An audit of the use of platelet transfusions at Universitas Academic Hospital, Bloemfontein, South Africa

Optimising platelet usage during the induction therapy of acute myeloid leukaemia: Impact of physician education

INTRODUCTION

Platelet products are scarce and expensive resources to be used judiciously. However, inappropriate usage is common. Lack of physician awareness is an important issue. We implemented a physician education program (PEP) along with repeated WhatsApp reminders at our centre. We audited the platelet usage practise before and after the intervention.

METHODS

Charts of patients with acute myeloid leukaemia (AML) treated between January 2020 and August 2020 was reviewed, and the mean platelet usage per patient per day was calculated. Physician education was implemented between September 2020 and December 2020 (2 PowerPoint lectures of 20 min each and weekly WhatsApp messages containing the guidelines). Data of patients treated between Jan 2021 and August 2021 was prospectively audited to understand platelet usage and the indications for transfusions. The British Committee for the Standards in Haematology (BCSH) platelet transfusion guidelines were used as the adjudication tool to evaluate compliance. The mean platelet usage per day per kg body weight of a patient before and after the PEP was compared using the t-test.

RESULTS

Group A (before physician education) consisted of 22 patients, and group B (after physician education) consisted of 23 patients. The mean number of platelet transfusions for each patient in a day per kg body weight was 125.7 × 10⁸ in group A whereas, after the PEP, it had reduced to 73.9 × 10⁸ amounting to an absolute reduction of 51 × 10⁸ (58.8%) from the baseline with a statistical significance of P = 0.001. After implementing the PEP, the mean number of random donor platelets used reduced by 10.25 units (34% reduction), and the mean single donor platelets used reduced by 0.83 units (19% reduction). The 190 requests for platelet transfusion received during this period were classified as appropriate (157/190), which constituted 82.63% of the requests, or inappropriate (33/190), which accounted for 17.36%.

CONCLUSIONS

A short-duration education programme supplemented with weekly WhatsApp messages and an active feedback mechanism on the rationale of platelet transfusion by the treating physician and transfusion specialist could significantly reduce platelet consumption during the therapy of acute myeloid leukaemia patients. This is a measure that can be considered by all high-volume haematology centres, which can improve patient safety and reduce costs.

Use of platelet components: An observational audit at a tertiary care centre

Background Platelets should be transfused appropriately, based on the cause of thrombocytopenia. The practice and policies of transfusion vary among institutions and even among clinical practitioners, leading to inappropriate use of platelets, which might increase the risk of transfusion-related complications to recipients, and lead to a shortage of platelets. An audit of platelet components helps to determine the effectiveness and appropriateness of their use and in improving transfusion practices. We did an audit of the use of platelet transfusions at our centre. Methods We conducted a prospective concurrent audit of the platelet transfusion practices. The audit cycle had four steps: (i) defining the standards; (ii) data collection; (iii) comparison against the standards; and (iv) presenting them to clinicians for further improvement. Results Platelet components were used appropriately in 93.6% (2420/2586) of episodes. The platelet count was not done before transfusion in only 6.4% (165/2586) of episodes. The dose of platelets was given appropriately in 84.3% (2180) of episodes of transfusion. Indications for appropriate transfusion classified as pre-procedure, prophylactic and therapeutic transfusions were 11.3% (293), 66.1% (1450) and 13% (412), respectively. Medicine and medical oncology were the specialties with the highest level of appropriateness. Conclusion An audit of transfusion practices benefits transfusion services and clinicians in terms of judicious use of platelet components and better inventory management.

An audit of platelet transfusion indications in acute leukaemia patients: six-year experience at an Academic Centre

BACKGROUND

Platelet transfusion plays a critical role in the supportive treatment of acute leukaemia patients who receive chemotherapy and haematopoietic stem cell transplantation (HSCT). There are few studies assessing appropriateness of platelet transfusion in this population. An audit was conducted to determine how appropriately platelets are transfused in acute leukaemia patients at a tertiary care health institution.

MATERIALS AND METHODS

A six-year retrospective audit was conducted in acute lymphoblastic (ALL) and acute myeloid leukaemia (AML) patients in an Academic Centre. Episodes were assessed as either appropriate or inappropriate based on guidelines from the British Society for Haematology (BSH). Pre-transfusion platelet count, transfusion indication, World Health Organization (WHO) bleeding score, and antibiotic use were all documented.

RESULTS

Overall, 745 platelet transfusion episodes in 154 patients were audited. The proportion of episodes appropriately indicated according to BSH guidelines was 75.3%. Paediatrics and Internal Medicine had the lowest and highest proportion of appropriateness by department at 63.9% and 86.8%, respectively. The best alignment to guidelines was found on the wards (82.3%). Inpatient cases were significantly better indicated (p=0.002), whereas therapeutic and HSCT-related transfusions were not. The majority of inappropriate transfusions had a pre-transfusion count >20×10⁹/L without a valid justification (45.1%), whereas appropriate episodes were mainly accounted for by a pre-transfusion count <10×10⁹/L (69%).

