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Dr. Jeannie Callum

Draft KHSC New Transfusion Guidelines presented by Dr. Jeannie Callum

Jummy Oladipo, MSc Candidate (Translational Medicine)

At the February 11th Medical Grand Rounds, the Department of Medicine had the honour of hosting Dr. Jeannie Callum, a professor and director of Transfusion Medicine at Queen’s University. Dr. Callum’s presentation gave an overview of transfusion guidelines, focusing on the need to improve the appropriateness and efficiency of transfusion practices.

 

Dr. Callum’s presentation began with an overview of Ontario’s blood utilization rates. Provincially, the red blood cell (RBC) and frozen plasma transfusion rates have decreased over time. While this is a step in the right direction, Dr. Callum noted that there is still room for improvement as recent province-wide audits displayed a high rate of inappropriate transfusions (1).

 

An overview of the updated guidelines for transfusion practices of RBC, platelets, plasma, and cryoprecipitate was presented. When discussing RBC transfusion, Dr. Callum provided evidence supporting the use of a restrictive transfusion approach over a liberal strategy. Many randomized control trials such as the Transfusion Requirements in Critical Care (TRICC) trial, and the Threshold in Transfusion in Septic Shock (TRISS) trial have compared the two strategies; almost all concluding that the restrictive method is the most efficient approach (2, 3). Dr. Callum outlined the RBC transfusion guidelines for the Kingston Health Sciences Centre which recommends a threshold of 70 g/L, one unit at a time, for the majority of inpatients (4). Emphasis was put on the importance of staying within the guidelines as resources lost on wasted blood could be put to better use in medicine.

 

Dr. Callum then went over the platelet transfusion guidelines and advised that physicians should avoid transfusing their patients above a platelet count of 10x109/L and should transfuse one unit at a time (4). This was based on studies showing no significant benefits from transfusions above this threshold. It was revealed that international normalized ratios are not required for low-risk procedures which many physicians are unaware of. There is large variation in plasma utilization rates across Ontario which Dr. Callum speculated could be attributed to institutional factors impacting physician ordering practices (1). Dr. Callum advised against ordering 1-2 doses of plasma as these are deemed placebo doses (1). In 2021, transfusion services are becoming more restrictive as to who requires plasma. There are many alternatives to plasma treatment which should be considered beforehand. Dr. Callum also indicated that cryoprecipitate is no longer transfused as fibrinogen concentrate has replaced it.

 

The Grand Rounds presentation concluded with Dr. Callum predicting where transfusion medicine is heading in 2021. Future endeavours include updating Ontario-wide protocols, new clinical trials, and implementing strategies to make blood cleaner.

 

In the post-rounds discussion, Dr. Callum and the TMED students focused on ways in which improving transfusion practices benefits patients. Transfusion medicine is shifting towards a more holistic approach, optimizing patient conditions before transfusion to minimize the amount of blood required. Some of the ongoing investigations in transfusion medicine were explained. Enzymes able to convert type A and B blood to type O (the universal donor) are underway and if successful, their use could increase blood’s storage capacity leading to less wastage (5).

 

The discussion progressed towards examining how transfusion guidelines are portrayed in the media. Topics related to increasing the diversity of blood donors were explored. Additionally, Dr. Callum highlighted many of the barriers that potential blood donors face preventing them from donating. Initiatives have been put in place to increase the awareness of the need for blood donations and increase access to donor sites. The effect of the pandemic on transfusion practices was also revealed. The pandemic brings many logistical challenges to transfusion services but also provides a unique opportunity for science to be more visible.

 

To conclude, the TMED students learned about Dr. Callum’s educational background. Dr. Callum completed her medical education at the University of Toronto and then pursued a fellowship in transfusion medicine with the Canadian Blood Services. The opportunities that transfusion medicine creates to collaborate with a wide variety of colleagues and patients is what drew her to the field. Dr. Callum advised those beginning their research careers to continually seek new opportunities, increase their professional networks and seek out mentorship as these are tools for a successful career. Having recently moved back to Kingston, Dr. Callum expressed how grateful she is for the opportunity to assist the KHSC in improving their Transfusion Medicine program.

