Prospective-concurrent audits and medical consultation for platelet transfusions

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.

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.

Is there a "magic" hemoglobin number? Clinical decision support promoting restrictive blood transfusion practices

Blood transfusion has been identified as one of the most frequently performed therapeutic procedures, with a significant percentage of transfusions identified to be inappropriate. Recent key clinical trials in adults have provided Level 1 evidence to support restrictive red blood cell (RBC) transfusion practices. However, some advocates have attempted to identify a "correct" Hb threshold for RBC transfusion; whereas others assert that management of anemia, including transfusion decisions, must take into account clinical patient variables, rather than simply one diagnostic laboratory test. The heterogeneity of guidelines for blood transfusion by a number of medical societies reflects this controversy. Clinical decision support (CDS) uses a Hb threshold number in a smart Best Practices Alert (BPA) upon physician order, to trigger a concurrent utilization self-review for whether blood transfusion therapy is appropriate. This review summarizes Level 1 evidence in seven key clinical trials in adults that support restrictive transfusion practices, along strategies made possible by CDS that have demonstrated value in improving blood utilization by promoting restrictive transfusion practices.

Evaluation of platelet transfusion triggers in a tertiary-care hospital

BACKGROUND

Our 1100-bed referral hospital uses approximately 12,000 units of random-donor platelets (PLTs) and 1,900 units of single-donor apheresis PLTs per year with a mean of 23 percent outdating. An analysis of patterns of utilization has been undertaken to evaluate practice.

STUDY DESIGN AND METHODS

Over a 9-month period, data were collected on a total of 1682 transfusion episodes in 464 patients. When the pretransfusion count was greater than 10 x 10(9) per L an attempt was made to identify the specific indications for PLT transfusions such as bleeding.

RESULTS

The majority (78%) of PLTs were transfused when the counts were above 10 x 10(9) per L. The mean pretransfusion counts for different services were: bone marrow transplant (BMT) 17.4 x 10(9) per L, hematology-oncology 14.6 x 10(9) per L, the Heart Institute 3 x 10(9) per L, and other services 36 x 10(9) per L. The percentage of transfusions given to patients with a count greater than 10 x 10(9) per L varied by service with 79 percent in BMT, 60 percent in hematology and oncology, 98 percent at the Heart Institute, and 81 percent in other services. Routine monitoring of counts shows a mean increment of 10.2 x 10(9) per L per transfusion. One hour posttransfusion counts, 24-hour posttransfustion counts, and documentation of clinical justification for transfusions was often not available.

CONCLUSIONS

The data show that most patients who receive PLTs have pretransfusion counts of more than 10 x 10(9) per L and more than one-third have pretransfusion counts of greater than 20 x 10(9) per L. The medical literature supports prophylactic PLT transfusion based solely on the count when the PLT number is 10 x 10(9) per L or less. Above this level additional justification is needed although there are different points of view concerning the appropriate triggers. Our data suggest that there is a need for clear hospital transfusion guidelines and ongoing monitoring of PLT use.

Transfusion audit of fresh-frozen plasma in southern Taiwan

BACKGROUND AND OBJECTIVES

The demand for transfusions has increased rapidly in southern Taiwan. Between 1993 and 2003, requests for fresh-frozen plasma (FFP) in particular rose dramatically at Kaohsiung Medical University Hospital (KMUH). Transfusion orders were not tightly regulated, and inappropriate use of blood products was common.

MATERIALS AND METHODS

We carried out a prospective analysis of transfusion requests from October 2003 to January 2004 at KMUH, and then repeated the audit for another 3-month period after the clinical faculty had undergone five sessions of education on transfusion guidelines. Later, our consultant haematologist applied computerized guidelines to periodic audits.

RESULTS

A 5.2% decrease in inappropriate FFP usage followed the educational programme and a further 30% reduction took place after the application of computerized transfusion guidelines. With the guidelines and periodic audits, FFP transfusions decreased by 74.6% and inappropriate requests from 65.2% to 30%.

CONCLUSIONS

Hospital policy, computerized transfusion guidelines and periodic audits greatly reduced inappropriate FFP transfusions. An educational campaign had a more limited effect.

Guiding the decision to transfuse

Guiding the decision to transfuse can improve transfusion practices. Effective processes must first identify problem(s) in transfusion practice and then include the attending physician as an educational target. Process improvements that have been shown to be effective include the following: (1) briefly meeting one-on-one with physicians, (2) teaching at scheduled conferences, (3) making daily clinical rounds of patients who receive transfusion, (4) concurrently reviewing orders for transfusion before issue of the blood product, and (5) installing algorithms and guidelines in the operating room. Transfusion practices improved with these process improvements.

