Mar 29, 2021
By Emily Durant , Donna Berta

Using Blood Wisely aims to decrease inappropriate red blood cell transfusion practice ProductionsThe rationale behind Using Blood Wisely’s transfusion guidelines is based on individual capacity to achieve and maintain homeostasis. Relatively healthy, asymptomatic patients can adapt to anemia through increasing cardiac output, decreasing physical activity or a combination thereof, without requiring a transfusion.

Takeaway messages

  • Using Blood Wisely is a national campaign aimed at improving red blood cell (RBC) transfusion practice for nonbleeding adult hospitalized patients.
  • Using Blood Wisely’s guidelines are based on the understanding that a hemoglobin value alone is an inadequate indicator for the decision-making process about the need for transfusion.
  • Nurses are integral to reducing inappropriate RBC transfusion; they observe and interact most with patients and are likely to perform any ordered interventions.

Within health care, professionals and patients alike must balance their perceived need for interventions with caution to avoid unwarranted actions. A report from the Canadian Institute for Health Information (2017) and Choosing Wisely Canada indicated that up to 30 per cent of tests and treatments are potentially unnecessary. This is particularly significant for blood transfusion, one of the most common interventions administered worldwide.

Under the umbrella of Choosing Wisely Canada and in partnership with Canadian Blood Services, Using Blood Wisely is a national campaign to improve transfusion practice (prescribing and administration). This approach supports appropriate use of a limited resource, focuses on ensuring that the benefits of transfusion outweigh the risks, proactively avoids transfusion risks and promotes optimal patient outcomes.

In this article, we will discuss this initiative, with a focus on how its intervention toolbox, which includes the recently published Using Blood Wisely: Guidelines, can be a resource for nurses when transfusion of non-bleeding adult inpatients is being considered.


Using Blood Wisely: key features

Using Blood Wisely aims to decrease unnecessary red blood cell (RBC) transfusion by increasing knowledge of the safety of restrictive transfusion practice (defined by evidence-based hemoglobin thresholds with concurrent clinical assessment and single-unit transfusion followed by reassessment). This initiative focuses on RBC transfusion in non-bleeding adult inpatients. The evidence base in this area is strong, with multiple clinical trials and systematic reviews supporting restrictive RBC transfusion practice. Although similar deliberations would benefit adult outpatient, pediatric and emergency patient populations, national transfusion guidelines for these groups currently do not exist as available evidence is limited. The Using Blood Wisely campaign encourages hospitals across Canada to reduce inappropriate transfusions and has established best practice interventions and data collection (audit) tools to measure the impact. These include the adoption of evidence-based transfusion guidelines, order sets, transfusion order screening and a concentrated effort to assess appropriateness against national benchmarks. The development of these benchmarks and a complement of evidence-based interventions has been guided by a national steering committee and various technical working groups.

Multiple clinical trials and systematic reviews supporting restrictive RBC transfusion practice.

Thakkar, Podlasek, Rotello, Ness, and Frank (2017) highlight the historical basis of frequent ordering of two-unit RBC transfusion. They note that prior to the 1990s, clinicians were taught that if an adult patient needed an RBC transfusion, two units was the optimal dose. In fact, single-unit transfusions were strongly discouraged, and authorities on the topic acknowledged that single-unit transfusions were unnecessary. This “more is better” position has been superseded by evidence demonstrating transfusion-related morbidity and mortality to be dose dependent (Callum et al., 2016; Choosing Wisely Canada, n.d.; Ontario Regional Blood Coordinating Network, n.d.). Research indicates that like any other therapeutic agent, the lowest effective dose, or number of units, should be transfused (Callum et al., 2016; Choosing Wisely Canada, n.d.; Ontario Regional Blood Coordinating Network, n.d.). Although Canadian Blood Services and Héma-Québec (Canada’s blood suppliers) are vigilant in screening, testing and maintaining blood safety protocols, an RBC transfusion is akin to a liquid organ transplantation, and the risks should be acknowledged as such.

Using Blood Wisely foundation: transfusion guidelines

The Using Blood Wisely approach begins with evidence-based transfusion guidelines. We know that there is a gap between evidence and transfusion practice. Evidence endorses restrictive transfusion guidelines (i.e., do not transfuse RBCs to non-bleeding, asymptomatic patients with hemoglobin greater than 70 g/L; do not transfuse more than one unit of RBCs at a time to non-bleeding patients) as best practice for patient safety and outcomes. Not only is this an additional 300+ mL of volume added in a relatively short time period, but each unit has an additive effect on the viscosity of the recipient’s blood. Considering restrictive thresholds in relation to transfusion-associated circulatory overload (TACO), Gosmann et al. (2018) discuss elevated hemoglobin transfusion triggers as potential risk factors. One trial they review found a significantly higher incidence of pulmonary edema among critically ill patients transfused at a liberal trigger threshold of 90 g/L compared to similar patients transfused at a restrictive 69 g/L, whereas another randomized controlled trial found that the incidence of TACO among patients with acute upper gastrointestinal bleeding was eight times higher in the liberal transfusion group (Gosmann et al., 2018).

