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

Med J Aust 1997; 167 (9): 473-476.
Published online: 3 November 1997

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

Annabel Tuckfield, Michael N Haeusler, Andrew P Grigg and Jack Metz

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Abstract - Introduction - Methods - Results - Discussion - References - Authors' details

- - ©MJA1997


 

Abstract

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 cases 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 inapproriate 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, current laboratory criteria can be retained, but should be applied with flexibility.

MJA 1997; 167: 473-476  

Introduction

In 1995, we reported results of an audit of blood product use at a tertiary teaching hospital (Royal Melbourne Hospital, Victoria).1 Indications for transfusion were analysed, mainly by retrospective review of medical records. We found that blood product use was inappropriate for 16% of red cell, 13% of platelet and 31% of fresh frozen plasma (FFP) transfusion episodes. In a significant number of episodes, the specific indication for transfusion was not documented in the medical record.

Blood products must be used appropriately to minimise patient exposure to potential hazards, to conserve a limited resource and to contain costs. Measures to reduce inappropriate use of blood products have had varying results. While retrospective audit and education do not produce consistent and continuing improvements,2-8 prospective monitoring (monitoring of requests for blood products before issue) has usually been more successful.9-15

Consequently, in March 1996, the Royal Melbourne Hospital introduced prospective monitoring of transfusion requests with the aim of reducing inappropriate use of blood products. We present the results of the first three months of this intervention.  

Methods

 

Intervention

Blood products request form: The blood products request form was redesigned to incorporate the indication for transfusion and relevant clinical and laboratory data. These included:

  • For red cells: haemoglobin level and clinical parameters (pulse rate and blood pressure);
  • For platelets: platelet count and presence or absence of bleeding;
  • For FFP: results of coagulation tests (prothrombin time [PT] or international normalised ratio [INR] and activated partial thromboplastin time [APTT]); and
  • For all blood products: reasons for transfusion and operation (if applicable).

In addition, the redesigned request form stipulates that the indication for transfusion must conform with the hospital's transfusion guidelines, which are printed on the reverse of the form (Box 1).

Criteria for appropriate transfusions: The criteria were the same as those used in the audit.1 For FFP use, the requirement for coagulation times to be prolonged by more than 50% translated to PT >20 seconds or APTT >40 seconds.

For massive blood transfusion (10 or more units of red cells in less than 24 hours), blood products were issued before laboratory results were available, and these transfusions were accepted as appropriate. In view of the potentially devastating effects of minor haemorrhage associated with neurosurgical procedures, these were exempted from the criteria for FFP use.1

Monitoring: On receiving a completed blood product request form, the senior medical laboratory scientist determined that the necessary information had been provided, and telephoned the requesting doctor to obtain any missing information. The scientist then checked that the indications conformed with transfusion guidelines, and if so, blood products were issued. If clinical or laboratory indications did not conform, the request was referred to the Haematology Registrar who consulted the requesting doctor. There were three possible outcomes: they agreed (i) either that the transfusion was not indicated and the blood products were not issued or (ii) that it was indicated and the products were issued or (iii) they disagreed and the products were issued. The consultation was never confrontational, and the blood product was always issued when there was disagreement. However, for the study these cases were subsequently referred to the Consultant Haematologist who reviewed the haematological data, transfusion request and medical record to decide if the transfusion was indeed inappropriate.  

Analysis of outcomes

For each type of blood product (red cells, platelets and FFP), we analysed 200 consecutive transfusion episodes between March and May 1996. As in the initial audit, we excluded FFP transfusions for patients with thrombotic thrombocytopenic purpura, because of the different rationales for FFP use in this condition and in coagulation factor depletion. Rates of inappropriate blood product use after introduction of prospective monitoring were compared with those found during the previous audit (pre-intervention) with two-sided Fisher's exact tests.  

Results

Indications for transfusion of red cells, platelets and FFP after introduction of prospective monitoring are shown in Box 2 (below). They were the same as in the pre-intervention audit.1


Numbers of transfusions referred to the Consultant Haematologist for review were: red cells, eight; platelets, 12; and FFP, 41. Final numbers of transfusion episodes deemed inappropriate were: red cells, six (3%); platelets, five (2.5%); and FFP, 30 (15%). Compared with the pre-intervention audit, rates of inappropriate transfusion episodes were significantly reduced, from 16% to 3% for red cells (P= 0.004), 13% to 2.5% for platelets (P=0.02) and 31% to 15% for FFP (P= 0.02).

