Introduction: Blood transfusions continue to be a critical intervention in patients presenting to emergency departments (ED). Improved understanding of the adverse events associated with transfusions has led to new research to inform and delineate transfusion guidelines. The Nova Scotia Guideline for Blood Component Utilization in Adults and Pediatrics was implemented in June 2017 to reflect current best practice in transfusion medicine. The guideline includes a lowering of the hemoglobin threshold from 80 g/L to 70 g/L for transfusion initiation, to be used in conjunction with the patient's hemodynamic assessment before and after transfusions. Our study aims to augment understanding of transfusion guideline adherence and ED physician transfusing practices at the Halifax Infirmary Emergency Department in Nova Scotia. Methods: A retrospective chart review was conducted on one third of all ED visits involving red-cell transfusions for one year prior to and one year following the guideline implementation. A total of 350 charts were reviewed. The primary data abstracted for the initial transfusion, and subsequent transfusion if applicable, from each reviewed chart included clinical and laboratory data reflective of the transfusion guideline. Based on these data, the transfusion event was classified one of three ways: indicated based on hemoglobin level, indicated based on patient's symptomatic presentation, or unable to determine if transfusion indicated based on charting. Results: The year before guideline implementation, the total number of transfusions initiated at a hemoglobin of between 71-80 was 31 of 146 total transfusions. This number dropped by 23.6% to 22 of 136 in the year following guideline implementation. The number of single-unit transfusions increased by 28.0% from 47 of 146 in the year prior to 56 of 136 in the year after guideline implementation. The initial indication for transfusion being unable to be determined based on charting provided increased by 120%. The indication for subsequent transfusions being unable to be determined based on charting increased by 1500% (P < 0.05). Conclusion: These data suggest that implementing transfusion guidelines effectively reduced the number of transfusions given in the ED setting and increased the number of single-unit transfusions administered. However, the data also suggest the need for better education around transfusion indications and proper documentation clearly outlining the rationale behind the decision to transfuse.

Background: In Canada, injuries represent 21% of Emergency Department (ED) visits. Faced with occupational injuries, physicians may feel pressured to provide urgent imaging to facilitate expedited return to work. There is not a body of literature to support this practice. Twenty percent of adult ED injuries involve workers compensation. Aim Statement: Tacit pressures were felt to impact imaging rates for patients with workplace injuries, and our aim was to determine if this hypothesis was accurate. We conducted a quality review to assess imaging rates among injuries suffered at work and outside work. A secondary aim was to reduce the harm resulting from non-value-added testing. Measures & Design: Information was collected from the Emergency Department Information System on patients with acute injuries over the age of 16-years including upper limb, lower limb, neck, back and head injuries. Data included both workplace and non-work-related presentations, Canadian Triage and Acuity Scale (CTAS) levels and age at presentation. Imaging included any of X-ray, CT, MRI, or Ultrasound ordered in EDs across the central zone of Nova Scotia from July 1, 2009 to June 30, 2019. A total of 282,860 patient-encounters were included for analysis. Comparison was made between patients presenting under the Workers’ Compensation Board of Nova Scotia (WCB) and those covered by the Department of Health and Wellness (DOHW). Imaging rates for all injuries were also trended over this ten-year period. Evaluation/Results: In patients between 16 and 65-years, the WCB group underwent more imaging (55.3% of visits) than did the DOHW group (43.1% of visits). In the same cohort, there was an overall decrease of over 10% in mean imaging rates for both WBC and DOHW between the first five-year period (2009-2013) and the second five-year study period (2013-2018). Imaging rates for WCB and DOHW converged with each decade beyond 35 years of age. No comparison was possible beyond 85-years, due to the absence of WCB presentations. Discussion/Impact: Patients presenting to the ED with workplace injuries are imaged at a higher rate than those covered by the DOHW. Campaigns promoting value-added care may have impacted imaging rates during the ten-year study period, explaining the decline in ED imaging for all injuries. While this 10% decrease in overall imaging is encouraging, these preliminary data indicate the need for further education on resource stewardship, especially for patients presenting to the ED with workplace injuries.