Article Text
PDF
Abstract
Background Up to 50% of blood is transfused inappropriately despite best evidence. In 2020, Choosing Wisely Canada launched a major national programme, ‘Using Blood Wisely’, the aim was to engage hospitals to audit their red blood cell transfusion use against national benchmarks and participate in a programme to decrease inappropriate use.
Study design Using Blood Wisely is a quality improvement programme including national benchmarks, an audit tool, recommended evidence-based effective interventions and a designation to reward success. Hospital engagement was measured using the number of hospitals signing up, performing a baseline audit, submitting the planning survey, entering two or more audits and achieving hospital designation. Barriers to implementation were collected.
Results From 1 September 2020 to 31 December 2022, 229 individual hospitals signed up over time to participate. Their results are reported as 159 hospitals and hospital groups. Collectively, this accounts for 72% of the blood used in Canada. Overall, 147 (92%) performed a baseline audit, 10 (6%) submitted a planning survey and 130 (82%) entered two or more audits. At baseline (time of enrolment), 75 (51%) met both benchmarks. The designation was awarded to 62 (39%) hospital groups (a total of 105 individual hospitals) that met and sustained benchmarks. Barriers to implementation included human resource shortages, lack of local expertise to advise the team, need for more education of transfusion prescribers and competing priorities.
Conclusion In its initial phase, Using Blood Wisely engaged a substantial number of hospitals in transfusion quality improvement work and maintained that engagement. This large-scale engagement across a big country was more successful than anticipated. Additional efforts are needed to rigorously evaluate the programme’s impact on utilisation.
- healthcare quality improvement
- implementation science
- laboratory medicine
- performance measures
Data availability statement
Data are available on reasonable request.
This is an open access article distributed in accordance with the Creative Commons Attribution Non Commercial (CC BY-NC 4.0) license, which permits others to distribute, remix, adapt, build upon this work non-commercially, and license their derivative works on different terms, provided the original work is properly cited, appropriate credit is given, any changes made indicated, and the use is non-commercial. See: http://creativecommons.org/licenses/by-nc/4.0/.
Statistics from Altmetric.com
WHAT IS ALREADY KNOWN ON THIS TOPIC
Studies show that 19%–50% of red blood cell (RBC) transfusions are unnecessary.
Thus, multiple societies have made Choosing Wisely recommendations to decrease inappropriate RBC transfusion.
WHAT THIS STUDY ADDS
Using Blood Wisely is a national programme that engaged 229 individual hospitals to participate in transfusion quality improvement work with 105 individual hospitals meeting and sustaining national benchmarks to achieve the Using Blood Wisely hospital designation.
HOW THIS STUDY MIGHT AFFECT RESEARCH, PRACTICE OR POLICY
This study describes a framework for developing a nationwide programme to successfully engage hospitals in quality improvement as well as the lessons learnt for future initiatives.
Background
Choosing Wisely, a programme to decrease unnecessary medical care, started in the USA, spread to Canada and then to over 30 countries in the world. The programme is based on national medical societies creating evidence-based recommendations to decrease tests, treatments or procedures in their specialty. In both the USA and Canada, multiple societies have created recommendations to decrease the overuse of red blood cell (RBC) transfusions,1 aligned with evidence for restrictive blood practices.2 Yet overuse of RBC transfusions is common in hospitals across the USA, Canada and other countries with studies showing that 19%–50% of RBC transfusions are unnecessary, leading to potential harm and wasting a limited resource.3–8 While creating the recommendations is a necessary first step, implementation of the recommendations to measurably reduce overuse is the ultimate goal.