The Using Blood Wisely: Guidelines resource (above) is part of a suite of resources in the campaign’s intervention toolbox.

Each hospital’s transfusion committee can facilitate stakeholders reaching a consensus on RBC transfusion indications and their approval at the hospital’s medical/interprofessional advisory committee. Individual provinces and health authorities can develop guidelines for practising clinicians and support their use through organizational policy. Using Blood Wisely’s evidence-based, best practice guideline template can be used as a starting point for clinical recommendations.

Understanding the basis of transfusion guidelines

The rationale behind Using Blood Wisely’s transfusion guidelines is based on individual capacity to achieve and maintain homeostasis. Basic human physiology dictates that oxygen supply is dependent on adequate cardiac output and the oxygen content of arterial blood. Oxygen content relies on respiration through the lungs and the oxygen-carrying capacity of hemoglobin within individual red blood cells. Relatively healthy, asymptomatic patients can adapt to anemia through increasing cardiac output, decreasing physical activity or a combination thereof, without requiring a transfusion. Proper nutrition, rest and time may be all these individuals require for healing, without exposure to the risk of a transfusion. Patients with compromised cardiac, pulmonary or hematological systems, however, have a diminished capacity to maintain homeostasis independently. For example, patients with cardiac insufficiency cannot increase their cardiac output and may show signs and symptoms of oxygen impairment despite having the same hemoglobin level as a non-compromised, asymptomatic peer.

In this physiological context, a hemoglobin value alone is an inadequate indicator for the decision-making process about the need for transfusion; the patient’s clinical signs and symptoms, as well as any comorbidities, must also be assessed, along with the circumstances of the hospitalization.

Additional interventions and tools afforded by Using Blood Wisely

Education to understand and support the rationale and benefits of change (for patients and the health-care system) is fundamental. Using Blood Wisely provides education modules tailored to key stakeholders (i.e., physicians/prescribers, nurses, medical laboratory technologists [MLTs]). Education as an unaided intervention, however, is unlikely to ensure a sustained decrease in inappropriate RBC transfusion.

To facilitate this knowledge translation, Using Blood Wisely endorses user-friendly transfusion order sets to prompt clinicians to adhere to guidelines in their daily patient care. Measures to foster compliance with order set use are helpful. A successful and more intense strategy is the action of prospective screening of RBC transfusion orders for compliance with guidelines by transfusion medicine laboratory (TML) technologists. Implementing this strategy requires technologists to be comfortable with and confident in this aspect of their role as regulated health-care professionals as well as to be supported by real-time transfusion medicine physician expertise. Tools to enable this approach are included on the Using Blood Wisely website. A modified approach with retrospective screening of RBC transfusion orders for compliance with guidelines can be considered. For patient safety, it must be cautioned that order set use and order screening practices are appropriate only for non-urgent, non-bleeding patients.

Collecting, manufacturing and distributing blood is an expensive and resource-intensive venture.

Blood transfusion as a precious resource

Blood transfusion is often perceived by health-care managers and providers as “free.” Blood components and products are not listed on hospital budget spreadsheets like pharmaceuticals and other patient care supplies. In Canada, blood is collected from volunteer donors and financed by federal and provincial/territorial funds (tax dollars), which are transferred to blood suppliers in order to provide blood to hospitals. Collecting blood, manufacturing blood products and distributing them is an expensive and resource-intensive venture. Using an eight‐step costing model to capture associated costs from the blood supplier to the time of transfusion to a patient, Lagerquist et al. (2017) found that one unit of RBCs cost approximately C$666.10. Administering blood and managing adverse events are additional fiscal and human resource considerations. The current viral pandemic of COVID-19 has only increased external pressures by reducing front-line and laboratory staff, along with available blood donors and opportunities to donate.

Potential harms of transfusions

Transfusion therapy is considered safe; however, transfusion adverse events or reactions (mild to life-threatening) occur despite all safety measures taken. Transfusion events or reactions can be characterized as common but not life-threatening; serious and life–threatening, requiring some prevention/treatment measures; and rare, with life-altering effects. A synopsis is provided in the table below (for inclusive transfusion risk details, refer to the Ontario Regional Blood Coordinating Network’s “Bloody Easy 4” or the Circular of Information specific to RBC transfusion provided by Canadian Blood Services and Héma-Québec).

