Life can be anything but predictable. The unforeseen arises quickly and suddenly an emergency strikes. Accidents occur all too frequently on our roads, in our homes and in our lives in general. In Canada we are fortunate to have some of the best medical care and expertise in the world. A clinical emergency in a hospital setting normally results in the appropriate care at the appropriate time. Competent clinicians however can only do so much if the right equipment and resources are not on hand or are in limited supply.
The availability of blood and blood products is one of those vital elements of managing many emergency situations. Its availability is needed to sustain life in many conditions. Blood has been characterized as the ‘essence of life’ and indeed we couldn’t live long without it. As a precious and essential commodity we need to be careful and protective of how we use it, to ensure its continued availability for all that may require it. The week of November 7 to 11 is designated as Blood Management Awareness Week to serve as a reminder of the need for the judicious usage of blood and blood products in order to ensure its unrestricted availability.
Transfusion is not without risks and there are many adverse reactions associated with transfusion. One must always evaluate carefully the relative benefits versus risks when considering blood transfusion.
In Canada the infection of more than 30,000 Canadians with hepatitis C and HIV during the 1980’s resulted in a government inquiry led by Justice Krever that spanned a period of four years. The final report in 1997 listed 50 recommendations for a safer blood system and consequently the Canadian Blood Services was founded. Many provincial initiatives were developed as a result of the Krever Commission. In Ontario the Blood Conservation and Bloodless Medicine Program provided short-term funding to several projects related to improving patient safety and education and encouraging the more efficient use of blood, particularly in the surgical setting. Some of these projects were deemed to be so valuable in reducing the use of red cells in Ontario hospitals, that funding was continued and in some cases projects expanded. One such project was the Ontario Nurse Transfusion Coordinator (ONTraC) program, which is now Ministry funded in 25 hospitals throughout the province on a five-year renewable contract basis.
The ONTraC program is aimed at the restriction of blood transfusion to appropriate need. Program coordinators are located on-site at each of 25 selected hospitals, ranging from tertiary centres in major cities such as Toronto and Ottawa, to hospitals in smaller centres. The blood conservation coordinator provides expertise in transfusion avoidance and particularly focuses on surgeries that are designated as ‘targeted’ procedures which traditionally have a higher blood loss and subsequent blood transfusion. For example, the waiting period before joint replacement surgery is the ideal time to optimize patients in preparation for the expected blood loss associated with hip or knee replacement. Similarly patients booked for radical prostatectomy or coronary artery bypass graft (CABG) surgery are also screened and optimized prior to going to surgery. The assessment involves identifying patients whose preoperative hemoglobin level may not be sufficient to withstand the predicted drop associated with the specific surgery. Blood loss varies individually and by procedure and each patient is counselled and or intervened with in a timely fashion prior to surgery. Once patients are aware that much can be done to mitigate the possibility of a blood transfusion they are more than willing to be actively involved in the plan. Those that avoid blood due to religious beliefs have also embraced the program.
The ONTraC blood conservation coordinator is also the hospital-wide resource for blood conservation needs and can be involved with perinatal, oncology, medical and general surgical patients as required. The coordinator works closely with physician champions and participates on pertinent hospital committees, as well as meeting the educational needs of staff and physicians about blood management strategies.
Ensuring that enough blood is available to meet the needs of those that really require it is critically important. Ask a trauma centre doctor, or a birthing suite nurse or thousands of renal and cancer patients in Canada just how much they depend on the availability of one more unit of blood. The ONTraC program helps to meet this objective.