Choosing Wisely Canada (CWC) considered the use of RBC to be an ideal focus for the first national quality improvement (QI) initiative. Reducing inappropriate RBC use became more imperative during the COVID-19 pandemic when there was a decrease in blood donations and rising concern about a potential shortage in the blood supply.9 A prior Canadian QI study demonstrated that hospitals could decrease RBC transfusions by 19%–31%,3 8 but the study approach was resource intensive, included only 13 hospitals, and was not feasible as a broad, Canada-wide strategy. Hence, in 2019–2020, during the early part of the pandemic in 2020, CWC launched a national programme called ‘Using Blood Wisely’ (UBW) in partnership with Canadian Blood Services, the national blood supplier. The aim was to determine whether we could engage a larger number of hospitals across Canada in a programme similar to the initial Canadian QI study, but with a less resource-intensive approach. Hospitals would be required to audit their RBC use against a CWC national benchmark and participate in various activities relevant to their hospitals in order to reach the benchmark, and reduce inappropriate RBC use. We also report on the success and challenges of UBW, lessons learnt and future work, so that this programme may serve as a template for future, large-scale QI initiatives.
Methods
Context
In Canada, Canadian Blood Services supplies blood to all provinces and territories, except the province of Québec. In 2019–2020, Canadian Blood Services supplied 690 000 RBC units to 563 hospitals. Blood services are funded by provincial governments; hospitals do not pay directly for blood. Hospitals have transfusion services or blood banks that are responsible for the storage and distribution of blood. The Canadian Standards Association mandates that hospitals have a transfusion committee that helps define local blood transfusion policies, sets criteria for the evaluation of ordering practices and regularly evaluates transfusion practices.10
The Using Blood Wisely programme
UBW engaged key stakeholders to develop an RBC transfusion QI programme, which included a national benchmark for ‘appropriate transfusion’, a benchmark measurement strategy, recommended evidence-based, effective interventions and a plan to motivate participation and reward success. In October 2019, a formal steering committee was established with stakeholders in the transfusion system which included clinicians in anaesthesiology, internal medicine, haematology and transfusion; nurses; medical laboratory technologists (MLTs); representatives from provincial blood offices, Canadian Blood Services and the Canadian Institute for Health Information; implementation scientists and two patient partners. The purpose of the committee was to provide direction and guidance to the project and to promote participation in their region.
The UBW toolbox included multiple components that were consistent with evidence for the most effective behaviour change interventions.11 A website (www.usingbloodwisely.ca)12 was launched in September 2020 to house resources including instructions on the RBC audit, a planning survey and key intervention tools. The planning survey, based on published literature13 14 and grounded in behaviour science,15 allowed hospitals to survey staff to help identify the drivers of current practice and barriers to changing practice (online supplemental appendix I). The intervention tools included three education videos for each of physicians, nurses and MLTs; sample guidelines; order sets (developed by the CWC team based on previous regional work16 with input from the steering committee) and standard operating procedures for prospective transfusion order screening by MLTs.
Supplemental material
The UBW programme launched in September 2020 with a recruitment strategy for hospitals to sign on via the website by 1 December 2020. Hospitals could sign up at any time as this was an ongoing initiative. Our initial target number was 50 hospital sign-ups and RBC audits, recognising that because of the COVID-19 pandemic, hospitals might not have the capacity to engage in the initiative. To increase engagement at the hospital senior leadership level, UBW partnered with Accreditation Canada, an organisation that accredits all hospitals in Canada. In addition, a letter was sent to the chief executive officer of each hospital introducing UBW with the aim of building senior leadership support for the implementation programme. Similarly, a letter was sent out by Canadian Blood Services to all hospital transfusion services receiving RBC units. The introduction and implementation of UBW was supported by monthly webinars from October 2020 to June 2021 to familiarise participants with the initiative, how to measure changes and available intervention resources. Local hospital experiences and successes were also shared at each of the webinars to demonstrate how each component of UBW could be implemented.
While there was no financial incentive for hospitals to participate in the programme, recognition for hospital efforts was identified by the steering committee and regional stakeholder meetings as key to engage and motivate hospitals as well as to raise the profile of RBC transfusion and UBW within the hospitals. As a result of this feedback, an UBW hospital designation certificate was created and awarded to hospitals that had successfully achieved the transfusion benchmarks and sustained these efforts for at least 4 months.
