Using Blood Wisely: A national Canadian programme

Dr Yulia Lin, Division Head, Transfusion Medicine and Tissue Bank, Sunnybrook Health Sciences Centre and Professor, Department of Laboratory Medicine and Pathobiology, University of Toronto, Canada, talked to the Haematology Association of Ireland Annual Meeting 2024 about the ‘Using Blood Wisely’ campaign in Canada. This is a national quality improvement programme which aims to reduce inappropriate red blood cell (RBC) transfusion. It includes national benchmarks, an audit tool, recommendations for evidence-based interventions, and a designation to incentivise and reward.

Dr Lin presented the evidence base supporting a restrictive approach to transfusion, including the AABB (Association for the Advancement of Blood and Biotherapies) guidelines that were developed by an international panel of experts and published in JAMA in late 2023. The panel, of which Dr Lin was a member, compared outcomes with restrictive haemoglobin-based transfusion thresholds – defined as 7-8g/dL – to more liberal transfusion thresholds – defined as 9-10g/dL – to reach their conclusions.

Dr Lin also presented a range of studies that investigated various transfusion thresholds in differing clinical scenarios; and provided a solid research base supporting the general consensus that transfusion should be considered when haemoglobin (Hb) levels are below 7g/dL in the haemodynamically stable hospitalised patient, with some exceptions such as patients undergoing cardiac or orthopaedic surgery. She also noted that both the Irish Blood Transfusion Service and the National Institute for Health and Care Excellence align with these recommendations, before highlighting that acute myocardial infarction is an “area that’s evolving”. “It is an exception” to a restrictive approach and an area “to stay tuned to”, she said, and outlined the current, limited, available data.

Dr Lin described the various steps taken to close the knowledge-practice gap in Canada. She pointed out how different societies have made recommendations that begin with the word “don’t”, particularly “don’t transfuse” unless necessary. “Using [Blood] Wisely had put out over 400 recommendations of what not to do. This was the first national campaign, launched in September 2020, to turn recommendations into action,” she said.

“This [Using Blood Wisely] was a red cell transfusion quality improvement programme to engage hospitals to audit their red cell use compared to national benchmarks, implement the recommended evidence-based interventions to promote appropriate transfusion practice, and, finally, be recognised for that success.”

Describing the steps of the Using Blood Wisely programme, Dr Lin said: “The first is that hospitals do a red cell audit and compare with national benchmarks. If it’s met and maintained, they proceed to designation. If not, then we have tools to implement different interventions until benchmarks are met and maintained and designation obtained.”

Addressing underperformance, Dr Lin discussed the steps taken in the START study, which was undertaken to increase transfusion appropriateness to above 90 per cent in 13 hospitals across three provinces in Canada. She described the multifaceted intervention that included education for clinicians ordering transfusions, emphasis on guidelines, empowering laboratory technologists to screen blood orders for appropriateness, and auditing of ordering practices monthly.

“We also looked at under-transfusion events,” Dr Lin said. “There were very few that were unexplained…. There was no impact on length of stay, ICU support, or in-hospital mortality. So, this is a demonstration of implementing the evidence into practice. The interventions were subsequently incorporated into the Using Blood Wisely campaign.”

Dr Lin concluded with an account of achievements to date, including 270 participating hospitals that when combined account for almost 80 per cent of all RBCs transfused in Canada. She shared some of the challenges faced, “lessons learned” during implementation, and what she anticipates the future will bring.

“Stay tuned for recommendations for patients with acute myocardial infarction…. Even in the last week there’s been a publication of whether we should use restrictive or liberal transfusion in acute traumatic brain injury, and that also seemed to favour liberal, so we are starting to see a few exceptions to that [restrictive] rule…. I hope I have encouraged you to compare your practice to these benchmarks and to determine the opportunities to use blood wisely in your clinical area.”