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

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.

Appropriateness of platelet, fresh frozen plasma and cryoprecipitate transfusion in New South Wales public hospitals

“…Our finding that a substantial proportion of transfusions were inappropriate is consistent with other studies in Australia 7 ‐ 9 and elsewhere 10 . ‐ 19 The value of our study is that the results are based on a representative State‐wide sample and provide statistically unbiased estimates for the three major categories of public hospitals.…”

Critical evaluation of justifications for the transfusion of red blood cells: the reality of a government emergency hospital

“…These and other studies reinforce the importance of the blood bank staff reviewing the indications for blood transfusions as well as the formation of a transfusion committee (29,30) . Other measures that could be adopted to reduce excessive blood consumption include strategies published in the literature that use the descriptors "blood conservation strategies" and "bloodless medicine" (4) .…”

“…Tuckfield et al showed a decrease in inadequate indications for RBC concentrates from 16% to 3% after a prospective intervention with careful monitoring of blood bank physicians (29) . These and other studies reinforce the importance of the blood bank staff reviewing the indications for blood transfusions as well as the formation of a transfusion committee (29,30) .…”

Clinical audit of the use of fresh‐frozen plasma and platelets in a tertiary teaching hospital and the impact of a new transfusion request form

“…Reversal of warfarin anti‐coagulant effects has emerged as the commonest contributory indication for FFP (34% compared to 4% previously reported from another tertiary referral hospital in Victoria in 1996) 3 . This is likely secondary to an increasing number of, especially elderly, individuals (0.5–1.8% described in two European populations) 4 warfarinized for a variety of cardiovascular indications, such as atrial fibrillation 5 .…”

“…There is a lack of guidance of target INR/aPTT and Plt counts in different procedures, compared with other published guidelines 8,9,18 . Uncertainty about the appropriate laboratory criteria may lead to a higher rate of inappropriate FFP transfusions 3 . Thrombocytopenia, as a major contributory factor in bleeding patients, is also imprecise.…”