Transfusion Therapy with Platelet Concentrates

At the end of 1960, the concept that platelet transfusion could reduce the death rate due to hemorrhage was confirmed by the reduction of life-threatening bleeding and prolonged survival in thrombocytopenic patients affected with acute leukemia and aplastic anemia. Thrombocytopenia is the result of an imbalance between platelet production and destruction: usually no bleeding problem will occur until circulating platelets fall below 20000/μl and even a platelet count of 5000/μl may be present in many patients without bleeding. Because of the high risk of alloimmunization in multiply transfused thrombocytopenic patients with random platelet concentrates, the main dilemma is the choice of strategy: “prophylactic”versus “therapeutic” treatment with platelet concentrates of cancer patients and the platelet count selected as the “transfusion trigger” for platelet support in patients without active bleeding. We describe our experience of 367 retrospective non-randomized leukemic patients transfused with platelet concentrates. A total of 225 patients (61.3%) received support therapy: the transfusions were administered prophylactically at a platelet count below 20000/μl in the group of patients with acute lymphoblastic leukemia (35% transfused) and acute myeloblastic leukemia (78% transfused). Only14 hemorrhagic episodes were observed in 148 patients receiving prophylactic platelets (9%), while 21 severe hemorrhages (27%) were documented in patients treated with therapeutic platelet concentrates. Several studies have concluded that maintaining the platelet count above 20000/μl was not justified in the majority of cancer patients. In the absence of more definitive data, a “transfusion trigger” of 10000/μl is selected for platelet transfusion support in leukemic non-bleeding patients receiving chemotherapy.

The red blood cell utilization review experience

The Joint Commission on Accreditation of Healthcare Organizations catalyzed peer-review of blood transfusion and gave it new form in 1984. This process became mostly comprehensive, retrospective, bi-level, and chart-based with an initial screening phase followed by physician- review. Studies were identified and evaluated to test the efficacy of this process, which has recently come under question. In two-thirds of the studies, transfusions were judged appropriate in over 90% of cases. In most hospitals reporting, there were no inappropriate transfusions. It is concluded that the process often results in too few inappropriate cases to readily identify opportunities for improvement.

The transfusion audit as an educational tool

Audits of transfusion used as educational tools can improve transfusion practices. Effective audits must first identify problem(s) in transfusion practice and must then include as educational target, the attending physician. Educational methods that have been shown to the effective include: (1) meeting briefly one-on-one with physicians, (2) teaching at scheduled conferences, (3) making daily clinical rounds on patients who receive transfusion, (4) concurrent review of orders for transfusion prior to issue of the blood product and (5) installing algorithms and guidelines in the operating room. Transfusion practices improved with these educational audit methods.

The transfusion audit as a tool to improve transfusion practice: a critical appraisal

Transfusion audits have a long history and they are required by many regulatory agencies. These audits have been touted as effective in reducing unnecessary transfusions as evidenced by many published articles on the subject. Most of these studies, however, have one or more flaws in their design including the use of historical controls, disregard of the Hawthorne effect, use of multiple interventions, and publication bias. Studies differ in the baseline rate of inappropriate transfusions and have different methods of measuring these rates. There is also little data on how long the effect of implementing a transfusion audit system may last. Transfusion audits appear most successful when there is a high baseline rate of inappropriate transfusions and interventions other than the audit itself are performed. Individual institutions should critically evaluate whether or not their current system of transfusion audits is useful.

Future directions in utilization review: the role of transfusion algorithms

Transfusion practice guidelines and retrospective utilization review have been ineffective in curtailing the inappropriate use of blood and blood products, particularly in cardiac surgical patients. Patients undergoing cardiac surgery with cardiopulmonary bypass (CPB) are at increased risk for excessive perioperative blood loss requiring transfusion of blood products. Recent evaluations have focused on the use of point-of-care coagulation assays for patient-specific therapy. Blood component administration in patients with excessive post-CPB bleeding is generally empiric, in part related to the times required to perform of laboratory-based tests. Methods are now available for rapid, on-site assessment of coagulation assays to allow appropriate, targeted therapy for acquired hemostatic abnormalities. Recent studies indicate that a rapid evaluation of thrombocytopenia and coagulation factor deficiencies, coupled with transfusion algorithms, can facilitate the optimal administration of transfusion-based therapy in patients who exhibit excessive bleeding after CPB. The use of point-of-care assays and transfusion algorithms may provide an effective concurrent method of utilization review of blood products in the surgical setting.

Reduction of inappropriate use of blood products by prospective monitoring of transfusion request forms

OBJECTIVE

To determine the effect of prospective monitoring on appropriateness of transfusions of red cells, platelets and fresh frozen plasma (FFP).

DESIGN

Prospective interventional study.

SETTING

Royal Melbourne Hospital (a tertiary teaching hospital), Melbourne, Victoria, March-May 1996.