Engagement, benchmarks and designation
Hospital engagement in UBW was measured up to 31 December 2022. To assess varying levels of engagement, the following data were collected: the number of hospitals: (1) signing up to the initiative; (2) performing a baseline audit; (3) submitting the planning survey; (4) entering two or more audits and (5) achieving UBW hospital designation. The baseline audit was the first audit submitted and subsequent audits could be submitted as often as monthly and were voluntary. Hospitals could sign up as a hospital group if they were organised in a group structure.
Hospitals used a standard audit tool provided in the UBW toolkit to capture transfusion appropriateness at baseline and throughout participation. Hospitals were asked to audit at least 50 RBC transfusion episodes in a 1-month period.12 Some hospitals with electronic reports chose to report on larger numbers of transfusion episodes. The audits were entered into a central database hosted by Canadian Blood Services. The audits focused on measurement of two benchmarks for inpatient RBC transfusions which needed to be attained and maintained for at least 4 months: (1) 65% of RBC transfusion episodes were single unit transfusions and (2) 80% of RBC transfusions had a pretransfusion haemoglobin of ≤80 g/L. Each hospital submitted a percentage value for each benchmark as the number of transfusions audited varied by hospital based on size and resources available to collect the data. The benchmark values were recognised to be surrogate measures of appropriate RBC transfusion practice and were based on audit data from hospitals participating in a prior regional QI initiative,17 representing the 75th percentile for these metrics. As hospitals varied in their RBC transfusion practices before UBW began, participating hospitals may have met the benchmarks at baseline. Hospital designation occurred once the hospital had submitted audits every 2 months and the benchmarks were met and sustained for 4 months.
Data on loss of engagement were also collected. Loss of engagement was defined as hospitals that had not moved to the next step after sign-up, doing a baseline audit or a subsequent audit after the repeat audit (not meeting benchmarks) in the last 12 months prior to 31 December 2022.
Statistical analysis
Descriptive statistics, including medians and IQRs, were calculated and non-parametric statistics were applied when appropriate. When hospitals signed up as group, their data were collected for the hospital group. Benchmark data were based on audits entered by hospitals into the central database. The baseline audit was defined as the first audit entered by the hospital. The designated audit was the audit metric that was used at the time of designation. Descriptive analysis was performed to examine for differences between hospitals that achieved designation and those that did not.
Results
Engagement
From 1 September 2020 to 31 December 2022, there were 229 hospitals that signed up to participate in UBW. Hospitals were permitted to sign-up and report their data in groups. Of the 229 sign-ups, 84 individual hospitals participated in one of 14 groups; most of these were small hospitals. The 229 individual hospitals that participated represented 41% of Canadian hospitals and accounted for 72% of the RBC units transfused nationally. The remainder of this report will refer to 159 hospitals (including hospital groups) because those that participated as a group reported results together.
There was broad and even representation of size and type of participating hospitals, from small to academic. Most hospitals had RBC transfusion guidelines (81%) in place at baseline (table 1). Hospitals signed up quickly in the initial launch of the programme exceeding the initial target of 50 and reaching 107 hospitals (including hospital groups) by 1 December 2020 (figure 1). Enrolment continued throughout the study period. Of the 159 hospitals, 147 (92%) performed a baseline audit, 10 (6%) submitted a planning survey, 130 (82%) entered 2 or more audits and 62 (39%) were designated as UBW hospitals (including hospital groups). Table 2 and online supplemental appendix II: figure show the progress of hospitals through the UBW programme.
Using Blood Wisely participating hospitals
Hospital engagement over time. Timing of elements of the Using Blood Wisely programme are noted. CBS, Canadian Blood Services.
