This example describes a multi-regional audit of the use of platelets in UK hospitals. These three audits used identical data collection forms to allow benchmarking against British Committee for Standards in Haematology (BCSH) guidelines and the new NICE guideline relating to transfusion (NG24).
- Blood transfusion (NG24)
Aims and objectives
These audits were agreed with the respective Regional Transfusion Committees (RTCs) covering the North West, Yorkshire and The Humber and East Midlands regions of the United Kingdom (UK) as part of a rolling programme of regional audits on blood transfusion practice. The underlying reason for conducting the audits was to determine the current demand for platelets across these regions and also their use against British Committee for Standards in Haematology and the NICE Guideline (NG24) on blood transfusion.
In addition, the audits were conducted to demonstrate that the recommendations of The 2010 National Comparative Audit of Platelet Use were being fulfilled3. This audit programme is also part of activity to support the concept of Patient Blood Management (PBM).
PBM is a multidisciplinary, evidence-based approach to optimising the care of patients who might need a blood transfusion. It represents an international initiative in best practice for transfusion medicine. It is a long-term approach requiring resource and investment.
The aim of PBM in England is to build on the success of the Better Blood Transfusion (BBT) initiatives but with an emphasis on improving patient outcomes through blood avoidance and the use of alternatives to transfusion where possible.
Reasons for implementing your project
NHS Blood and Transplant supplies blood components to hospitals across England. Transfusion of blood components is not without significant risks if these components are used incorrectly. NHSBT carries out internal and external audits of blood component use on a regional and national basis to help ensure these components are used in accordance with recommended guidelines and standards. Platelets are one such component. Platelet transfusions may be required in the event of haemorrhage, as prophylaxis or pre-procedure where blood loss is anticipated. As with all transfusions the risks and benefits should be carefully considered. The 2010 National Comparative Audit (NCA) of platelet transfusions in Haematology audited 3,296 platelet transfusions over a three month period against the Standards in the British Committee for Standards in Haematology (BCSH) Guidelines for the use of platelet transfusions (2003) and found that:
• 28% of the platelet transfusions were inappropriate
• 69% of the platelet transfusions were given as prophylaxis, 34% of these were inappropriate and 10% were double-dose transfusions
• 13% of the platelet transfusions were therapeutic 15% of platelet transfusions were given pre-procedure and 23% of these were inappropriate
There were two key recommendations of the audit with regard to the use of prophylactic platelet transfusions:
1. Platelet transfusion are not required routinely prior to bone marrow aspiration/biopsy or as prophylaxis in stable patients with long term bone marrow failure
2. Double dose platelet transfusions should not be used
These three re-audits were conducted to establish the extent to which these recommendations are being fulfilled, compliance to BCSH standards, and the degree of compliance to the recently issued NICE guidance relevant to platelet transfusions. However, It should be noted that the audits were completed prior to the issue of NG24.
How did you implement the project
An audit sub group of the North West Regional Transfusion Committees established the initial questions for the audit tool. These questions remained consistent when the audit was repeated across the two other RTC areas, East Midlands and the Yorkshire and The Humber Regions.
While there was some variation in the numbers of hospitals in the regions, all included a mix of very high and very low users of platelets. This approach allowed a large dataset to be accrued. Benchmarking across regions was also examined. The transfusion practitioners elected to undertake the data collection using a hard copy data collection form or to submit data online.
Appropriate governance arrangements were implemented and approval to participate in the audit obtained. Caldicott Guardians in each participating site were also informed. Data anomalies were discussed and followed up at a subsequent RTC meeting before final analysis. No overt identifying patient details were taken.
Where data anomalies could not be resolved, the data was discarded. Participating hospitals were asked to audit all platelet transfusions up to a specific number of transfusions aligned to their platelet use from very high user (up to 40 cases) to very low user (up to 10 cases). Clinical audit standards that were applied were taken from the guidelines published by the British Committee for Standards Haematology, Blood Transfusion Task Force 2003. After completion of the audits, some aspects of the NICE guideline on Blood Transfusion 2015 (NG24) were examined.
In total 936 platelet transfusions were audited across the three regions. Over 95% of prophylactic platelet transfusions in this total had a pre transfusion platelet count performed.
A single dose of platelets was given in over 80% (84% - 93%) of platelet transfusions given for prophylactic purposes across the three regions. Up to 27% of platelet transfusions were given prior to an invasive procedure and between 80% and 90% of these transfusions were monitored by undertaking post transfusion platelet counts.
For all platelet transfusions, over 70% received a post transfusion platelet count. For those patients undergoing invasive procedures, overall more than 86% had a post transfusion platelet count undertaken.
Where a request form was used, over 60% had the reason for the transfusion documented. However, there were no responses indicating the platelet transfusion had been guided by thromboelastographic approaches.
In total, over 90% had a reason for the transfusion communicated either by form, telephone or other explanation (massive haemorrhage, GI bleed etc). In up to 87% of cases, the platelet count justified the reason for the transfusion regardless as to how it was requested. Levels of wastage were low across all three regions, averaging around 3%.
Key learning points
A limitation of this audit was the lack of a clear definition of prophylactic transfusion and transfusion episodes (e.g. more than one unit given but over time).
It is recommended that clear definitions (of all categories) are provided for future audits. Improvements resulting from audit are iterative and require repeats over time. It would appear that improvements in practice have been made since the NCA audit in 2010; the proportion of patients having a pre-transfusion platelet count increased from around 85% to 95% and there has been a big increase in the numbers having a pre–procedure platelet transfusion also having a post transfusion platelet count compared to a national average of 30% in 2010.
However, double/multiple dose prophylactic transfusions continue and addressing this should be a priority for the transfusion community. In around 87% of cases, the reason for the platelet transfusion was justified. Percentage compliance to the indicated standards was generally consistent across all three regions included in the audit. In none of the cases included in these audits, was the decision to transfuse guided by thromboelastography.
The NICE diagnostic guidance (DG13) has indicated that using this technology outside a research setting may not be necessary.
1. Investigate the reasons why over 10% of prophylactic transfusion recipients were given more than one dose
2. Continue to raise awareness that “double dose prophylactic transfusions should not be used routinely” .
All three audits were completed before the publication of the NICE guideline on Blood Transfusion (NG24). Specific audit points are raised in this guideline.
Although some of the findings here are consistent with the recommendations, more detailed and targeted audits could be undertaken using this new guidance.
Acknowledgments: All transfusion practitioners and other staff who helped in the data collection.