Appropriateness Of Transfusion Research Articles

INAPPROPRIATE USE OF FRESH FROZEN PLASMA AN AUDIT OF A TERTIARY CARE HOSPITAL.

Introduction: As the use of Fresh Frozen Plasma (FFP) is having establishedcomplications including Allergic reactions, infectious complications, hemolysis, fluid overload, transfusion related acute lung injury (TRALI) and immune suppression, therefore it mustbe used cautiously. Objectives: To evaluate the inappropriate use of FFPs, to carry out anaudit of appropriateness of FFP transfusion with reference to international guidelines and setfoundations for blood bank and transfusion protocols. Study Design: Cross sectional study.Setting: Khyber Teaching Hospital Peshawar. Period: 6 months, 1st January 2016 to 30th June2016. Methods: During which FFP transfusion requests made to the blood bank by various unitsof the hospital were studied including general surgery, surgical ICU, general medicine, medicalICU, gynecology and obstetrics. Seventy Six requests were received that were judged using6 variables: indication for FFP use, sampling errors, laboratory analysis errors, interpretationerrors, dosage of FFP (number of units being transfused) and timing of FFP transfusion. Scoreof “1” was given for each correct variable. After matching data to the international protocols, ascore of 4-5 was taken as appropriate and <3 was classified as inappropriate. Results: TwentySeven (35.5%) FFP transfusions were done with a score of 4-5 and were considered appropriatewhile 49(64.5%) FFP transfusions were given a score of 3 or less and were consideredinappropriate. Conclusions: Almost two third of FFP were used inappropriately in our hospital,the commonest indication being acute Disseminated Intravascular Coagulation (DIC) andmostly requested from surgical units. Maximum cases of inappropriate transfusions were dueto wrong sampling techniques and wrong dosage calculations. Most inappropriate transfusionswere done in MICU. It is recommended that annual clinical audit of all blood products usageshould be conducted. Local guidelines for physicians and training programs for nurses andparamedics regarding proper use of blood products should be established.

P132: Real life management of patients presenting with upper gastrointestinal bleeding in a tertiary care emergency department - Are we delivering the standard of care?

Introduction: Upper gastrointestinal bleeding (UGIB) is a common Emergency Department (ED) presentation. Early endoscopic intervention, supported by Glasgow Blatchford Score (GBS) severity, has been shown to reduce re-bleeding rates and lower morbidity and mortality. However, emergent endoscopy is not necessary for all patients. Low-risk patients can be managed with outpatient follow-up. Other important management decisions such as blood transfusion (Hb &lt;70) and use of proton pump inhibitors (PPI) also warrant evaluation. The aim of this study was to compare the timing and appropriateness of endoscopy and blood transfusion and proton pump inhibitor (PPI) use in a tertiary care setting to the standard of care. Methods: A retrospective cohort study was conducted to examine the management of patients presenting with UGIB to the ED in 2016 using a standard chart review methodology. TANDEM and EDIS (Emergency Department Information System) databases were queried to identify patients using specified ICD 10 codes and the CEDIS (Canadian Emergency Department Information System) presenting complaints of vomiting blood or blood in stool/melena. Outcome measures included: patient characteristics, the GBS to determine appropriateness of endoscopic intervention, diagnoses, blood transfusion indications and utilization of oral or intravenous PPIs. Data were entered into a REDCap database and analyzed using standard non-parametric statistical tests. Results: A total of 200 patients, 59% male (118/200), mean age 59 years (range 18 - 92 years) were included. The median GBS was 9. 79% of patients (157/200) underwent endoscopy during the hospital visit: 30% of patients with GBS 0-3 (13/43) and 80% patients with GBS 4 (125/157) underwent endoscopy 24 hours. The two most common endoscopic diagnoses were peptic ulcers (39%, 61/157) and varices (18%, 28/157), while 14% (22/157) had a normal diagnosis or mild gastritis. 174/200 patients (87%) were given IV or oral PPI in the ED whereas the remaining 26 (13%) did not receive PPI in hospital. 46% of patients (89/194) received blood transfusion, but only 51% (45/89) were administered based on the 70 g/L threshold while in 40% (36/89) of patients the less restrictive threshold of 90 g/L was used. Conclusion: A majority of UGIB patients presenting to a tertiary hospital ED appropriately received endoscopy 24 hours based on a GBS score 4. PPI use was appropriate but a proportion of patients received inappropriate blood transfusions.