Progress of hospitals through the Using Blood Wisely programme
There was loss of engagement as defined by absence of proceeding to the next step in the 12 months prior to 31 December 2022: 11 hospitals that had signed up had not performed a baseline audit; 17 hospitals that had done a baseline audit did not do a repeat audit and 20 of 56 hospitals that had done a repeat audit (and not met benchmarks), had not done a subsequent audit in 2022.
Benchmark measurements
Baseline audits were submitted by 147 hospitals. Of those, 91 (62%) met the benchmark for single unit transfusions and 106 (72%) met the benchmark for pretransfusion haemoglobin ≤80 g/L (figure 2). For percentage single unit transfusion audits, the median was 69% (IQR 50–80). For percentage pretransfusion haemoglobin ≤80 g/L, the median was 86% (IQR 78–94). Seventy-five hospitals (51%) met both benchmarks at baseline, while 16 (11%) met benchmarks for single unit transfusions only, 31 (21%) met benchmarks for pretransfusion haemoglobin only and 25 (17%) met neither benchmark.
Using Blood Wisely baseline audits (n=147). Each dot on the scatter plot represents a participating organisation. The vertical line represents the benchmark for single unit transfusions, where at least 65% of inpatient transfusion episodes are single unit transfusions. The horizontal line represents the benchmark for pretransfusion haemoglobin (Hb), where at least 80% of inpatient transfusions have a pretransfusion Hb ≤80 g/L.
One hundred and thirty hospitals registered two or more audits with a median number of audits per hospital of 8 (IQR 4–18).
Designation
As of 31 December 2022, 62 hospitals (including 9 hospital groups for a total of 105 individual hospitals) were designated UBW hospitals having met and sustained the benchmarks for at least 4 months. As compared with non-designated hospitals, a greater proportion of designated hospitals were academic, large and regional (table 1). At baseline, designated hospitals had implemented more interventions, in particular prospective transfusion order screening (53% vs 29%, p=0.002).
Baseline audits for the designated hospitals showed that 54 (87%) met the single unit transfusion benchmark and 52 (84%) met the pretransfusion haemoglobin benchmark. For percentage single unit transfusion audits, the median was 76% (IQR 68–82) at baseline and 77% (IQR 69–83) at designation. For percentage pretransfusion haemoglobin ≤80 g/L, the median was 90% (IQR 82–95) at baseline and 90% (IQR 86–95) at designation.
Designated hospitals were asked to describe the interventions that they had implemented to reach UBW designation. They reported implementing guidelines (89%), education (79%), transfusion order screening (73%), transfusion order sets (69%), audit and feedback (68%) and transfusion alternatives (35%). At baseline, interventions to reduce unnecessary RBC transfusions were significantly more frequent in designated hospitals than in non-designated hospitals (table 3). Designated hospitals were divided into four quartiles for the percentage of single unit transfusions (online supplemental appendix III). Analyses (χ2 test or Fisher’s exact test as appropriate) did not show any significant differences in interventions implemented among the four quartile groups of designated hospitals, nor when comparing the highest quartile with the lower three quartiles.
Interventions implemented at non-designated (baseline) versus designated hospitals (at time of designation)
Non-designated hospitals
Baseline audits for the non-designated hospitals showed that 37 (44%) met the single unit transfusion benchmark and 54 (64%) met the pretransfusion haemoglobin benchmark. For percentage single unit transfusion audits, the median was 60% (IQR 45–77) at baseline and 64% (IQR 50–77) at the last audit performed. For percentage pretransfusion haemoglobin ≤80 g/L, the median was 84% (IQR 75–92) at baseline and 83% (IQR 75–94) at last audit.
Hospitals progressed at different rates through the UBW framework (table 2; online supplemental appendix II: figure). In the programme’s second year, attention was focused specifically on hospitals that were entering audit data and were not reaching benchmarks. A survey and follow-up telephone interviews were conducted with these hospitals. Challenges in achieving UBW designation included human resource shortages due to COVID-19 to lead the QI initiative locally or perform audits; lack of local staff with expertise to advise the team; the need for more guideline education for transfusion prescribers; UBW being lower priority than ongoing major projects such as implementation of electronic medical record systems, new laboratory analysers or renovations and data skewing in smaller hospitals due to single patient episodes or individual clinician practices.