Of the six patients in whom red cell use was deemed inappropriate, five had a pretransfusion haemoglobin concentration greater than 100 g/L, the threshold for appropriate transfusion (range in these patients, 104-114 g/L). The sixth patient had a haemoglobin concentration of 98 g/L, but no clinical indications to warrant transfusion.

In four of the five inappropriate platelet transfusion episodes, the platelet count was greater than 63x109/L (range, 63x109-159x109/L), a level at which platelets are not indicated except in the case of excessive bleeding with cardiac bypass surgery. Although three of these four transfusions were given in association with cardiac bypass surgery, there was no evidence of excessive bleeding.

In 30 patients, FFP transfusion was deemed inappropriate as coagulation test results did not meet the criterion of a 50% prolongation of coagulation times. In one of these 30, this was because no coagulation tests had been performed.  

Discussion

We found that the rate of inappropriate transfusion episodes fell significantly after introduction of prospective monitoring, from 16% to 3% for red cells, from 13% to 2.5% for platelets and from 31% to 15% for FFP.

The success of prospective monitoring in reducing rates of inappropriate transfusions for red cells and platelets was not matched for FFP. This agrees with results of three previous studies, which have found persistently high rates of FFP transfusions despite monitoring (>40%,8 33%13 and 27%,15 respectively). As in these studies, we found the reason for deeming FFP use inappropriate was almost invariably failure to show sufficient abnormality in coagulation test results. The need to document abnormal coagulation with a PT or APTT greater than 1.5 x the control value, before FFP transfusion is deemed appropriate, rests on the assumptions that abnormal bleeding is unlikely if coagulation times are shorter than this but likely if they are longer, and that, when coagulation times are greater than 1.5 x the control value, FFP transfusion is likely to prevent or control bleeding. Detailed analysis of published data suggests that these assumptions are questionable.16-23

It is of interest that we found that lowering the cut-off for appropriate FFP transfusions from PT >20 seconds (1.5 times the control value) to PT >17 seconds would have lowered the rate of inappropriate transfusions from 15% to 3%, comparable to the rate found for red cell and platelet transfusions. A PT of 17 seconds is still 3.5 seconds longer than the median control value. Further investigation is needed to establish the clinical guidelines for FFP transfusion. Two publications24,25 have pointed to the need for a large multicentre prospective randomised controlled clinical trial to provide a definitive answer for the role of FFP in patients with acquired multiple coagulation defects. In the interim, it would seem reasonable to require docu mentation of abnormal coagulation as a criterion for appropriate FFP use, but the available evidence does not warrant rigid application of a cut-off level, such as 50% prolongation of PT or APTT.

Other issues that must be addressed before a system of prospective monitoring can be introduced include exemption criteria. Some protocols exempt operating room patients,6 "desperate situations"14 and haematology and oncology patients.13 Emergency situations are also usually exempted from the requirement for laboratory data if the laboratory cannot provide urgent results at all times. If the criteria are to be applied to emergency situations, laboratory facilit ies must be available to provide the data quickly.

In some programs of prospective monitoring, blood products are never withheld, but apparently inappropriate transfusions are later reviewed.11,14 Refusal to issue blood products leads to an adversarial relationship between clinicians and laboratory staff, which may compromise patient care. Refusal might also have medicolegal implications if subsequent patient morbidity or death could be attributed to withholding of the transfusion.

For sustained improvement in practice, prospective monitoring must be continued indefinitely.11 This is both time consuming and demanding of staff. The demand might be lessened by computerised audit of transfusion requests; clinical and laboratory data could be entered into a program which flags non-compliant requests for review by blood bank staff.26

In conclusion, prospective monitoring was successful in reducing inappropriate use of red cells and platelets, but only partly successful for FFP. This probably reflects uncertainty about the appropriate clinical guidelines for FFP use, and although current laboratory criteria for FFP use should probably be retained, they should be applied with flexibility.  