(Tables are best viewed on a desktop computer.)

Transfusion Adverse Event/Risk Incidence/Unit Comment
Common, not life-threatening
Minor allergic (urticaria) 1 in 100 Generally resolves with antihistamine
Febrile, non-hemolytic 1 in 300 Generally resolves with antipyretic
Serious and life-threatening, requiring some prevention/treatment measures
RBC alloantibodies 1 in 13 All future RBC transfusions require antigen-negative blood
Risk of hemolytic disease of fetus/newborn for females with child-bearing potential
Transfusion-associated circulatory overload (TACO) 1 in 100 Pre-transfusion: assess for risk
Prevention: pre-transfusion diuretic, slow rate of infusion, single-unit transfusion
Transfusion-related acute lung injury (TRALI) 1 in 10,000 Supportive care (oxygen, respiratory support, vasopressors)
Acute hemolytic 1 in 40,000 Unequivocal patient identification steps critical at sample collection and administration
Anaphylaxis 1 in 40,000 Close monitoring during transfusion, identify early, prompt medical treatment
Bacterial sepsis 1 in 250,000 Close monitoring during transfusion, identify early, prompt medical treatment
Rare, life-altering
Transmission of hepatitis B 1 in 7.5 million Medical treatment
Transmission of hepatitis C 1 in 13 million Medical treatment
Transmission of HIV 1 in 21 million Medical treatment

From Callum et al. (2016).

Underdiagnosed and underreported TACO warrants additional discussion as it is the leading cause of transfusion-related deaths (Callum et al., 2016). TACO is characterized by acute or worsening respiratory distress, decreased oxygen saturation, tachycardia, increased blood pressure and acute pulmonary edema occurring during or within 12 hours after transfusion (International Society of Blood Transfusion Working Party on Haemovigilance, 2019; Wiersum-Osselton et al., 2019). There are two categories of risk factors:

  • Patient risk factors for TACO are described as advanced age, frailty or a deconditioned state, a history of heart failure or myocardial infarction, left ventricular dysfunction, renal dysfunction and positive fluid balance (Alam et al., 2013).
  • Administration risk factors include a lack of volume assessment prior to transfusion, transfusing more than one unit at a time in a stable patient and transfusing too quickly (Alam et al., 2013).

A common theme to all Using Blood Wisely interventions and tools is that interdisciplinary collaboration is integral to reducing inappropriate RBC transfusion.

When an RBC transfusion is clinically necessary, the patient should be thoroughly assessed for TACO risk factors. If indicated, TACO prevention strategies (i.e., pre-transfusion diuretic, slow rate of infusion over three to four hours per unit, single-unit transfusion) must be implemented, along with attentive monitoring during administration (Callum et al., 2016).

Role of nursing

A common theme to all Using Blood Wisely interventions and tools (guidelines, education, order sets, order screening) is that interdisciplinary collaboration is integral to reducing inappropriate RBC transfusion. The nurse is the health-care professional who observes and interacts most with patients throughout their hospitalization. As well, a nurse is the professional most likely to perform any ordered interventions. Professional accountability mandates that nurses act to prevent or minimize potential patient safety incidents (Canadian Nurses Association, n.d.). Nurses act as advocates to attain patients’ highest possible level of health and well-being while avoiding unnecessary risk of harm (Canadian Nurses Association, n.d.).

Specific to transfusion, the nurse’s role includes the following:

  • Maintain knowledge of evidence-based transfusion guidelines. If an RBC transfusion is ordered, understand the indication for that specific patient.
  • Collaborate with MLTs in your hospital’s transfusion service; their expertise is a vast resource.
  • Prompt prescribers to use transfusion guidelines as appropriate for patient-specific situations. Question orders outside guidelines. Ensure that potential transfusion risks (e.g., TACO) have been addressed.
  • When an RBC transfusion is ordered:
    1. Review the order to ensure the appropriate indication, dose and rate of infusion.
    2. Perform a baseline patient assessment and monitor diligently as per the clinical context.
  • Post-transfusion:
    Assess the patient and the hemoglobin level before further transfusion. For stable, non-bleeding patients, the hemoglobin can be checked the next day. For a one-unit RBC transfusion in a non-bleeding patient, the hemoglobin should increase by about 10 g/L (Callum et al., 2016).