Discussion
The UBW programme, a major national QI programme, exceeded expectations for hospital participation and demonstrated the feasibility of a broad, Canada-wide initiative. Healthcare delivery is a provincial or territorial jurisdiction, and each jurisdiction has its own healthcare system despite being in the same country. The UBW programme was successfully able to engage hospitals to implement and sustain (although still in early years) a national programme despite the diverse environments created by multiple healthcare systems. Over the 2-year period, 159 hospitals and hospital groups (229 individual hospitals), comprising 41% of hospitals in the country signed up for and actively participated in UBW by conducting audits and using intervention tools delivered in a programme that was not resource-intensive. Furthermore, 62 hospital and hospital groups (105 individual hospitals) were successful in receiving the UBW hospital designation demonstrating that it is possible to implement a national benchmark.
Several lessons can be learnt about hospital engagement, which is often one of the biggest challenges when implementing a programme of this scope. The key strength of the initiative was the focus on a common procedure that occurs in many hospitals (in all provinces and territories), including small hospitals. This allowed hospitals of all sizes to participate. The programme focused on a CWC recommendation that was common to multiple societies allowing participation from different areas within each hospital. Consultation with regional stakeholders during development and prior to launching the programme socialised the initiative and provided an opportunity to adjust the programme based on stakeholder feedback increasing the probability of success. As a result of this feedback, the designation programme was developed. Designation gave hospital teams the opportunity to celebrate successes and be recognised by their hospitals and communities. Communication from accreditation bodies (eg, Accreditation Canada) to the senior leadership level raised awareness of the initiative and garnered support at the hospital level for the clinical and laboratory teams leading the QI work.
Another key strength of the UBW programme was that no financial incentives were required to make this engagement successful; the programme was able to engage hospital teams across the country solely on a voluntary basis.18 Although monetary incentive was seriously considered by the UBW programme team, CWC recognised that it was not sustainable for the long-term success of the programme, and CWC did not want to set a precedent of sending money and then asking hospitals to make changes independently. The goal was to provide a balanced initiative: while the programme was led by the CWC team and the UBW steering committee helped guide hospitals in reducing unnecessary blood transfusions, the hospitals remained autonomous, developing a community of support among the hospitals and allowing them the choice of which intervention components they had the capacity to implement. The programme gave guidance, direction and access to transfusion medicine expertise while providing a level of independence and autonomy at the hospital.
Because of this balanced approach, there were also lessons learnt about this iterative programme. UBW provided hospitals with intervention tools that addressed identified barriers and added resources for how to use the tools in the form of webinars, educational modules and frequently asked question documents. The programme did not require intensive individual/group coaching like the prior QI study in 13 hospitals8; rather, hospitals were supported to learn independently. All the tools and educational modules were available to hospitals on a website; group webinars explained and supported tool use with real-life examples of successes and challenges; an UBW email was provided for hospitals to ask specific questions about the audits and intervention tools and the project team made themselves available for one-on-one support as required. Hence, the intervention could be rolled out broadly at a pace that was acceptable to the hospital teams. There was no set timeline for hospitals to achieve UBW designation. Additional webinar sessions were added so that hospitals could meet to discuss specific challenges and brainstorm solutions. Active participation including using the audit tool, submitting data and the observation that some hospitals appeared to improve their utilisation suggests to us that a less resource-intensive approach is feasible and can lead to meeting successful de-implementation targets.
