October 2019

Principal Findings in ORBCoN Platelet Utilization Audit

Author: Troy Thompson MLT, BAHSc (Hons), Regional Manager, ORBCoN CE Region

Platelet transfusions are used for the treatment or prevention of hemorrhage in patients with deficiency in total numbers and/or function of platelets, whether as a direct or indirect result of disease or as a consequence of medical treatment such as chemotherapy, massive transfusion or use of platelet inhibitors.

Numerous audits of platelet transfusion practice world-wide have revealed highly variable rates of inappropriate platelet transfusions with non-conformance rates commonly estimated in excess of 30%.

A voluntary platelet utilization audit was conducted in Ontario with 69 participating hospitals of which 57 reported platelet orders made during the audit period. (41 community and 16 teaching hospitals) The audit was conducted between January 9th and April 7th, 2017.

Data were collected using a web-based audit tool and included: Hospital Site, Patient Care Area, Date of Transfusion, Patient Age and Sex, Number of Platelet Doses Ordered and Transfused, Ordering Physician Specialty, Indication for Transfusion, Administration of Antiplatelet Therapies, Patient Bleeding Status [“minor” (WHO grade 1 and 2) or “major” (WHO grade 3 and 4)] and Pre- and Post-Transfusion Platelet Counts. Data for patients aged over 18 years (“Adults”) and 18 years and under (“Pediatric”) were analysed separately.

The audit was intended to assess the current state of the clinical practice of platelet transfusion in Ontario in respect of:

• Determining the proportion of platelet transfusions deemed inappropriate against defined, validated criteria
• Identifying the patient and provider factors associated with inappropriate platelet transfusion
• Providing guidance in the way of remediation efforts that could lead to improvements in the clinical practice of platelet transfusion

For the purposes of this audit, the criteria used were derived from recent guideline recommendations published by the AABB (Kaufman et al., 2015a) and the International Collaboration for Transfusion Medicine Guidelines (Nahirniak et al., 2015), and validated in a preliminary pilot study (Etchells et al. 2018).

Principal Finding Highlights

• Of the total of 1903 platelet transfusion orders audited, 834 (43.8%) did not meet criteria and were deemed “inappropriate”.
• Of the 1693 transfusion orders for “Adult” patients, 701 (41.4%) were deemed inappropriate (266 [40.3%] of 660 in academic centres and 435 [42.1%] of 1033 in community hospitals).
• Of the 210 orders for “Pediatric” patients, 133 (63.3%) orders were deemed inappropriate (119 of 181 [65.7%] orders in academic centres and 14 of 29 [48.3%] orders in community hospitals).
• In adult patients, the highest number of platelet transfusion orders and the lowest rate of “inappropriate” orders, at 24.1%, were for oncology patients. The highest rates of inappropriate platelet transfusion orders were for patients in acute care settings – intensive care units, emergency departments, operating rooms and acute care in-patient bed units.
• 60% of platelet transfusion orders were for prophylaxis in non-bleeding patients and 40% were either for management of bleeding or in anticipation of surgery or other invasive procedure.
• In pediatric patients, the highest number of orders were in hematology/oncology patients but inappropriate platelet transfusion order rates were in the range of 56-71% regardless of patient service identified (minimum ≥ 10 platelet orders).
• 31 of the 57 (54%) participating hospitals reported the presence of guidelines for platelet transfusion at their facility.
• The presence of guidelines in an institution did not appear to significantly improve platelet transfusion appropriateness; however the use of pre-printed order sets and pretransfusion order screening resulted in lower rates of “inappropriate” orders for platelet transfusion.

Inappropriate platelet transfusions accounted for 44% of the total platelet orders audited, a figure in keeping with the results of similar audits world-wide. A variety of strategies should be employed to improve appropriate platelet utilization including mechanisms to understand the reasons for non-compliance and focusing on the “specialities” having a higher rate of inappropriate platelet transfusions. With this knowledge, educational content can be developed and directed to improve appropriateness of platelet transfusions. Additionally, other practice improvement initiatives founded on evidence-based guidelines, including the use of pre-printed order sets and implementation of an effective pre-transfusion screening process by technologists with sufficient Medical Director support, show promise as effective strategies for reducing inappropriate transfusions.

In spite of advances in improving the inherent safety of blood and blood products, the transfusion of blood and blood products remains potentially hazardous. Adverse reactions including allo-immunization, febrile and allergic reactions, Transfusion Associated Circulatory Overload (TACO) and Transfusion Related Acute Lung Injury (TRALI) remain important, often serious, patient outcomes. The prevention and reduction of these types of adverse events comes first with recognizing when a transfusion should or should not be prescribed in compliance with evidence based transfusion guidelines. Furthermore, the costs of transfusion are considerable (estimated at approximately $60 million per year in Ontario for platelets alone) and the supplies are not without limitation. Reducing inappropriate transfusions will help to prevent adverse reactions but also ensure that these blood and blood products are available to those patients that legitimately require them, while respecting the financial sources of support.

More detailed information for the Provincial Platelet audit will be available shortly on transfusionontario.org

1. Etchells M, Spradbrow J, Cohen R et al. Audit of appropriate use of platelet transfusions: Validation of adjudication criteria. Vox Sang 2018; 113:  40-50.
2. Kaufman RM, Djulbegovic B, Gernsheimer T et al. Platelet transfusion: a clinical practice guideline from the  AABB. Ann Intern Med 2015a; 162: 205-213.
3. Nahirniak S, Slichter SJ, Tanael S et al. Guidance on platelet transfusion for patients with hypoproliferative thrombocytopenia. Transfus Med Rev 2015; 29: 3-13.

Report: 2019 Annual Videoconference “Platelets – The Sticky Truth and why it matters to you!”

Author: Tracy Cameron, Regional Project Coordinator, ORBCoN NE Region

ORBCoN and CBS provided another great educational opportunity for medical laboratory technologists, nurses, physicians and other allied health professionals on April 10th, 2019. This year’s Platelet themed videoconference symposium was well attended with a total of 1006 attendees, from over 100 sites within Ontario and 5 other provinces.

The symposium was offered through videoconference and by webcast. The majority attended by videoconference, while 40% attended via webcasting. There were 28 in attendance at the host site at Thunder Bay Regional Health Sciences Centre.

This educational symposium is primarily designed for community and small hospitals who don’t have as much opportunity to attend educational events as staff in larger teaching hospitals. The primary focus is to provide up-to-date information on a variety of topics that  community primary care physicians, nurses and lab staff may not encounter on a regular basis.

99% of attendees indicated they felt the overall symposium objectives and the objectives of each speaker were met and that they were satisfied with the overall symposium. Each presentation was rated favorably.

The recorded webcast is available through the ORBCoN archived webcasting centre  .The PowerPoint presentations can also be found on the ORBCoN website or by clicking on each of the presentations below.

All attendees were eligible to win a prize for attending the symposium and the draw was held on June 13th once all attendance records were received. We would like to send out congratulations to the following winners:

Planning for the 2020 Videoconference symposium will begin in September. A “Save the Date” will be sent out in early fall so that you can secure videoconference rooms. We encourage everyone involved in the circle of care  whose patients may require a transfusion to attend.

The organizing team would like to thank you again for attending this year’s videoconference symposium and making it another successful event. We look forward to bringing you next year’s event.

If you attended this years symposium and did not receive your certificate of attendance, have any suggestions for topics to present on, or if your site is interested in hosting this annual event, please contact transfusionontario@gmail.com.