Improving quality of care for patients with iron deficiency anemia presenting to the emergency department.

Patients presenting to the emergency department (ED) with iron deficiency anemia (IDA) are underrecognized, undertreated with iron, and overtransfused. A 3-month audit of red blood cell (RBC) transfusions at the Sunnybrook Health Sciences Centre ED in 2013 showed that only 53% of transfusions for IDA were appropriate. The aim of this quality improvement project was to increase the rate of appropriate transfusion to greater than 80%. Since November 2013, several quality improvement interventions have been implemented, including educational presentations, development of an algorithm on IDA management in the ED, and development of an ED IDA toolkit. The primary outcome was appropriateness of RBC transfusions per month. The process measure was monthly intravenous (IV) iron use in IDA patients managed exclusively by ED staff. Balancing measures included IV iron use according to the algorithm and undertransfusion. Over a 24-month period beginning January 2014, assessment of 193 units transfused in the ED showed an improvement of RBC appropriateness to 91% (range 50%-100%). IV iron use increased from one dose in the 3-month audit to an average of 2.6 and 4.7 per month in 2014 and 2015, respectively. IV iron use did not follow the algorithm in 19% (18 of 93) of cases: 12 were given to patients with less severe iron deficiency or bleeding. Improved RBC transfusion appropriateness for IDA in the ED can be achieved and maintained with the implementation of simple educational and practical interventions.

Patient blood management strategies in total hip and knee arthroplasty

Background: Patient blood management in total hip and knee arthroplasty involves a three-pillar approach of optimizing red blood cell mass, minimizing blood loss, and managing anemia. We describe the effect of implementation of various strategies over a 7-year period. Methods: We prospectively collected blood transfusion data over a yearly quarter in the years of 2009, 2012, 2014, and 2015 with patients undergoing total hip arthroplasty (THA) and total knee arthroplasty (TKA), primary and revision procedures. Evidence-based patient blood management strategies were introduced, including a tranexamic acid (TXA) protocol. The data were retrospectively analyzed, with observations of rates and appropriateness of blood transfusions in the context of changes in Australian National Blood Authority guidelines. Results: There was a significant reduction in transfusion rates from 2009 to 2015 in both THA (38.5%, 24.4%, 8.5%, and 12.5% for 2009, 2012, 2014, and 2015, χ2=17.9, P&lt;0.05), and TKA (12.4%, 6.1%, 7.8%, and 2.1% for 2009, 2012, 2014, and 2015, χ2=4.2, P&lt;0.05). This coincided with an increased adherence to national blood management guidelines in both THA and TKA (χ2=7.19, P=0.027). Conclusions: Patient blood management is multifaceted, and significant reductions in transfusion can be achieved in adherence to perioperative patient blood management guidelines. Tranexamic acid also is an important contributor in the improvement of transfusion rates in THA and TKA.

Utilization of frozen plasma, cryoprecipitate, and recombinant factor VIIa for children with hemostatic impairments: An audit of transfusion appropriateness.

Blood transfusions and fractionated products are not without risk and may lead to acute and long-term adverse events. The objective of this study was to evaluate the appropriateness of usage of frozen plasma (FP), cryoprecipitate (CRYO), and recombinant factor VIIa (rVIIa) in a pediatric setting. All orders for FP, CRYO, and rVIIa were prospectively audited over 6weeks. Data collected included demographics, laboratory values, indication, and adverse reactions. The appropriateness of each order was independently evaluated using adjudication criteria rated by two hematologists. Two hundred sixty-five products were ordered; 67% of the orders were issued to operating rooms or intensive care units. The most common indication for all products was cardiac surgery. FP was ordered as fluid replacement (15/215; 7%) to correct abnormal coagulation tests (23/215; 11%) and for patients with minor or no bleeding (111/242; 46%). FP was more likely to alter the international normalized ratio (INR) if the INR was over 2.0 (P<0.0001). The rate of inappropriate products was judged as FP 19%, CRYO 21%, and rVIIa 91%. FP, CRYO, and rVIIa are most commonly used in the operating room and intensive care units. FP was often used for fluid resuscitation and for patients with mild to no bleeding. FP was only effective in lowering the INR when the INR was over 2.0. Use of rVIIa was rarely ordered for an appropriate indication. Results of this study inform its readers where trials of pediatric transfusion should be performed to clarify how these products should be used in clinical practice.

