DON'T US E T WO WHE N ONE WIL L DO L OP AG AUDIT OF - PowerPoint PPT Presentation

DON'T US E T WO WHE N ONE WIL L DO L OP AG AUDIT OF DOUB L E -DOS E P L AT E L E T S Dr Megan R owley, Haem atologis t NHS B T and ICHNT

P latelet us age in E ngland has ris en by 26.5% over 7 years 26.5%

Do we us e too m any platelets ? Generally, a s ingle unit or 1 adult therapeutic dos e (AT D) typically gives an im m ediate ris e in platelet count of 20-40 x10 9 / l in throm bocytopenic patients 1 without platelet antibodies A random is ed controlled trial s howed no difference in the num ber of patients who had s ignificant bleeding (WHO grade 2 or above) when they received s ingle 2 or double-dos e platelet trans fus ions 1 Norfolk D (Ed) (2013) Handbook 2 Slichter SJ et al (2010). Dose of prophylactic 1 Norfolk D (Ed) (2013) Handbook 2 Slichter SJ et al (2010). Dose of prophylactic of Transfusion Medicine 5 th Edition, of Transfusion Medicine 5 th Edition, platelet transfusions and prevention of haemorrhage. platelet transfusions and prevention of haemorrhage. The Stationary Office. New England Journal of Medicine ;362:600 - 13 The Stationary Office. New England Journal of Medicine ;362:600 - 13

2010 NCA P latelet Us e in Haem atology P atients Clinical Leads: Drs Lise Estcourt and Janet Birchall 139 Hos pitals s ubm itted 3296 platelet trans fus ion epis odes 40 s equential trans fus ions over 3 m onths T he reas on for trans fus ion was prophylactic in 69%, pre-procedure in 15%, therapeutic in 13% and unclear in 3% 10% (220/ 2277) of prophylactic platelet trans fus ions were double-dos e trans fus ions T he m ajority, 73% (161/ 220) of double-dos e trans fus ions , were adm inis tered to inpatients R E COMME NDAT ION R E COMME NDAT ION Double-dos e prophylactic platelet trans fus ions s hould not Double-dos e prophylactic platelet trans fus ions s hould not be us ed routinely be us ed routinely

A s urvey of platelet trans fus ion practice in the North of E ngland 24% s urgery 24% s urgery 75% m edicine* 75% m edicine* [*54% haematology] [*54% haematology] 153 doses (8% of total) 153 doses (8% of total) 57 double - dose 57 double - dose 9 triple dose 9 triple dose 3 quadruple 3 quadruple 47% of the m ultiple dos es 47% of the m ultiple dos es were given to patients with were given to patients with haematological disease. haematological disease. Where did platelets go in 2012? A. Charlton, J. Wallis, J. Robertson, D. Watson, A. Iqbal & H. T inegate Transfusion Medicine , 2014, 24 , 213 218

L oP AG Double-Dos e P latelet Audit AUDIT AIMS 1. T o determ ine how com m on reques ts for double-dos e (or m ultiple-dos e) platelets are 2. T o determ ine the reas on for double-dos e platelets and the clinical s pecialty m aking thos e reques ts 3. T o determ ine how often review by a haem atologis t m odifies the reques t for double-dos e platelets S T ANDAR D T he dos e of platelets in adults s hould not exceed one unit (1 AT D)

Collect all double-dos e reques ts for one week (Monday 9am to Monday 9am )

Us e thes e indication codes to record the reas on for trans fus ion

S end back the data with s om e overall us age and was tage data for the s am e week This badly This badly worded questions worded questions on the data on the data collection form collection form meant we did not meant we did not get denominator get denominator data data

R es ults 29/ 50 (58%) hos pitals in the L ondon R T C At leas t 1 m ultiple dos e platelet reques t was received by 26/ 29 (90%) hos pitals (3 nil returns) 205 s eparate m ultiple trans fus ion reques ts for 431 units of platelets 4/ 29 (14%) did not s upply data for the total num ber of platelets fated as trans fus ed during the audit period (no denom inator) 6/ 29 (21%) did not s upply data for the num ber of units fated as was ted during the audit period

Num ber of m ultiple-dos e platelet reques ts

Clinical S pecialty R eques ting Multiple Dos e P latelets Cl inical S p ec iality No o f Ca s es 36% of multiple dose requests were Ha ema tology 62 in haematology Ca rd iac 30 patients L iv er 23 Oncology 19 Only 2 of the 30 I TU 10 multiple dose requests in S u rg ical 12 cardiac/cardiac Th ea t res 8 surgery were A& E 6 referred for To tal 170 haematological advice

Indication and appropriate trans fus ion Indication Threshold Cases % requested Code Pl count outside (x109/L) threshold P1: Prophylaxis in BMF 10 17 53% P2: Prophylaxis in BMF + risk 20 15 73% P3: Prophylaxis for invasive procedures 50 8 35% P4: Massive transfusion 75 3 50% P6: DIC 5 - P10: NAIT** 30 15 73% Other 12 - Not recorded 73 Total 205 ** one hospital ? correct indication code used

Advice of a haem atologis t Haem atological advice was s ought in 111/ 205 (54%) of cas es 86% (96) double platelet dos e was is s ued 6% (7) the dos e was reduced 3% (3) reques ts were cancelled 5% (5) the outcom e was not docum ented

S um m ary Hopefully this audit highlighted the extent of m ultiple dos e platelet us e to the trans fus ion team s who undertook the data collection and triggered local dis cus s ion Haem atology and Cardiac S urgery account for the larges t num ber of double-dos e platelets and m any were given above the thres hold for that indication code As king a haem atologis t to clarify if the double-dos e was indicated did not m ake a difference in the m ajority of cas es

Dis cus s ion Can we us e audit to im prove platelet pres cribing? If s o, what do we do next?

Dis cus s ion what do you want? You can choos e which week you do and, if there are no double dos e reques ts then it would be helpful to have a nil return Get your haem atologis ts on board with the indication codes and vetting of reques ts m ay need s om e negotiation particularly if you dont do this already. What about the overnight reques ts ? B rian Hockley will analys e the data and produce us a regional report and a local report. He s aid he could s et up an on-line data collection tool - do you want that?