There were also challenges and limitations with the UBW programme. A major limitation was that the programme was not designed as a formal QI programme and hospitals started their interventions at different times which we did not formally document. A more rigorous method such as an interrupted time series or randomised controlled trial would be required to assess the impact of UBW. The planning for UBW also coincided with the onset of the COVID-19 pandemic making rigorous evaluation less feasible. Although delaying the launch was considered, the concerns of blood shortages made the programme timely and important. In this initial phase of UBW, many of the hospitals that reached designation met the benchmarks at baseline. This was acknowledged at the outset of the programme as the goal was for broad engagement. As a result of multiple hospitals engaging by entering benchmarks into a central database, UBW was able to document that the benchmarks were achievable. Including these high-performing hospitals allowed recognition for the successes that they had already achieved, and with their inclusion, would influence others to reach for designation. In addition, while UBW had dedicated resources in terms of a project manager and part-time physician leadership to provide support to hospital teams, the QI work and benchmark measurement was led and implemented locally. Because of the autonomous nature of the programme, it was not possible to capture in detail how hospitals operationalised the tools available or how often hospitals used specific UBW resources. The only information about intervention tools used was provided through voluntary reporting at the time of the hospital designation application. Therefore, no single intervention component or combination of components could be identified as being most important for the hospitals to reach the UBW benchmarks and obtain hospital designation.
Future work
To support large hospitals that have improved but not yet met benchmarks, the programme is running a mentoring pilot programme. Hospitals continue to enrol in the programme and meet designation status. Over the course of its first year, the programme expanded to include the province of Québec in collaboration with its blood supplier, Héma-Québec, designating the first Québec hospital in February 2022. Thus, including Québec hospitals, as of 20 February 2024, a total of 188 hospitals or hospital groups (258 individual hospitals) have signed up and 90 hospitals or hospitals groups (153 individual hospitals) have reached designation status. One of the key subsequent steps in the programme is sustainability. In order to avoid the programme being a ‘one and done’ type of programme, hospitals are encouraged to maintain the UBW benchmarks. To help facilitate this, a requirement has been added for designated hospitals to submit audits at 1-year, 2-year and 4-year time points to maintain their UBW hospital designation.
Conclusion
In the 2 years since its launch, UBW has illustrated that it is possible to successfully engage hospitals in almost all provinces and territories throughout Canada in a transfusion QI programme and maintain that engagement. The UBW programme has been a catalyst for transfusion appropriateness by providing support and non-monetary incentives for hospitals that want to participate and has facilitated the availability of resources to help guide local QI work. The lessons learnt can help inform other large-scale QI initiatives in Canada and globally.
Data availability statement
Data are available on reasonable request.
Ethics statements
Patient consent for publication
Ethics approval
Not applicable.
Supplementary materials
Supplementary Data
This web only file has been produced by the BMJ Publishing Group from an electronic file supplied by the author(s) and has not been edited for content.
Footnotes
YL and WL are joint first authors.
Twitter @andreapatey
Contributors All authors were responsible in establishing the Using Blood Wisely programme. YL and DD were responsible for data collection and analysis. YL, WL, DD and AMP wrote the manuscript. All authors reviewed the manuscript. YL and WL are the guarantors of this work. The corresponding author attests that all listed authors meet authorship criteria and that no others meeting the criteria have been omitted.
Funding The authors have not declared a specific grant for this research from any funding agency in the public, commercial or not-for-profit sectors.
Competing interests YL has received research funding from Canadian Blood Services and Octapharma and is a consultant with Choosing Wisely Canada.
Patient and public involvement Patients were involved in the Using Blood Wisely Steering Committee and development of the Using Blood Wisely programme.
Provenance and peer review Not commissioned; externally peer reviewed.
Supplemental material This content has been supplied by the author(s). It has not been vetted by BMJ Publishing Group Limited (BMJ) and may not have been peer-reviewed. Any opinions or recommendations discussed are solely those of the author(s) and are not endorsed by BMJ. BMJ disclaims all liability and responsibility arising from any reliance placed on the content. Where the content includes any translated material, BMJ does not warrant the accuracy and reliability of the translations (including but not limited to local regulations, clinical guidelines, terminology, drug names and drug dosages), and is not responsible for any error and/or omissions arising from translation and adaptation or otherwise.