Administering Blood Products Before Selected Interventional Radiology Procedures: Developing, Applying, and Monitoring a Standardized Protocol

PurposeTo apply and monitor a single institution’s adherence to internally established guidelines for the preoperative administration of platelets and/or fresh frozen plasma (FFP) before a specified subset of minimally invasive interventional radiology (IR) procedures. Materials and MethodsBeginning in December 2008, we implemented a set of restrictive guidelines for preoperative platelet and/or FFP administration before IR procedures at a single academic hospital. Basing our program on the methodology of Lean Six Sigma, we compared the number and appropriateness of transfusions between the months of January and October in 2008 (prepolicy), again in 2010 (postpolicy), and finally in 2015 (follow-up). Patients with a platelet count less than or equal to 50,000 or an international normalized ratio greater than or equal to 1.7 met criteria for receiving platelets or FFP, respectively, before their IR procedure. For all three periods, we compared the rates of transfusion, hemorrhagic complications, and proportion of appropriate versus inappropriate blood product administration (BPA) per our guidelines. ResultsThere was a significant increase in the number of appropriate BPAs between 2008 and 2010 from 58% to 76% (P = .021). Between 2010 and 2015, the rate trended up further, from 76% to 88% (P = .051). Overall, between 2008 and 2015, the improvement from 58% to 88% was significant (P < .001). The rate of hemorrhagic complications was extremely low in all three groups. ConclusionRestrictive guidelines for receiving platelets and FFP administrations before IR procedures can sustainably decrease the rate of overall BPA while increasing the proportion of appropriate BPA without impacting the rate of hemorrhagic complications.

Postpartum obstetric red cell transfusion practice: A retrospective study in a tertiary obstetric centre.

Traditional management of anaemia due to postpartum haemorrhage (PPH) has relied upon salvage therapy with red cell transfusion. Recently published guidance recommends a change in approach toward holistic patient blood management. To determine whether postpartum red cell transfusion practices are consistent with best practice and to identify opportunities for improvement. A retrospective audit of postpartum red cell transfusions was conducted at a tertiary level obstetrics unit. Relevant clinical and laboratory data were collected for all cases of postpartum red cell transfusions and PPH. Clinical decision making and appropriateness of transfusions were evaluated. Among the 3235 women who delivered in 2013, 110 (3.4%) received a postpartum red cell transfusion. About 101 of the transfusions were associated with primary PPH. Overall PPH complicated 460 (14.2%) deliveries. Antenatal anaemia was identified as a major correctable risk factor for transfusion in women who experienced PPH (odds ratio 6.55, 95% CI: 3.17-13.6). Volume of blood loss and the aetiology of PPH were additional risk factors for transfusion. Transfusion was associated with lower birth weight and increased maternal length of stay. Transfusion triggers were more likely to be appropriate when transfusion took place in the operating theatre, within 12h of delivery and when prescribed by anaesthetists. Post-transfusion Hb levels were uniformly above target for all women transfused. A significant number of red cell transfusions were outside the recommendations of the new guidelines. Maximising red cell mass during pregnancy and improving transfusion practices were identified as opportunities for future improvement.

Improving Appropriateness of RBC Transfusion for Iron Deficiency Anemia Patients Presenting to the Emergency Department

Improving Appropriateness of RBC Transfusion for Iron Deficiency Anemia Patients Presenting to the Emergency Department

P117: Emergency physicians are choosing wisely when transfusing patients with non-variceal upper gastrointestinal bleeding and hemoglobins &gt;70 g/L

Introduction: Acute non-variceal upper gastrointestinal bleeding (NVUGIB) is a common presentation to the Emergency Department (ED) associated with significant mortality and morbidity. Recent evidence suggests that overt-transfusion is associated with poor patient outcomes and that stable patients above a hemoglobin (hgb) above 70 g/L should be transfused judiciously. This retrospective health records review aims to determine the proportion of NVUGIB patients with hemoglobin greater than 70 g/L who were still appropriately transfused based on clinical parameters. Methods: A retrospective review was conducted on randomly selected patients that presented to one of two major tertiary hospitals with a primary diagnosis of NVUGIB who received blood products, despite a presenting hemoglobin &amp;gt;70 g/L. Standardized case report forms were developed through chart abstraction using a pilot-tested template. The appropriateness of transfusion was then adjudicated separately by a trained medical student and an emergency physician; discrepancies were resolved by discussion. Results: Following independent review of the charts, agreement was met on 94% (45/48) of the charts and after collective discussion 100% consensus was reached and all 48 patients’ transfusion appropriateness and categorized into one of three groups: Appropriate, Potentially avoidable, and clearly avoidable. Only in 22.9% (11/48) of the cases was transfusion deemed to be clearly avoidable while emergency physicians appropriately transfused 45.8% (22/48) of patients based on clinical status and other factors. In 31.3% (15/48) of the cases, transfusion was potentially avoidable in favor of other management options. We calculated the mean GBS for the appropriate, potentially avoidable, and clearly avoidable categories yielding 12.8, 12.7, and 10.2 respectively. Mortality occurred in 2 of the 48 cases (4%). Conclusion: In most instances, emergency physicians are effectively integrating hemoglobin thresholds and clinical status to determine if a patients with NVUGIB and hgb &amp;gt;70 require blood products.

