to an inventory reduction of 152 Red Cell units being stocked at hospital sites in Nova Scotia. Removal of fresh (less than 7 days) O negative, cmv negative, irradiated units at sites who do not routinely transfuse neonates has led to a decrease of non O negative patients receiving O negative red cell units. The development of provincial Rh testing guidelines will eliminate unnecessary WinRho injections in pre natal patients with a weak D type 1 to 4.1 as these patients can be considered Rh positive as well as provide the ability to transfuse these same patients with Rh positive red cells in the even transfusion is required.

CMV negative blood products: Nova Scotia is one of the highest users of CMV negative blood products in the country. The NSPBCP with the advice of clinical experts in Nova Scotia is in the process of developing guidelines for the use of CMV negative blood products in Nova Scotia. These are based on the NAC guideline statements for CMV negative blood products 2014.

Redistribution of Plasma Protein Products Sites report inventory expiring within 6 months to the NSPBCP who facilitates the redistribution From January 2012 to September 2015, a total of 924 vials have been redistributed for a total cost avoidance of $1,056,500.

Prothrombin Complex Concentrates In 2014/15, utilization (Labelled + UnLabelled) increased by 15% when compared to the previous FY Labelled use = 89.3% UnLabelled use = 10.7% (32 patients) 20 patients were not on a vitamin K antagonist 9 patients were on a vitamin K antagonist but the pre-INR was less than 1.7 1 patient was on a vitamin K antagonist but the pre-INR was not done 2 patients received PCC for an elevated INR but the patient was not bleeding or requiring an urgent invasive procedure

Fibrinogen There is one patient in Nova Scotia receiving fibrinogen concentrate for labeled indications. The remaining use in Nova Scotia is off-label. Off-Label Data: In 2014/15, 194 patients received 813 grams. Cardiac surgery – 73.2% Bleeding – 17.5% Liver transplant – 7.7% Other indications – 1.5%

rFVIIa Use in massively bleeding patients: 2012/13 - 26 patients received 154 mg 2013/14 - 11 patients received 46 mg 2014/15 - 6 patients received 33 mg (45.5% decrease in the number of patients receiving rFVIIa with a 28.3% decrease in the volume administered)

Plasma and Cryoprecipitate The NSPBCP, with advice from the expert working group, continues to develop provincial guidelines promoting appropriate plasma and cryoprecipitate use.