 

It was a pleasure to hear Dr. Callum speak on transfusion medicine guidelines. On behalf of the TMED Graduate Program, we sincerely thank Dr. Callum for her time and extensive insight.

 

References:

 

1.         Qiang JK, Thompson T, Callum J, Pinkerton P, Lin Y. Variations in RBC and frozen plasma utilization rates across 62 Ontario community hospitals. Transfusion. 2019;59(2):545-54.

2.         Hebert PC, Wells G, Blajchman MA, Marshall J, Martin C, Pagliarello G, et al. A multicenter, randomized, controlled clinical trial of transfusion requirements in critical care. Transfusion Requirements in Critical Care Investigators, Canadian Critical Care Trials Group. N Engl J Med. 1999;340(6):409-17.

3.         Holst LB, Haase N, Wetterslev J, Wernerman J, Guttormsen AB, Karlsson S, et al. Lower versus higher hemoglobin threshold for transfusion in septic shock. N Engl J Med. 2014;371(15):1381-91.

4.         Callum JL, Pinkerton PH, Lima A, Lin Y, Karkouti K, Lieberman L, et al. Blood Easy 4: Blood Transfusions, Blood Alternatives and Transfusion Reactions: A Guide to Transfusion Medicine. Canada: Ontario Regional Blood Coordinating Network; 2016.

5.         Rahfeld P, Withers SG. Toward universal donor blood: Enzymatic conversion of A and B to O type. J Biol Chem. 2020;295(2):325-34.

 

Comments

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Jordan Harry

Tue, 02/16/2021 - 12:12

Thank you Jummy for that excellent summary of last week’s Medical Grand Rounds. I found Dr. Callum’s presentation to be incredibly enlightening. I had minimal prior knowledge of blood transfusion protocols and I learned a lot. I was particularly interested in the portion of the talk that discussed where transfusion medicine is headed in 2021. I am very interested in following the use of enzymes to convert types A and B blood to type O, as Jummy explained. I believe that this could be a particularly beneficial approach to maximize the use and availability of blood. I was also interested in the discussion regarding the use of computerized physician controls. This is a monitoring system that regulates the ordering of blood that can stop the user for a variety of reasons and require them to re-evaluate their order and confirm. I think that this programming could provide a way to minimize error and reduce the use of blood.

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Jordan Harry

Thank you, Jordan for the kind compliment. I agree with you that it was very interesting to hear Dr. Callum speak on the direction of transfusion medicine in the near future. The enzymatic conversion of Type A and B blood to type O has great potential to give a new direction to transfusion practices. Something we did not have time to discuss in our post-round talk was how it could impact the area of organ transplantation. Identifying suitable organ donors is a very involved process, therefore, removing the A/B antigens in the blood of the organ and keeping the recipient’s immune system in check could lead to successful transplantations. The paper discusses this in greater depth. I have linked it below if you would like to look more into the topic.

https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6956546/

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Jummy

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Michaela Spence

Tue, 02/16/2021 - 18:15

Thank you Jummy for the excellent summary and to Dr. Callum for the wonderful and informative presentation at Grand Rounds.
I had very limited knowledge of the importance of transfusion protocols prior to this presentation and discussion period. I found it interesting that Alberta used a single EMR system enabling them to better track transfusion data for patients. It would be interesting to see if something like OLIS could be implemented to track transfusion data for all Ontario patients. This could potentially provide a more efficient way of analyzing transfusion data and thus the optimization of transfusion protocols around Ontario improving our blood utilization rates.