Appropriateness of Plasma Transfusion: A College of American Pathologists Q-Probes Study of Guidelines, Waste, and Serious Adverse Events.

- Plasma transfusion guidelines support patient care and safety, management of product wastage, and compliance; yet, there is little information across multiple institutions about use of and adherence to plasma transfusion guidelines. - To survey multiple institutions regarding their plasma transfusion guidelines and compliance, plasma wastage rates, and incidence of transfusion reactions associated with plasma transfusion. - The College of American Pathologists Q-Probes model was used to collect data from 89 participating institutions. Each site was asked to provide data relevant to its most recent 40 adult patient plasma transfusion episodes, and complete a questionnaire regarding plasma transfusion guidelines, utilization and wastage of plasma, and transfusion reactions related to plasma transfusion. - The participating institutions reported a total of 3383 evaluable plasma transfusion episodes with transfusion of 9060 units of plasma. Compliance with institution-specific guidelines was seen in 3018 events (89%). Pretransfusion and posttransfusion coagulation testing was done in 3281 (97%) and 3043 (90%) of these episodes, respectively. Inappropriate criteria were noted for more than 100 transfusion episodes. Thirty-two plasma transfusion episodes (1%) were associated with a transfusion reaction. Serious and fatal reactions were reported. Median plasma wastage rate for the year preceding the study was 4.5%. - Most participating institutions are compliant with plasma transfusion guidelines based on published references, supported by appropriate testing. With transfusions for indications that lack evidence of efficacy and incidence of transfusion reactions, there is an ongoing role for transfusion service leaders to continue to update and monitor plasma transfusion practices.

Educational interventions encouraging appropriate use of blood transfusions.

The integration of a restrictive packed red blood cells (PRBC) transfusion strategy into daily clinical practice presents a challenge. This study describes the effect of an intervention including educational presentations and computerized alerts on PRBC utilization at a tertiary hospital. During December 2014, lectures describing recommended PRBC transfusion indications were presented to all non-intensive care departments. Starting from January 2015, an alert was added to the electronic drug ordering system recommending transfusions at a haemoglobin (Hb) level <7 g/dl or Hb < 8 g/dl in symptomatic patients. The physician was not required to acknowledge the alert. Data regarding measured Hb preceding transfusions were collected. The primary end-point was defined as the percentage of PRBC administered at Hb ≥ 8 g/dl in 2015 compared with 2014. Secondary end-points were the percentage of PRBC administered to patients with Hb < 7 g/dl and the absolute number of PRBC transfused in 2015 compared with 2014. Compared to 2014, in 2015, the percentage of PRBC transfused when the Hb ≥ 8 g/dl was reduced by 18·8% (P < 0·001) and made up 29% of the total PRBC transfused. The absolute number of PRBC transfused decreased by 7·7%. The percentage of PRBC transfused when the Hb < 7 g/dl increased by 25·9% (P < 0·001). Following the described intervention, there was a significant improvement in the appropriateness of PRBC transfusions in our medical centre. These changes occurred despite the lack of interruption of the physician's workflow from the computerized alert. This simple strategy might be of use in implementing a restrictive PRBC transfusion strategy.

Inappropriate Packed RBC Transfusion in a Tertiary Care Center.

