ONTraC: A 20-Year History of a Successfully Coordinated Provincewide Patient Blood Management Program: Lessons Learned and Goals Achieved

Abstract

Our understanding of the risks associated with perioperative anemia and transfusion, in terms of increased morbidity and mortality, has evolved over the past 2 decades. By contrast, our understanding of the potential mechanisms of injury and optimal treatment strategies remains incomplete. As such, the important role of effective patient blood management (PBM) programs, which address both the effective treatment of anemia and minimizes the need for red blood cell (RBC) transfusion, is of central importance to optimizing patient care and improving patient outcomes. We report on important clinical outcomes of the Ontario Transfusion Coordinator (ONTraC Program), a network of 25 hospital sites, working in coordination over the past 20 years. Transfusion nurse coordinators were assigned to apply multimodal best practice in PBM (including recommended changes in surgical approach; diagnosis, assessment, and treatment of anemia; and adherence to more restrictive RBC transfusion thresholds). Data were collected on various clinical parameters. We further described lessons learned and difficulties encountered in this multisite PBM initiative. A significant reduction in RBC transfusions was observed for numerous indexed surgeries. For example, RBC transfusion rates for knee arthroplasty decreased from 25% in 2002 to 0.4% in 2020. For coronary artery bypass graft (CABG) surgery, transfusion rates decreased from 60% in 2002 to 27% in 2020. We also observed a decrease in RBC units utilized per transfused patient for knee (2.1 ± 0.5 [2002] vs 1.0 ± 0.6 [2020] units per patient) and CABG surgery (3.3 ± 0.6 [2002] vs 2.3 ± 1.9 [2020] units per patient). These reductions were associated with favorable clinical outcomes, including reduced length of hospital stay (P = .00003) and a reduced rate of perioperative infections (P < .001) for nontransfused versus transfused patients. These advances have been achieved with estimated savings in the tens of millions of dollars annually. Our experience and data support the hypothesis that instituting an integrated network of transfusion nurse coordinators can provide an effective provincewide PBM program, reduce RBC transfusions, improve some patient outcomes, and reduce health care costs, as an example of a “win-win-win” medical program.

Patient Blood Management Is a New Standard of Care to Optimize Blood Health

“…PBM programs represent an organized top-down approach aimed to improve clinical outcomes and reduce costs. 23 Our Canadian colleagues report on the success of PBM programs in the article by Pavenski et al 24 This comprehensive report from a province-wide network of 25 hospitals, working in coordination, details the impact of dedicated PBM programs. Blood transfusion reductions were associated with reduced length of hospital stay, reduced perioperative infections, and a cost savings in the tens of millions of dollars annually.…”

Patient blood management using dedicated personnel in the operating room—you get what you pay for

“…It is important to note that a significant investment is made in these practitioners as they complete a formal teaching programme, including educational and competency assessment workbooks, together with practice‐based education in TEG and other near‐patient testing 1 . Pavenski et al 7 reviewed the past 20 years of the Ontario Transfusion Coordinator (ONTraC) programme and showed the importance of proper investment in personnel to achieve a successful PBM programme. The ONTraC is an Ontario Ministry of Health‐supported programme that places registered nurse coordinators dedicated to PBM in 25 Ontario hospitals 7 .…”

“…Pavenski et al 7 reviewed the past 20 years of the Ontario Transfusion Coordinator (ONTraC) programme and showed the importance of proper investment in personnel to achieve a successful PBM programme. The ONTraC is an Ontario Ministry of Health‐supported programme that places registered nurse coordinators dedicated to PBM in 25 Ontario hospitals 7 . There are defined duties for the coordinators so that they can focus on PBM that include: advanced knowledge and skills to provide personalised PBM care to patients/families (50% of time), providing patients/families and hospital staff education (25%), and collection and reporting of data on interventions and outcomes (20%), as well as local institutional/regional activities (5%) 7 .…”

“…These dedicated efforts have achieved remarkable success. For example, red blood cell (RBC) transfusion rates for knee arthroplasty decreased from 25% in 2002 to 0.4% in 2020 and for coronary artery bypass graft surgery, transfusion rates decreased from 60% in 2002 to 27% in 2020 7,8 . This translated to favourable clinical outcomes, including reduced length of hospital stay ( p = 0.00003) and a reduced rate of perioperative infections ( p < 0.001) for non‐transfused versus transfused patients 7 .…”

“…For example, red blood cell (RBC) transfusion rates for knee arthroplasty decreased from 25% in 2002 to 0.4% in 2020 and for coronary artery bypass graft surgery, transfusion rates decreased from 60% in 2002 to 27% in 2020 7,8 . This translated to favourable clinical outcomes, including reduced length of hospital stay ( p = 0.00003) and a reduced rate of perioperative infections ( p < 0.001) for non‐transfused versus transfused patients 7 . The study concluded that an integrated network of transfusion nurse coordinators can provide an effective provincewide PBM programme, reduce RBC transfusions, improve some patient outcomes, and reduce healthcare costs, as an example of a ‘win‐win‐win’ medical programme 7 .…”