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Michaela Spence

Thank you, Michaela. I was also intrigued by the fact that Alberta uses a single software system to maintain digital medical data. I agree with you that using a single platform such as OLIS would make it easier to track transfusion data and use it to improve transfusion practices. Currently, sites across Ontario use different electronic record systems, making it more difficult to have patient information in one central place. Moving towards a more universal platform like Alberta could be ideal but will take a large effort to shift away from the current information storage systems in place..

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Jummy

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Kassandra Coyle

Tue, 02/16/2021 - 19:00

Thank you Jummy for the excellent summary. As someone with very minimal knowledge about blood transfusions, Dr. Callum’s insightful talk taught me a lot about the many factors that need to be considered. Further investigation into this field led me to a study which reported that there may be over-utilization of RBC transfusion and an infrequent use of iron supplementation among patients with iron deficiency anemia (1). I found this study to be incredibly interesting as during our talk, Dr. Callum mentioned the high prevalence of iron deficiency in Canada. I am interested to continue to follow the literature to see if the efforts to improve the efficiency of blood transfusion practices will have an impact on the treatment of iron deficiency.

Another interesting study that I found, looked at the effects of a new computer-based screening protocol at a hospital outpatient pharmacy. It was found that the use of a computer-based prescribing system resulted in major changes, with pharmacist’s spending 12.9% more time correcting prescription problems, while also being significantly more efficient as they spent 34% less time actually filling prescriptions (2). I am interested to see if a future use of a computer-based monitoring system that regulates the ordering of blood transfusions would have a similar success rate as this study.

1. Spradbrow J, Lin Y, Shelton D, et al. Iron deficiency anemia in the emergency department: over-utilization of red blood cell transfusion and infrequent use of iron supplementation. Can J Emerg Med 2017;19:167-74.
2. Murray, M. D., Loos, B., Tu, W., Eckert, G. J., Zhou, X. H., & Tierney, W. M. (1998). Effects of computer-based prescribing on pharmacist work patterns. Journal of the American Medical Informatics Association : JAMIA, 5(6), 546–553. https://doi.org/10.1136/jamia.1998.0050546

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Kassandra Coyle

Thank you for sharing these interesting studies. I was especially intrigued by the idea of using computer-based systems to monitor blood transfusion practices. After our discussion with Dr. Callum, it seems that this could be a possibility in the near future. The monitoring system would be beneficial for provincial auditing as it may reveal sites that could be more restrictive in their transfusion practices. Additionally, it could provide learning opportunities for health care professionals to become more familiar with transfusion guidelines.

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Jummy

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Melinda Chelva

Wed, 02/17/2021 - 10:03

Excellent post Jummy! You did an outstanding job highlighting all of the topics that were discussed during the MGR last week. Similar to Jordan, I was also very interested to learn about the growth and trajectory of transfusion medicine in 2021.

The need to have blood donors across various cultures and backgrounds in order to achieve a diverse supply of blood and to provide greater access to rare phenotypes, continues to remain. The post-rounds discussion allowed me to become more aware of the range in barriers that continue to inhibit individuals from donating blood. I hope more educational sessions and initiatives that use culturally-relevant messaging are developed and implemented in order to address concerns and to provide accurate information about donations.

Ultimately, I am looking forward to following the growth of transfusion medicine for years to come.

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Melinda Chelva

Thank you for your kind words, Melinda. You bring up an important topic in transfusion medicine. Working towards diminishing the barriers that exist preventing marginalized groups from donating is essential for obtaining a blood supply that can serve the diverse patient population in need of transfusions. I too learned a lot from Dr. Callum about the efforts that are being taken to reach, inform and encourage those across various backgrounds to donate. With the increasing power of social media, this could serve as a useful tool for getting the correct information about the requirements for blood donation into circulation. I have included a link to a campaign that launched in Héma-Québec that focuses on recruiting Black blood donors to help treat sickle cell anemia. I am interested to see the outcome of this campaign. If successful, potentially a similar one can be implemented in Ontario.

https://sicklecellanemia.hema-quebec.qc.ca/en

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Jummy

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Charmi Shah

Wed, 02/17/2021 - 12:36

Thank you Dr. Callum for your informative insight and Jummy for the wonderful summary.