DISCUSSION

The 25% rate of inappropriate platelet transfusion in acute leukaemia patients underscores the learning needs of physicians, particularly those in training, regarding adequate use of platelets in haematologic malignancies to optimise its utilisation and patient outcome.

Evaluating the appropriateness of platelet transfusions compared with evidence-based platelet guidelines: An audit of platelet transfusions at 57 hospitals

BACKGROUND

Platelet transfusions are used to prevent or control bleeding in patients with thrombocytopenia or platelet dysfunction. The pretransfusion platelet count threshold has been studied extensively in multiple patient settings yielding high-quality evidence that has been summarized in several comprehensive evidence-based platelet guidelines.

STUDY DESIGN AND METHODS

A prospective 12-week audit of consecutive platelet transfusions using validated and evidence-based adjudication criteria was conducted. Patient demographic, laboratory, and transfusion details were collected with an electronic audit tool. Each order was adjudicated either electronically or independently by two transfusion medicine physicians. The aim was to determine platelet transfusion appropriateness and common scenarios with deviations from guidelines.

RESULTS

Fifty-seven (38%) of 150 hospitals provided data on 1903 platelet orders, representing 90% of platelet usage in the region during the time period. Overall, 702 of 1693 adult (41.5%) and 133 of 210 pediatric orders (63.3%) were deemed inappropriate. The most common inappropriate platelet order was for prophylaxis in the absence of bleeding or planned procedure in patients with hypoproliferative thrombocytopenia and a platelet count over 10 x 10⁹ /L (53% of inappropriate orders in adults and 45% in pediatrics). Platelet transfusions ordered with either a preprinted transfusion order set (odds ratio [OR], 1.97; 95% confidence interval [CI], 1.44-2.73) or technologist prospective screening (OR, 1.40; 95% CI, 1.10-1.78) were more likely to be appropriate.

CONCLUSION

There is a discrepancy between clinical practice and evidence-based platelet guidelines. Broad educational and system changes will be needed to align platelet transfusion practice with guideline recommendations.

Platelets transfusion in Greece: Where, when, why? A national survey

BACKGROUND

Platelet transfusion is among the most useful therapeutic tools in modern clinical settings which mean that ensuring an adequate supply is of paramount importance.

AIM

The aim of our study was to record the use and wastage of platelet concentrates (PCs) in Greece, so as to come up with evidence-based interventions.

METHODS

The study was conducted during May and June 2015. We evaluated the use of random-donor platelets (RDPs) and single-donor apheresis platelets (SDPs). We analyzed such parameters as hospital department and diagnosis, indication for transfusion, PCs' age at the time of transfusion, and wastage rate.

RESULTS

We used data from 21 hospitals across the country. A total of 12,061 RDPs and 1189 SDPs were transfused, with an average of 4.84 (±2.72) and 1.12 (±2.73) units per episode, respectively. Most patients had been admitted to the internal medicine and hematology departments. The transfusions were mostly given prophylactically, usually in cases of acute leukemia, and mostly on the day before expiration. Wastage rate was 16.75% for RPDs and 2.70% for SDPs, primarily because of the expiration of the use-by date.

CONCLUSIONS

This is the first national survey regarding platelet transfusion in Greece. Since most patients were admitted in internal medicine and hematology departments, we recommend that the staff of the abovementioned departments should undergo training on contemporary transfusion guidelines. Platelet discard rate could further be lowered through the centralization of inventory management along with the extension of the lifetime of PCs by means of emerging technologies.

How low can you go: What is the safe threshold for platelet transfusions in patients with hematologic malignancy in sub-Saharan Africa

Background

Despite the importance of platelet transfusions in treatment of hematologic cancer patients, the optimal platelet count threshold for prophylactic transfusion is unknown in sub-Saharan Africa.

Methods

We followed patients admitted to the Uganda Cancer Institute with a hematological malignancy in 3 sequential 4-month time-periods using incrementally lower thresholds for prophylactic platelet transfusion: platelet counts ≤ 30 x 10⁹/L in period 1, ≤ 20 x 10⁹/L in period 2, and ≤ 10 x 10⁹/L in period 3. Clinically significant bleeding was defined as WHO grade ≥ 2 bleeding. We used generalized estimating equations (GEE) to compare the frequency of clinically significant bleeding and platelet transfusions by study period, adjusting for age, sex, cancer type, chemotherapy, baseline platelet count, and baseline hemoglobin.

