Rationalised premedication practice for blood product transfusions: A single‐centre quality initiative

Abstract

Aim: Blood and platelets are scarce resources that are an essential part of the supportive care for paediatric cancer patients. There are many inherent risks involved with transfusions including acute transfusion reactions (ATRs). Following an initial ATR, prophylactic medications are commonly given prior to subsequent transfusions. However, there are risks with medication administration as well as negative implications for the health system. Our aim was to prevent the automatic prescribing of premedications prior to blood and platelet transfusions for ATRs. We hypothesised this would not increase the risk of harm. Methods: Our intervention was to eliminate automatic prescribing of intravenous corticosteroids and intravenous promethazine prior to a transfusion. This was approached through a behaviour change model and the implementation of recommended prescribing guidelines. Three Plan Do Study Act (PDSA) cycles refined the guidelines to align with clinicians' needs and build support through co-design. Data gathered on individual patients receiving transfusions and reaction rates during the trial were compared to international data. Results: A total of 100 patients received a transfusion during the trial. Eleven patients either had a previous reaction or experienced their first reaction during this time. All patients followed the guidelines and had either no premedication or an oral antihistamine premedication. There were no breakthrough reactions using oral antihistamines. The overall reaction rate was 1.33%, which aligns with the reported data on ATRs internationally. Conclusion: A restricted prescribing approach to pharmaceutical cover prior to blood and platelet transfusions can be implemented effectively in a paediatric cancer population, without an increase in the risk of harm to the patients.

Improving Blood Product Transfusion Premedication Plan Documentation: A Single-institution Quality Improvement Effort

“…As noted in previously published studies, our QI team successfully standardized local clinical practice by implementing a triad of passive CPOE alerts, 22,25 clinical care pathways, 9,23 and clinical education. 24 The rate of premedication plan documentation improved during the planning stage without formal intervention, suggesting that providers changed practice when they realized they were being monitored.…”

“…) In contrast, supporters argued that the value of potentially preventing FNHTR and MATR outweighs both the cost and risk from acetaminophen and diphenhydramine and that the sample size of the trials was small. [8][9][10]12,13,16 Nevertheless, this practice variation has led to the inefficiency of the blood product ordering process that negatively affected patient and clinician satisfaction at our institution. Providers had to spend time reviewing the electronic health record (EHR), looking for information about a patient's premedication needs.…”

“…5,6 Clinicians have been using acetaminophen and diphenhydramine to prevent FNHTR and MATR for several decades. 1,2,[7][8][9] However, FNHTR and MATR have become less frequent with the increasing use of leukoreduced products. [10][11][12][13][14][15] The efficacy of premedication has not been extensively studied, perhaps due to the safety profile and low cost of acetaminophen and diphenhydramine and the benign nature of FNHTR and MATR.…”

“…[19][20][21] Previous data showed that clinical pathway implementation, computerized provider order entry (CPOE), standardized documentation, education, and patient engagement could reduce variation and improve communication between healthcare teams. 9,16,[22][23][24][25] Thus, using a quality improvement (QI) approach, our team sought to improve ordering efficiency by increasing the rate of blood product premedication plan documentation. We aimed to improve the premedication plan documentation rate from a baseline of 19%-80% in 1 year.…”

Decreasing Premedication for Blood Transfusions: A Quality Improvement Project

“…However, the focus of this QI project wasn't only to add to the already robust evidence that premedication doesn't reduce adverse reactions, but also to implement evidence-based strategies to change a longstanding culture and reduce ordering clinicians' use of premedication. Four articles found in the literature search focused on evidence-based interventions to decrease the use of premedication in blood transfusions (see Table 1 [5][6][7][8] ); these were used as the basis for the QI project. Three of these articles were published in 2022, [6][7][8] while the fourth, by Wong-Sefidan and colleagues, was published in 2014.…”