Transfusion of packed red blood cells (pRBC) with appropriate indications is not only important for patient safety and well-being but is also crucial for proper utilization of resources and health care-related cost reduction. We aimed to investigate the clinical appropriateness of blood transfusion in Shariati Hospital, one of the largest academic medical centers in Tehran. In this prospective observational study, 1000 transfusions of allogenic pRBCs from April 1st to October 31st, 2015 were included. The patients' characteristics, reason for hospitalization, indications for pRBC transfusions and ordering wards were collected. The mean level of hemoglobin before transfusion was 7.4 ± 2.3 g/dL in the emergency department, 7.5 ± 1.0 g/dL in medical wards, 10.4 ± 2.6 g/dL in surgical wards, and 9.1 ± 2.2 g/dL in the intensive care unit. The baseline hemoglobin levels differed significantly between the departments (P < 0.001). Approximately 22% (219 patients) with hemoglobin level ≥ 10 g/dL received pRBC, which appeared to be unnecessary and inappropriate. Despite current international guidelines emphasizing the importance of restricted transfusion policy, the transfusion of pRBC with insufficient indications occurred frequently in Shariati Hospital, particularly in surgical wards.

Design and Validation of a Survey Questionnaire for the Assessment of Physician Transfusion Medicine Knowledge

The clinical appropriateness of blood transfusion rests with physicians having the correct knowledge when making decisions concerning the selection and transfusion of blood and blood components. Transfusion medicine knowledge (TMK) is typically acquired during medical school, as on-the-job training during residency or fellowship, and through continuing education (e.g., online, seminars, workshops) in practice. To obtain a baseline of TMK in physicians at Augusta University Medical Center (AUMC) (formerly Georgia Regents University Medical Center), a multiple-choice survey questionnaire was designed and validated using input from individuals with expertise in the field of transfusion medicine. The survey was then deployed to physicians at AUMC. Analysis of survey response data showed that there were significant knowledge gaps among physicians that varied among specialty groups as well as with the number of formal education hours that physicians received as part of their medical training and in practice. The purpose of this research study was to establish the baseline TMK level of physicians at AUMC. ABBREVIATIONS:TMK - Transfusion Medicine Knowledge, AUMC - Augusta University Medical Center -, ARC - American Red Cross, CMS – Centers for Medicare & Medicaid Services, CFR - Code of Federal Regulations, ASCP - American Society for Clinical Pathology, BEST - Biomedical Excellence for Safer Transfusion, TJC - The Joint Commission, PBM - Patient Blood Management

Evaluation of the hemostatic potential at coronary artery bypass surgery during long-term aspirin therapy

To estimate thrombin generation test parameters in patients with coronary heart disease during coronary artery bypass surgery under extracorporeal circulation after transfusion of donor platelet concentrates during long-term therapy with acetylsalicylic acid (ASA). A total of 148 patients with coronary heart disease who had undergone elective primary coronary artery bypass surgery under extracorporeal circulation during preserved therapy with ASA (75-100 mg/day) were examined. According to donor platelet concentrate transfusion, all the patients were divided into 2 groups: 1) 76 patients undergoing donor platelet transfusion and 2) 72 without this procedure. A control group consisted of 20 apparently healthy individuals. At the pre-, intra-, and early postoperative stages, the investigators evaluated the following thrombin generation test parameters: lag time (min); peak thrombin concentration (nM/l); time to peak (min); the area under the thrombin generation curve (nM), and thrombin generation rate (nM/min). During long-term ASA therapy, the patients were found to have an activated endogenous thrombin potential in the pre- and intraoperative periods, as evidenced by the high peak concentration of thrombin and the increased rate of its generation. At the same time, the time of prothrombinase complex activation and that of thrombin generation were longer than those in the control group. In the early postoperative period, the patients who had not been transfused with platelet concentrates with a further increase in the temporal parameters, showed a decreased hemostatic potential, reaching the control level, whereas donor platelet transfusion stimulated endogenous thrombin generation: the time to initiate clotting and that to reach the peak were shorter; in this case, the thrombin generation rate and concentrations increased, but the preoperative level was not reached. No perioperative (hemorrhagic or thrombotic ischemic) events were noted in the examined groups. The hemostatic potential was preserved in patients receiving long-term therapy for ASA. Taking into account laboratory and clinical findings, platelet concentrate transfusions are unnecessary for preventive purposes. The appropriateness of donor platelet transfusion should be strictly individually approached with regard to the laboratory parameters of the thrombin generation test, by minimizing the risk of perioperative ischemic and hemorrhagic events in each specific patient.

Adequacy of physician documentation and correlation with assessment of transfusion appropriateness: a follow-up study in the setting of prospective audits and patient blood management.