Case studies

Inappropriate RBC transfusion order
J. Doe is a 35-year-old female, postoperative day 3, who underwent complex hip surgery for congenital hip dysplasia. She is otherwise healthy. Her physiotherapist reports that with the aid of a walker, her mobility is progressing well, and she is safe for discharge home. Her vital signs are stable, within the normal range. Her hip incision is well approximated, with no drainage; she does have significant bruising. On postoperative day 1, her hemoglobin was 78 g/L; today, postoperative day 3, her hemoglobin is 72 g/L. Her physician has ordered transfusion of 1 unit of RBCs over 2 hours. On review of Ms. Doe’s preoperative workup, her nurse notes that iron deficiency anemia secondary to menorrhagia was diagnosed and was treated with intravenous (IV) iron. Nursing steps include discussion with Ms. Doe’s physician, emphasizing that her hemoglobin is outside guidelines, she is asymptomatic and the indication for transfusion is unclear. In this case, an alternative treatment for iron deficiency anemia (i.e., iron supplementation) can be considered.

Transfusion leading to TACO
J. Smith is an 80-year-old oncology patient admitted for anemia. Her previous medical history includes lymphoma, hyperlipidemia and borderline hypertension. Her baseline vital signs reflect her normal trends (temperature 36.5oC, pulse 72, blood pressure 130/86, respirations 18, oxygen saturation 96%) and remained within in normal range after the first 15 minutes of the RBC administration. Thirty minutes later, with 200 mL transfused, her nurse answers the call bell to find Mrs. Smith tachypneic and reporting chest tightness. Vital signs are now temperature 37.4oC, pulse 110, blood pressure 180/99, respirations 26, and oxygen saturation 89%. The concern is that the patient has volume overload, as evidenced by the increased blood pressure. Nursing steps would now include stopping the transfusion, providing supplemental oxygen, elevating the head of the bed and contacting the authorized prescriber to report the symptoms and receive an order for investigations (e.g., chest X-ray) and an IV diuretic. Additional measures would be based on the patient’s response to the diuretic.

Reducing unnecessary/inappropriate RBC transfusion: success story

In 2016, the Ontario Transfusion Quality Improvement Plan (OTQIP) was launched to provide guidance for hospitals to implement a quality improvement plan with strategies to reduce unnecessary RBC transfusion. The plan’s tools and templates focus on education, evidence-based transfusion guidelines, transfusion order sets, prospective transfusion order screening by MLTs and data to evaluate outcomes. Employing these strategies at a large Ontario hospital yielded a 31 per cent sustained decrease in RBC use (Lin et al., 2016). The Using Blood Wisely campaign is poised to achieve similar outcomes across Canada.

Summary/next steps

In this article, we introduced the fundamentals of Using Blood Wisely as applied to RBC transfusion, as well as the importance of this initiative and evidence-based transfusion guidelines. We explored the role of nurses in this campaign and reviewed the risks for transfusion reactions.

Hospitals that successfully attain the Using Blood Wisely benchmarks can be designated as a Using Blood Wisely Hospital. Accreditation Canada’s Qmentum Program recognizes this initiative as a hospital quality improvement endeavour. Achieving designation requires activities such as formalizing best practice guidelines, partnering with stakeholders, and conducting spot audits to document progress.

Declaration of interests

The authors declare no competing interests.


The Ontario Regional Blood Coordinating Network (ORBCoN) gratefully acknowledges funding support provided by the Ontario Ministry of Health. The views expressed in publication are those of the authors and of ORBCoN and do not necessarily reflect those of the Ontario Ministry of Health or the Government of Ontario.


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Callum, J. L., Pinkerton, P. H., Lima, A., Lin, Y., Karkouti, K., Lieberman, L., … Webert, K. E. (2016). Bloody easy 4: Blood transfusions, blood alternatives and transfusion reactions: A guide to transfusion medicine (4th ed.). Toronto: Ontario Regional Blood Coordinating Network. Retrieved from

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Thakkar, R. N., Podlasek, S. J., Rotello, L. C., Ness, P. M., & Frank, S. M. (2017). Things we do for no reason: Two-unit red cell transfusions in stable anemic patients. Journal of Hospital Medicine, 12(9), 747-749. doi:10.12788/jhm.2806

Wiersum-Osselton, J. C., Whitaker, B., Grey, S., Land, K., Perez, G., Rajbhandary, S., … Schipperus, M. (2019). Revised international surveillance case definition of transfusion-associated circulatory overload: A classification agreement validation study. The Lancet Haematology, 6(7),E350-E358. doi:10.1016/S2352-3026(19)30080-8

Emily Durant, RN, BScN, is a transfusion practice coordinator with the Nova Scotia Health Authority. When she is not developing educational resources for health professionals on blood components and products, she volunteers her time with the Institute of Personalized Therapeutic Nutrition, which works to foster a “food first” culture in Canada for treating chronic diseases.

Donna Berta, RN, BScN, is a clinical project coordinator, nursing, with the Ontario Regional Blood Coordinating Network. Her professional passion is transfusion medicine, promoting best practice for patient safety.

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