I enjoyed listening to Dr. Callum shed light on the evolution of transfusion medicine throughout the years. I appreciated her insight of moving transfusion medicine towards a holistic approach to minimize the amounts of blood required by optimizing patient conditions before transfusions. In hindsight, these changes seem like a clear direction to take in this field, but I know it is never that apparent or simple to facilitate for those involved. This is why I always appreciate hearing insight from individuals who have years of experience to help me build my understanding of not only why changes occurred in medical practice, but also how certain progress took place.

As Michaela mentioned, I found Alberta’s use of a single EMR system to be fascinating. Alberta’s electronic health records (EHRs) are built to be shared with other health care providers, as reported on their province health page: https://myhealth.alberta.ca/Health/Pages/conditions.aspx?hwid=abo4950. With this system, the family physicians can instantly send medical records to a patient’s heart specialist, their hospital, the lab, their pharmacy, and even their computer at home. The goal of EHRs is to improve the coordination of patient care by giving healthcare providers accurate, up-to-date information.

If other provinces in Canada could adopt a similar system, it would streamline patient data sharing and improve coordination between healthcare providers so they could improve patient outcomes more productively.

I look forward to hearing about how Dr. Callum benefits the KHSC in improving their Transfusion Medicine program.

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Charmi Shah

Thank you, Charmi. I also enjoyed hearing about how transfusion medicine is shifting towards a more holistic approach. Not only does this improve patient outcomes, but it also helps maintain the blood supply for those who really need it. I am curious to see whether this holistic approach will be adopted by all centres or whether it will be site-specific.

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Jummy

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Caitlyn Vlasschaert

Wed, 02/17/2021 - 16:13

Thank you, Dr. Callum, for the scoping and sobering review of local blood product usage and best practices (and thank you, Jummy, for capturing it so well). The presentation highlighted the importance of institution-wide standard indications and thresholds for the use of blood products; as Dr. Callum mentioned, transfusion medicine "is a science, not an art". I look forward to participating in future resident-targeted educational sessions on the topic.

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Caitlyn Vlasschaert

Thank you, Caitlyn. You brought up an interesting part of the rounds about transfusion decisions being a science, not an art. As someone without a medical degree, it is interesting to hear this take on transfusion medicine because when I think of medicine, I think of it spanning both realms. This was a great reminder of how practices should not be accepted solely because they were the norm historically but rather, they should be challenged as more evidence leans toward other, more appropriate practices.

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Jummy

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Max Moloney

Thu, 02/18/2021 - 10:02

Thank you, Jummy for your detailed summary of Dr. Callum’s presentation during Medical Grand Rounds this past Thursday.

I was pleased to learn about Dr. Callum’s work in establishing new guidelines for blood transfusions in Ontario. It is encouraging to see research outcomes being translated into new practices in an efficient manner which will lead to limiting waste from our blood banks. I was also interested to learn about how Alberta’s single EMR system allows the province of Alberta’s healthcare system to use blood transfusion information more efficiently across the province. I see great value in moving to a single EMR system in other provinces as well, not only for blood transfusions but to improve information sharing for all patient health records.

I would also like to thank Dr. Callum for the candid discussion of her journey to her current role as a clinician-scientist at Queen’s. Dr. Callum was able to provide insight on the benefits and challenges of managing a multi-site research program and continuing to operate a research program while moving universities, providing an inspiration to all young researchers in attendance.

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Max Moloney

Thank you, Max. I agree. Moving towards a single EMR would be very useful for improving access to all patient records. Something that came to my mind when this was spoken about during the discussion is what moving towards a universal system would mean for patient data security. Would this make patient data more vulnerable to a cyber attack? I am wondering if this could be a reason for the various platforms that are being used across Ontario currently. I do agree with you though that this would improve the sharing of patient information across the province.

Name
Jummy

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