A previous study in our hospitals correlated suboptimal documentation and failure to justify transfusions. In light of implemented blood-conservation strategies, including patient blood management (PBM) and prospective audits (PAs), we performed a follow-up study. We reviewed prospectively audited red blood cell (RBC) transfusions received by adult patients from January to July 2014. Survey forms were used to assess the level of documentation and to classify documentation as adequate, intermediate, or inadequate. Transfusions were deemed justified or not by comparisons with hospital transfusion guidelines. We also analyzed the effect of implemented blood-conservation strategies on our hospital transfusion rates and costs from 2009 to 2015. During the study period, there were 259 prospectively audited transfusion events (TEs) (one or more RBC units transfused to a patient), of which we reviewed 94 TEs (36.3%) in 87 patients. TEs with suboptimal (intermediate and inadequate) documentation accounted for 46.8% of the reviewed TEs, of which 81.8% could not be justified compared with 18.0% of nonjustified, adequately documented TEs. The correlation between suboptimal documentation and failure to justify transfusion was significant (p < 0.001). This correlation remained even in a comparison between the site with a PBM program and the sites without such a program. Overall transfusion rates declined after the introduction of PA, although the decline was only statistically significant at the sites with a PBM program. Suboptimal transfusion documentation remains problematic and is highly correlated with nonjustifiable transfusions. Newly adopted approaches to minimize blood transfusions have not improved transfusion documentation and corresponding out-of-guideline transfusions, although overall transfusions have been reduced by PA, particularly in the setting of a PBM program.

Iron deficiency anemia in the emergency department: over-utilization of red blood cell transfusion and infrequent use of iron supplementation.

Three are no clinical practice guidelines that specifically address the management of patients with iron deficiency anemia (IDA) in the emergency department (ED). The goal of this study was to describe the characteristics of IDA patients who present to the ED, documentation of IDA by emergency physicians, utilization of iron supplementation, and the appropriateness of red blood cell (RBC) transfusions ordered in the ED. A retrospective medical chart review was performed of IDA patients who visited the ED of a large tertiary center over a three-month period. Appropriateness of RBC transfusion was determined using a novel algorithm developed by our institution. Over the study period, there was a 0.3% (49/14,394) prevalence of IDA in the ED. In thirty (30/49; 61%) patients, IDA was documented by an emergency physician. RBC transfusions were administered to 19 patients; 10 transfusions (53%) were appropriate, 3 (16%) were appropriate for indication, but more than the required number of units were ordered, and 6 (32%) were inappropriate. Of the patients discharged, one (1/25; 4%) patient received intravenous iron in the ED and 6 of the 11 patients (55%) that were not already taking oral iron received a prescription at discharge from the ED. This assessment demonstrated that management of IDA patients presenting to the ED may represent an important knowledge-to-practice gap. It revealed that RBC transfusion may be over-utilized and could be replaced by safer, lower-cost alternatives such as intravenous and oral iron. Guidelines for management of IDA in the ED may be necessary to achieve consistent IDA management and avoid inappropriate use of RBC transfusion.

Evaluating appropriate red blood cell transfusions: a quality audit at 10 Ontario hospitals to determine the optimal measure for assessing appropriateness.

Evaluating the appropriateness of red blood cell (RBC) transfusion requires labor-intensive medical chart audits and expert adjudication. We sought to determine the appropriateness of RBC transfusions at 10 hospitals using retrospective chart review and to determine whether simple metrics (proportion of single-unit transfusions, RBCs/100 acute inpatient days, proportion of transfusions with pretransfusion hemoglobin <80 g/L or posttransfusion hemoglobin <90 g/L) could be used as surrogate markers of appropriateness by comparing their values with the results from the audit. An initial block of 30 RBC units was dually adjudicated for appropriateness followed by additional blocks of 10 units until the difference between the cumulative percentage of appropriate RBC units in the preceding block and final block was <3%. Pearson correlation tests were used to evaluate associations between the metrics and percentages of appropriate transfusions per hospital. Two-by-two tables were used to assess the utility of the metrics to classify transfusions for appropriateness. Of the 498 units audited, 78% were adjudicated as appropriate (κ = 0.9603), with significant variability between institutions (p < 0.0001). Fifty audits or less were required at nine of the institutions. The values of the metrics were not found to have significant correlations with appropriateness, and the metric that misclassified the smallest proportion of transfusions for appropriateness was pretransfusion hemoglobin <80 g/L, at 24%. Our findings suggest that a chart audit of 50 RBC transfusions with adjudication using robust criteria is the optimal means of evaluating RBC transfusion appropriateness at an institution for benchmarking and quality-improvement initiatives.

