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Hematology/Transfusions Consent Update

28-Sep-2016

1) Informed Consent audits for RQHR -the below information was presented to the RQHR Transfusion Committee on September 12, 2016.

We continue to conduct monthly chart audits checking for documented consent for blood and blood products. RQHR’s rate of documented informed consent for blood and blood products is currently at 84%. We should be very proud of the significant commitment our health region has demonstrated!

At the last Transfusion Committee meeting, we reported that the N/A option on the Consent to Diagnostic and Treatments Procedures forms (RQHR #370 and #254) was replaced with “Transfusion not routinely required” and available through the RQHR Print Shop. I am happy to report the new revised forms are also now available in the EMR databases. We have begun the next step which is to communicate to our physician partners the availability of the revised forms so that the EMRs in physician offices are using the most current versions.

 

The RGH Transfusion Laboratory conduct audits monthly looking at documented consent for patient’s receiving WinRho. Data collected from August 2015 to July 2016 shows documented consent is obtained 87% of the time. 

Update on Day Surgery Admission Assessment and History form 

 At the last Transfusion Committee meeting we discussed the possibility of adding a transfusion history question to the daysurgery admission assessment form. I was to contact Debra McCabe, manager of day surgery to discuss this amendment to their form. Debra requested I meet with the educators regarding this request. Dr. Ledingham and I meet with Tara Griffiths and Kathy Jellow to discuss adding a question on previous transfusions to the day surgery admission assessment form. At the end of the discussion it was decided not to make any changes to the form. It was felt in day Surgery the risk of transfusion is very low and if transfusion is required the physician will obtain consent OR take responsibility if medically essential (e.g., unmatched blood).

2) Saskatchewan Immune Globulin Optimization Program –RQHR rollout

RQHR continues to pilot the IVIG PPOs, (adult and pediatric). It has been a little over a year since we have begun using the new IVIG PPOs. Rollout to other health regions has not and will not occur at this time as the Saskatchewan Ministry of Health is looking at a multi provincial IVIG project with a slightly broader scope. Judy Hoff spoke on this project during the recent Transfusion Committee meeting. She indicated RQHR should continue as we are until the new project is initiated.

3) Refusal of Blood Working Group

The last meeting we had was April 29, 2016. At that meeting, Marlene Glettler, Advance Care Planning Program, agreed to discuss the possibility of adding the example of no blood products to the Additional Directions section on the MVLST/Goals of Care Order. Her group met in June and discussed this request and decided not to recommend this change. Their feeling was that there was already an approved process in place with the Refusal of Blood Products form, located on the 1163 form. That they did not feel the need to add it to the MVLST/GOC order in the Additional Directions section.

During the Transfusion Committee meeting, we discussed the possibility of adding a “No Blood” alert in the New Enovation registration system – Sunrise Enterprise Registration (SER). Lois Schultz agreed to take this request to the next stakeholders meeting. She will report back to the Transfusion Committee. Lois met with the group and reported to Paula on Sept. 15th, 2016 that at this time the “No Blood” alert would not be considered.

4) New blood administration set – Manufacture recommendation to change at least every 4 hours

A) RQHR Nursing Procedure – Blood Products administration

CSA Z902-15 11.4.14 Administration sets for blood products shall be changed in accordance with the recommendations of the blood product manufacturer and the administration set manufacturer.

There appears to be little evidence to support the manufactures new labelling; either in the literature or from the manufacture. To comply with the standards Nursing has revised their procedure to comply with the new recommendations of changing the blood administration set at least every 4 hours.

The Nursing procedure “Blood Products Administration” was revised on June, 2016. The new wording reads –“Filtered tubing should be changed after every 4 units of blood, q4 hours or if occluded.”

B) Feedback to Hospira – The blood administration manufacturer

RQHR, 3S Health and a team from Hospira participated in several conference calls. Based on the feedback received from Saskatchewan, Hospira has agreed to update their blood set labeling. They are looking to include reference to the local or country standards and at the same time include the 4 hour statement recommending the change of sets every 4 hours from the manufacturer. We received a written statement from the company indicating their commitment to this action on April 27, 2016. To date we have not seen an update to the blood set labeling.

C) Proposed study – Bacterial Growth in Blood Transfusion Sets

Dr. Ledingham, Paula, the team from Pfizer, (Hospira), and Dr. Sandra Ramirez from CBS discussed the possibility of conducting a study on Bacterial Growth in Blood Transfusion Sets. Dr. Sandra Ramirez has submitted a draft work plan to Pfizer. Dr. Ledingham and Dr. Ramirez will work on the actual work plan more fully this fall. This is still a proposed project and waiting to hear if Pfizer will be interested to move forward with this collaboration .

5) Appropriateness of Care project - Perioperative patient blood management program - Elective Hip and Knee procedures

This initiative will determine the frequency of elective hip and knee patient blood transfusion. Promote evidence based blood conservation practices through education of health care professionals. Apply appropriate evidence based principles regarding utilization of allogeneic blood products and their alternatives in elective surgery patients. Create algorithms to optimize patients prior to surgery to improve pre surgical Hgbs and reduce post-surgery transfusions. Promote one unit transfusions and reassess patient prior to giving a second unit of RBCs.

We have created posters to promote “Why Use Two When One Will Do” using RQHR physicians. These posters will be used to promote and educate the clinicians.

6) Physician Lead for the Blood Transfusion and Stewardship Program

Dr. Ryan Lett has taken on this role and will be collaborating with Dr. Ledingham and Paula to develop within RQHR a Patient Blood Management Program.

7) The Saskatchewan Transfusion Medicine Working Group RBC Audit

The results of this audit will be presented to the TMWG on Sept. 29th. The presentation to the TMWG will include results from all health regions. A slide presentation will be made available to each health region allowing them the opportunity to disseminate the data to their physician partners. To date we have presented Cypress Health Region, Five Hills Heath Region, and RQHR their individual results. Discussions following the presentations have been robust.

8) Joint CSTM Education Day (webex) and Saskatchewan Transfusion Medicine Symposium.

This is the 10th Anniversary of the Saskatchewan Transfusion Symposium. The symposium will take place on Friday, September 30th, 2016 at the WRC Auditorium. Planning and arrangements are well on track. So far we have 100 participants registered to attend the symposium at WRC and about 40 participants registered to view the lectures via webex . The auditorium capacity is 108 so registration is now closed.

9) 3P – Repatriate Crossmatch testing from Canadian Blood Services in Regina to Saskatchewan Hospitals.

The advance testing and complex laboratory working group has completed a draft Saskatchewan Crossmatch /Antibody investigation referral requisition. RQHR – RGH Transfusion Laboratory and Cypress Health Region – Swift Current Transfusion Laboratory have agreed to pilot the referral requisition. Michele Burns from RGH and Tammy Masson from Swift Current are heading the pilot.

The province has been communicating with CBS and other provinces to discuss the new CBS shipping boxes. A working group has been created with representation from the programs that are doing significant amount of redistribution (BC, ON, NS and MB). A national decision has not been communicated and provincially we need to determine how we will be shipping crossmatched units of blood between facilities. Many of our new processes are affected by this important complex decision and cannot be finalized until a decision has been made. I have attached an analysis by ORBCON for your information with permission from Judy Hoff.