Results

Overall, 188 patients were enrolled. The median age was 22 years (range 1–80). Platelet transfusions were given to 42% of patients in period 1, 55% in period 2, and 45% in period 3. These transfusions occurred on 8% of days in period 1, 12% in period 2, and 8% in period 3. In adjusted models, period 3 had significantly fewer transfusions than period 1 (RR = 0.6, 95% CI 0.4–0.9; p = 0.01) and period 2 (RR = 0.5, 95% CI 0.4–0.7; p<0.001). Eighteen patients (30%) had clinically significant bleeding on at least one day in period 1, 23 (30%) in period 2, and 15 (23%) in period 3. Clinically significant bleeding occurred on 8% of patient-days in period 1, 9% in period 2, and 5% in period 3 (adjusted p = 0.41). Thirteen (21%) patients died in period 1, 15 (22%) in period 2, and 11 (19%) in period 3 (adjusted p = 0.96).

Conclusion

Lowering the threshold for platelet transfusion led to fewer transfusions and did not change the incidence of clinically significant bleeding or mortality, suggesting that a threshold of 10 x 10⁹/L platelets, used in resource-rich countries, may be implemented as a safe level for transfusions in sub-Saharan Africa.

Long-term audit of platelet consumption in a university hospital

OBJECTIVES

To determine the long-term trend in platelet consumption in a university hospital.

MATERIALS AND METHODS

The annual consumption of platelets concentrate (PC) was analyzed over 23 years (1985-2007) in King Khalid University Hospital (KKUH), Riyadh, Saudi Arabia.

RESULTS

The total 23 years consumption was 100,466 units of PC. Consumption went through 3 phases: the first, 1985-1994: the annual consumption increased from 1706 to 5912 which coincided with the increase in the number of patient admissions; the second, 1994-2003:featured a remarkable drop (48.9%) in annual consumption while patient admission remained stable. There was a concurrent decline in platelet consumption and all-cause mortality/patient. Third phase: 2003-2007, the consumption increased to reach 5642 units/year in 2007. The Department of Medicine consumed (52%), followed by Pediatrics (21%), and General Surgery (16%).

CONCLUSION

This audit uncovered evidence of inappropriate platelet consumption that reached 48.9% in the period 1994 to 2003, which coincided with widely publicized HIV scare that dominated blood transfusion during that period. We also found evidence suggesting that reducing platelet transfusion could improve patient outcome.

Platelet transfusion therapy in sub-Saharan Africa: bacterial contamination, recipient characteristics, and acute transfusion reactions

BACKGROUND

Little data are available on bacterial contamination (BC) of platelet units or acute transfusion reactions to platelet transfusions (PTs) in sub-Saharan Africa (SSA).

STUDY DESIGN AND METHODS

This prospective, observational study evaluated the rate of BC in whole blood-derived platelet units (WB-PUs), the utility of performing Gram stains to prevent septic reactions, characteristics of patients receiving PTs, and the rate of acute reactions associated with PTs at the Uganda Cancer Institute in Kampala, Uganda. An aliquot of each WB-PU studied was taken to perform Gram stains and culture using the Bactec 9120 instrument. Study participants were monitored for reactions.

RESULTS

In total, 337 WB-PUs were evaluated for BC, of which 323 units were transfused in 151 transfusion episodes to 50 patients. The frequency of BC ranged from 0.3% to 2.1% (according to criteria used to define BC). The Gram stain had high specificity (99.1%) but low sensitivity to detect units with BC. The median platelet count before PT was 10,900 cells/µL (interquartile range, 6000-18,900 cells/µL). Overall, 78% of PTs were given to patients with no bleeding. Acute reactions occurred in 11 transfusion episodes, involving 13 WB-PUs, for a rate of 7.3% (95% confidence interval, 3.7%-12.7%) per transfusion episode. All recipients of units with positive bacterial cultures were receiving antibiotics at the time of transfusion; none experienced a reaction.

CONCLUSIONS

The rate of BC observed in this study is lower than previously reported in SSA, but still remains a safety issue. Because Gram staining appears to be an ineffective screening tool, alternate methods should be explored to prevent transfusing bacterially contaminated platelets in sub-Saharan Africa.

Lessons learned from transfusion audits

BACKGROUND

In times of patient blood management, studies focus on appropriate transfusion strategies to improve patient's outcome. Little is known about the quality assurance in preparation of blood transfusion and thereafter. In the present study, the indication, informed consent, mandatory immunohematology tests and documentation of blood transfusions were evaluated using assessed self-inspection forms approved by the hospital transfusion committee.

MATERIALS AND METHODS

47 medical records of transfused patients were retrospectively reviewed by a clinical transfusion audit team in six hospital facilities from 2012 to 2015. Self-inspection forms were used to classify the physicians' documentation of transfusion into 3 groups: adequately, intermediately, and inadequately documented.

RESULTS

Adequate documented records were only found in 5 cases (10.6%), followed by intermediate (51.1%) and inadequate documentation (38.3%). Informed consent was identified most often as inappropriate, and this was a critical point with respect to medico legal aspects.

CONCLUSION

Continuous education of physicians defining parameters to be documented is almost essential in daily transfusion medicine routine. The use of a check list with physician's documentation of transfusion is strongly recommended.