Raise the Bar: A quality improvement project to improve the diagnosis and management of iron deficiency and anemia

The project team

Michelle Sholzberg (Co-Chair), St. Michael’s Hospital, Unity Health Toronto

Lusia Sepiashvili (Co-Chair), The Hospital for Sick Children (SickKids)

Daniel Beriault, St. Michael’s Hospital, Unity Health Toronto

Laboratory shortages of blood tubes, syringes, collection needles and more

How can primary care providers and hospitals manage utilization to help with current laboratory shortages? See the latest guidelines below.

Read a related story in the Ottawa Citizen Beriault and Weinerman: Shortage of lab supplies plagues many Canadian hospitals

Iron deficiency is an issue of health equity in Toronto, Ontario, Canada and globally. The most reliable diagnostic test for iron deficiency, in the absence of concomitant inflammation, is serum ferritin. Despite ferritin being a highly sensitive, widely available, and relatively inexpensive test, it is often under-utilized, even in high-risk patient populations. 

Unclear clinical decision limits for serum ferritin are a significant barrier to recognizing and appropriately managing patients with iron deficiency. This project will change current ferritin lower limits of normal to ferritin clinical decision limits for iron deficiency to 30 mcg/L in adults and 20 mcg/L in pediatrics in the largest community laboratories and multiple hospital laboratories in Ontario.

This change has been coupled with a knowledge translation strategy. We expect this change will increase ferritin testing rates, prompt treatment of iron deficiency, decrease risk of anemia and improve quality of life among affected individuals.

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Latest guidelines from the laboratory test utilization working group

Global Blood Collection Tube Shortage

Laboratory test utilization
Mar 1, 2022

Open this on a separate page.

Download this guide as a printable PDF.

Disruptions in global supply chains due to COVID-19 have resulted in global supply constraints related to bloodcollection tubes. Supply constraints for blood collection tubes are expected to stabilize in the coming months. However, current shortages are impacting all healthcare organizations and there is a need for immediate action to conserve tubes.

Suggested conservation strategies are below.


For Clinicians

  • Do not order non-essential laboratory tests; critically assess the potential for a test result to impact immediate patient care before ordering.
  • Avoid blood work in stable or asymptomatic outpatients.
  • Avoid blood work in alternate level of care patients.
  • Do not order routine standing orders and consider cancelling unnecessary standing orders.
  • Do not perform annual screening blood tests unless directly indicated by the risk profile of the patient.
  • Consider reviewing or pausing medical directives, order sets and order panels in clinical areas where blood work is drawn routinely (e.g. Emergency Department).
  • Refer to Choosing Wisely Canada recommendations (below) for appropriate test utilization guidance for specific clinical situations.

For Laboratorians

  • Laboratory medicine departments should consider validation of alternative blood collection tubes and supplies.
  • Consider reviewing blood draw practices with local stakeholders to identify opportunities to reduce blood draws.
  • Consider partnering with local laboratories to share supplies and off-set respective critical shortages.


For Clinicians

  • Review previous laboratory test results including point-of-care test results that may have already included the test of interest, for e.g., glucose meter checks and electrolytes on blood gas analyzers.
  • Whenever possible, add-on tests to existing blood draws.

For Phlebotomists and Laboratorians

  • Follow laboratory guidelines on grouping tests on single tubes to make the most efficient use of tubes and collection.


For all

  • Engage with local laboratory medicine and procurement teams to gain awareness of the status of supplies, recommended usage, and validated alternatives.
  • Ask your hospital or community laboratory for clarification on unnecessary tests and procedures.
  • Connect with your local data analytics team to consider feasibility of development of a blood collection tube dashboard to best track supply and demand, send alerts, help inform the feasibility and safety of clinical care ramp up based on blood tube availability.

Other resources: Choosing Wisely Canada


Dr. Michelle Sholzberg


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View an update from the project team

We held a workshop on May 5, 2021, covering an update and discussion on the project, presented by Dr. Michelle Sholzberg and Dr. Daniel Beriault.

Other working groups of interest

The Canadian Society of Clinical Chemists (CSCC) Utilization Management Interest Group aims to share best practices for laboratory utilization management among other laboratories, develop recommendations for laboratory utilization management, and promote optimal laboratory utilization among laboratory users.

Other available guidelines

Dr. Dan Beriault has led a national working group with Choosing Wisely Canada to produce utilization recommendations aimed at helping to deal with the severe shortages that clinical labs are facing (blood tubes, syringes, collection needles etc.). 

Relevant publications for further information

These will be added soon.

Latest news

Sep 23, 2021
A team at the University of Toronto has just published the first study of Ontario genetics laboratories' practice of reporting critical values to help define standards for the industry.

No upcoming events were found.

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