INTERVENTION

The blood product request form was modified to incorporate indications for transfusion and clinical and laboratory data. Requests were monitored by blood bank laboratory staff for conformation with hospital transfusion guidelines; non-conforming requests were discussed with the requesting medical practitioner by the Haematology Registrar before blood products were issued. In case of disagreement, blood products were always issued.

SUBJECTS

200 consecutive transfusion episodes for each product (red cells, platelets and FFP).

OUTCOME MEASURES

Appropriateness of transfusion, assessed by a Consultant Haematologist according to hospital guidelines. Rates of inappropriate transfusion episodes after intervention were compared with rates in a previous study.

RESULTS

After intervention, rates of inappropriate transfusion episodes fell significantly (red cells, 16% to 3% [P = 0.004]; platelets, 13% to 2.5% [P = 0.02]; and FFP, 31% to 15% [P = 0.02]). Almost all inappropriate FFP transfusion episodes post-intervention were due to failure to demonstrate prolongation of prothrombin or activated partial thromboplastin times more than 1.5 times the control value.

CONCLUSION

Prospective monitoring of request forms can reduce rates of inappropriate transfusions. High rates of inappropriate FFP transfusions possibly reflect uncertainty about appropriate laboratory criteria for FFP transfusion. While results of large prospective randomised controlled clinical trials of FFP transfusions are awaited, currently laboratory criteria can be retained, but should be applied with flexibility.

Current red blood cell transfusion practices

The appropriate use of blood transfusions remains variable among health-care institutions and patient populations. Transfusion practices are discussed in this article in relation to medical practice guidelines and utilization review. Specific transfusion practices in the settings of intensive care, orthopedic surgery, and open heart surgery are reviewed. A new, promising approach to improving transfusion outcomes is the use of transfusion algorithms. Transfusion algorithms may prove especially useful if they incorporate point-of-care testing that is both physiologic and patient-specific for transfusion decisions. Transfusion algorithms are discussed and data presented for cardiac surgical adults.

Audit and education in transfusion medicine

Because transfusions carry risks to the patient and because inappropriate transfusions are costly, interest in audits and effective education in transfusion medicine has increased over the last decade. Audits identify areas of practice that can be improved by follow-up education of the physicians who prescribe the transfusions. Successful educational approaches to follow-up on problems identified by audit include 30-min one-on-one meetings with surgeons, traditional scheduled teaching conferences, daily clinical rounds on transfused patients, prospective review of blood transfusions and installation of transfusion practice algorithms in the operating room. Other than identifying inappropriate transfusions, audit and education have also been used successfully to improve bedside blood administration practices, decrease unnecessary crossmatches and reduce outdating of donor blood. Multi-institutional audits play a useful benchmarking role. In summary, audit followed by targeted education can improve practices in transfusion medicine.

Can mandatory pretransfusion approval programmes be improved?

To improve the appropriateness of blood-component prescribing, a mandatory haematologist pretransfusion approval programme of all non-red-cell components was instituted. This was associated with a 33% decrease in the units of fresh frozen plama (FFP) transfused. Platelet transfusions increased but utilization of both platelets and FFP are now the lowest of the six comparable blood transfusion regions in New Zealand. A subsequent concurrent audit, using preset criteria, of FFP, cryoprecipitate and platelet usage over a 3-month period showed that further reductions in blood component usage could still be achieved, despite the continuing pretransfusion approval policy. This audit showed that 33% of FFP and 30% of cryoprecipitate units transfused were inappropriately given, despite prior haematologist approval. Hospital transfusion practices can be improved by mandatory blood-component pretransfusion approval but concurrent auditing of this programme is required to identify and correct continuing inappropriate blood-component prescribing. Haematologists need to agree on blood-component indications prior to instituting a pretransfusion approval programme in order to provide optimal management.

Blood component treatment: a retrospective audit in five major London hospitals

A retrospective audit of 200 transfusion episodes involving the use of platelets or fresh frozen plasma (FFP) was performed in five hospitals in London. It examined the currently used practices of transfusion and assessed the appropriateness of blood component treatment. It was necessary to search for an excess of case notes to provide a sufficient number of patients for review. In 61.5% of cases the reason for using the components was not stated. Inadequate documentation of the use of blood components occurred in 66% of cases. An accepted clinical indication for the use of components was evident in only 36% of the total; inappropriate use of FFP was particularly apparent. It is concluded that many aspects of transfusion practice need to be improved.

Blood component transfusion audit: a comprehensive microcomputer program

Blood usage review is an essential aspect of hospital quality assurance. As part of a system for reviewing transfusion practices, the American Red Cross/New Jersey Blood Services has developed a series of microcomputer programs called the Blood Component Transfusion Audit. The programs use transfusion data collected on a standardized form to produce reports of utilization and analyses of transfusion practices, including the extent to which transfusions are justified by established criteria.