References

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  2. Lam HTC, Schweitzer SO, Petz L, et al. Are retrospective peer-review transfusion monitoring systems effective in reducing red blood cell utilization? Arch Pathol Lab Med 1996; 120: 810-816.
  3. Toy PTCY. Audit and education in transfusion medicine. Vox Sang 1996; 70: 1-5.
  4. Bamerte RE, Fish DJ, Eisenstaedt RS. Modification of fresh frozen plasma transfusion practices through educational intervention. Transfusion 1990; 30: 253-257.
  5. Soumerai SB, Salem-Schatz S, Avorn J, et al. A controlled trial of educational outreach to improve blood transfusion practice. JAMA 1993; 270: 961-966.
  6. Solomon RR, Clifford JS, Gutman SI. The use of laboratory intervention to stem the flow of fresh frozen plasma. Am J Clin Pathol 1988; 89: 518-521.
  7. Brien WF, Buttier RJ, Inwood MJ. An audit of blood component therapy in a Canadian general teaching hospital. Can Med Assoc J 1989; 140: 812-815.
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  10. McCullough J, Steeper TA, Connelly DP, et al. Platelet utilization in a university hospital. JAMA 1988; 259: 2414-2418.
  11. Silver H, Tahhan HR, Anderson J, et al. A non- computer dependent prospective review of blood and blood component utilization. Transfusion 1992; 32: 260-265.
  12. Brandis K, Richards B, Ghent A, et al. A strategy to reduce inappropriate red blood cell transfusion. Med J Aust 1994; 160: 721-722.
  13. Hawkins TE, Carter JM, Hunter PM. Can mandatory pretransfusion approval programmes be improved? Transfus Med 1994; 4: 45-50
  14. Cheng G, Wong HF, Chan A, et al. The effects of a self-educating blood component request form and enforcements of transfusion guidelines on FFP and platelet usage. Clin Lab Haem 1996; 18: 83-87.
  15. Marconi M, Almini D, Pizzi MN, et al. Quality assurance of clinical transfusion practice by implementation of the privilege of blood prescription and computerized prospective audit of blood requests. Transfus Med 1996; 6: 11-19.
  16. Counts RB, Haisch C, Simon TL, et al. Hemostasis in massively transfused trauma patients. Ann Surgery 1979; 190: 91-99.
  17. Braunstein AH, Oberman HA. Transfusion of plasma components. Transfusion 1984; 24: 281-286.
  18. Ciavarella D, Reed RL, Counts RB, et al. Clotting factor levels and the risk of diffuse microvascular bleeding in the massively transfused patient. Br J Haematol 1987; 67: 365-368.
  19. Harvey MP, Greenfield TP, Sugrue ME, et al. Massive blood transfusion in a tertiary referral hospital. Clinical outcomes and haemostatic complications. Med J Aust 1995; 163: 356-359.
  20. Houry S, Georgeac C, Hay J, et al. A prospective multicentre evaluation of preoperative hemostatic screening tests. Am J Surg 1995; 170: 19-23.
  21. Gelb AB, Roth RI, Levid J, et al. Changes in blood coagulation during and following cardiopulmonary bypass. Lack of correlation with clinical bleeding. Am J Clin Pathol 1996; 106: 87-99.
  22. Murray DJ, Olson JD, Strauss AR, et al. Coagulation changes during packed red cell replacement of major blood loss. Anesthesiology 1988; 69: 839-845.
  23. Murray DJ, Pennell BJ, Weinstein SL, et al. Packed red cells in acute blood loss: dilutional coagulopathy as a cause of surgical bleeding. Anesth Analg 1995; 80: 336-342.
  24. McVay PA, Toy PTCY. Lack of increased bleeding after liver biopsy in patients with mild hemostatic abnormalities. Am J Clin Pathol 1990; 94: 747-753.
  25. Cohen H. Avoiding the misuse of fresh frozen plasma. BMJ 1992; 307: 395-396.
  26. Gardner RM, Golubjatnikov OK, Laub RM, et al. Computer critiqued blood ordering using the HELP system. Comput Biomed Res 1990; 23: 514-528.

(Received 20 Mar, accepted 1 Jul 1997)
 


Authors' details

Department of Diagnostic Haematology, Royal Melbourne Hospital, Melbourne, VIC.
Annabel Tuckfield, FRACP, FRCPA, Registrar;
Michael N Haeusler, FAIMS, Senior Scientist, Blood Bank;
Andrew P Grigg, FRACP, FRCPA, Haematologist;
Jack Metz, MD, FRCPA, Head.

Reprints will not be available from the authors. Correspondence: Dr A Tuckfield, Diagnostic Haematology, Post Office, Royal Melbourne Hospital, Parkville, VIC 3050.

E-mail: depATmis.medrmh.unimelb.edu.au

©MJA 1997

<URL: http://www.mja.com.au/> © 1997 Medical Journal of Australia.

Received 25 September 2018, accepted 25 September 2018



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