Thrombocytopenia and guideline‐evaluated appropriateness of platelet transfusion in a tertiary care intensive care unit

Background and ObjectivesPlatelet transfusions are common in clinical practice especially in the intensive care unit settings without acceptable clinical evidence. A retrospective audit was undertaken to evaluate the prevalence of thrombocytopenia, transfusion triggers and indications of transfusion and to assess the appropriateness of platelet transfusions based on current guidelines in patients admitted to a tertiary care intensive care unit (ICU) in South Australia.MethodsPlatelet counts on ICU admission, during ICU stay, use of platelet transfusion and clinical outcomes including bleeding for each consecutive admission to ICU over a 12‐month period was collected.ResultsThe prevalence of thrombocytopenia (platelet counts &lt;150 × 109/l) was 51·7% in 1790 ICU patients, of which 32·4% (580/1790) were thrombocytopenic at admission while 19·4% (347/1790) of patients developed thrombocytopenia during their ICU stay. Severe thrombocytopenia with platelet counts &lt;50 × 109/l was observed in 4·2%, with 2·6% at admission and 1·6% subsequently. Two hundred and thirteen patients (11·6%) received 480 units of platelets through 319 transfusion episodes. A total of 82·1% (262/319) of these transfusion episodes were therapeutic and 17·9% (57/319) prophylactic. Based on criteria developed from prevailing guidelines and literature, 14·1% (45/319) of platelet transfusion episodes were assessed to be inappropriate, which was 15·8% (9/57) in the prophylactic and 13·7% (36/262) in the therapeutic transfusion episodes.ConclusionThrombocytopenia is common in ICU patients, and a significant proportion of ICU patients receive platelet transfusions to control bleeding and maintain haemostasis. A minority of patients receive inappropriate platelet transfusions with unclear benefits with a potential to develop serious transfusion‐related adverse events.

What's the emergency? Identification of iron deficiency anaemia to evaluate transfusion appropriateness

What's the emergency? Identification of iron deficiency anaemia to evaluate transfusion appropriateness

A Systematic Review and Meta-Analysis of the Clinical Appropriateness of Blood Transfusion in China.

The issue of the clinical appropriateness of blood transfusion has become a focus of transfusion medicine worldwide. In China, irrational uses of blood have often been reported in recent years. However, to date there lacks a systematic review of the rational uses of blood. This study aimed to determine the clinical appropriateness of blood transfusion in China. We searched PubMed, Web of Science, the Cochrane Library, China National Knowledge Infrastructure (CNKI), China Science and Technology Journal Database, WanFang Database, and Chinese BioMedical Literature Database, and the retrieval cut-off date was June 31, 2015. SPSS 17.0 and MetaAnalyst 3.13 were employed as the statistics tools in this review. A pooled rate of clinical inappropriateness of transfusion was analyzed by DerSimonian-Laird method. In this study, a total of 39 observational studies were included, which related to 75,132 cases of blood transfusion. According to the meta-analysis results, the overall incidence of clinical inappropriateness of transfusion in China was estimated to be 37.3% (95% confidence interval [CI] [32.1, 42.8]). The subgroup analyses revealed that the pooled rates of clinical inappropriateness of transfusion of plasma, red blood cells (RBCs), cryoprecipitate, and platelets were 56.3% (95% CI [45.8, 66.2]), 30.9% (95% CI [27.1, 35.0]), 25.2% (95% CI [13.2, 42.7]), and 14.1% (95% CI [8.8, 21.9]), respectively. However, the pooled incidence of inappropriateness of transfusion in operative departments was 47.5% (95% CI [36.8, 58.3]), which was significantly higher than that in nonoperative departments, 25.8% (95% CI [18.7, 34.4], P < 0.05). The overall rates of inappropriate use were 36.7% (95% CI [30.2, 43.6]) in major cities and 37.5% (95% CI [31.2, 44.3]) in other cities, respectively; there was no statistically significant difference (P > 0.05). In conclusion, China has suffered from a disadvantage in the clinical appropriateness of blood transfusion, especially in plasma and RBC use. In future, comprehensive measures should be implemented in order to improve the clinical appropriateness of blood transfusion.