Microsoft
Acknowledgements
We wish to thank all those who have participated in the 2016 Audit of Red Cell and Platelet Transfusion in Adult Haematology Patients. We recognise that those giving up their valuable time have been many and that this will inevitably have been on top of a heavy workload. This audit would clearly not be possible without their support. We are equally grateful to many colleagues for their valuable and constructive comments.
HOSPITALS THAT AGREED TO PILOT THE AUDIT
Aintree University Hospital; The Christie Hospital; Conquest Hospital; Darlington Memorial Hospital; Doncaster & Bassetlaw Hospitals NHS Foundation Trust; Eastbourne District General Hospital; The Hillingdon Hospital; The Ipswich Hospital; James Paget University Hospital; King’s College Hospital; Manchester Royal Infirmary; The Newcastle upon Tyne Hospitals NHS Foundation Trust; Queen Elizabeth Hospital, Woolwich; Royal Berkshire Hospital; Royal Oldham Hospital; Salford Royal Hospital; Sandwell & West Birmingham Hospitals NHS Trust; Tameside Hospital; University Hospital of North Durham; Wexham Park Hospital; and Ysbyty Gwynedd.
MEMBERS OF THE PROJECT GROUP
Medical
Dr. Janet Birchall - Joint Clinical Audit Lead: Consultant Haematologist, NHS Blood and Transplant and North Bristol NHS Trust
Dr. Marina Karakantza - Joint Clinical Audit Lead: Consultant Haematologist, NHS Blood and Transplant and Leeds Teaching Hospitals NHS Trust
Dr. Lise Estcourt - Consultant Haematologist, NHS Blood and Transplant
Dr. Charlotte Kallmayer - Consultant Haematologist, United Lincolnshire Hospitals NHS Trust
Dr. Will Lester - Consultant Haematologist, Birmingham Women’s Hospital
Dr. Sally Killick – Royal Bournemouth Hospital
Nursing/Scientific
Jayne Addison – PBM Practitioner, NHS Blood and Transplant
Melanie Wood - Clinical Nurse Specialist, Northumbria Healthcare
Hayley Bond - Transfusion Practitioner, Nottingham University Hospitals NHS Trust
Wendy McSporran - Transfusion Practitioner, Royal Marsden
Audit Support
Derek Lowe – Statistician, Astraglobe Ltd
David Dalton – Project Officer, National Comparative Audit of Blood Transfusion
John Grant-Casey - Programme Manager, National Comparative Audit of Blood Transfusion
For correspondence, please contact
John Grant-Casey, Programme Manager, National Comparative Audit of Blood Transfusion, FREEPOST (SCE 14677), BIRMINGHAM, B2 4BR
Email john.grant-casey@nhsbt.nhs.uk Tel : +44 (0)7720 275388
Contents
Abbreviations 4
Executive Summary 5
Summary of recommendations 10
Aims of the audit 11
Audit standards 11
Methodology 13
Results: Standards 14
Results: Organisational audit 17
Clinical audit 24
Discussion 41
Quality Account statement 44
Appendices
Appendix A –Additional figures 45
Appendix B – Analysis algorithms 48
Appendix C – Clinical Audit Tool 56
Appendix D – Organisational Audit Tool 65
Appendix E – List of participating sites 71
Appendix F – Comparative results for the 148 sites 75
Abbreviations
BCSH British Committee for Standards in Haematology
BMF Bone marrow failure
Hb Haemoglobin
IHD Ischaemic heart disease
IQR Interquartile range
IT Information Technology
NBTC National Blood Transfusion Committee
WHO World Health Organization
Executive Summary
This audit was conducted in July 2017 in hospitals throughout the United Kingdom and Ireland. 127/138 (92%) eligible NHS English Trusts contributed data.
Organisational audit
107 sites (hospital/Trust) participated in the organisational audit.
11% (12/107) of sites reported that written transfusion guidelines were not available (Organisational standard 1). When available there was variable agreement with national guidelines. In red cell transfusion indications for “stable acute anaemia” without additional risk factors and “anaemia with cardiovascular disease or symptoms” non-compliance was around 30%. The main reason for non-compliance for these was because a higher haemoglobin (Hb) threshold was stated. Only 28 % of platelet transfusion guidelines stated that prophylactic transfusions were not required in chronic bone marrow failure (BMF). In only 51% of platelet transfusion guidelines were grades of bleeding specified.
49% (45/91) of sites stated that local audit had been performed within the last 12 months (Organisational standard 2).
Clinical audit
153 sites participated in the clinical audit. Patients audited were adults with a haematological malignancy or a myeloid failure syndrome who had received a red blood cell or platelet transfusion.
We analysed a total of 4098 patient records with information on 5383 transfusion episodes. There were 3830 red cell transfusions and 1553 platelet transfusions. 31% of patients received both red cell and platelet transfusions.
When additional units received by audited patients during the study period were included this accounted for around 13% (14484/111567) of all red cell and 39% (7820/19803) of all platelet components requested by participating hospitals.
The majority of patients included in this audit were over sixty years of age (median 73 years). Myelodysplasia, largely a disease of older people, was the commonest haematological diagnosis (29.7%). 72% of all patients were managed without curative intent with either transfusion alone or with the addition of low dose chemotherapy. 5% (150/2805) of all patients whose weight was known weighed less than 50 kg.
Compliance with national guidelines was no better in hospitals that manage complex patients that may require prolonged inpatient care (BCSH level 2b or level 3 care) compared to hospitals that manage more straight forward patients who required less intensive management or only outpatient care (BCSH level 1 or 2a care).
Red cell transfusion
In 58% (2187/3780) of transfusion episodes the reason for transfusion was chronic anaemia.
94% (3606/3829) of patients had an Hb measured within 24 hours if they were an inpatient or within 72 hours if they were an outpatient (Red cell standard 1).
Single unit transfusions were given to 43% (527/1217) of inpatients and 24% (629/2602) of outpatients.
When more than one unit of red cells was transfused only 12% (80/684) of inpatients and 1.3% (25/1941) of outpatients had an Hb measured in between units. Results were similar in patients weighing less than 50 kg. Five patients weighing less than 50 kg received 3-unit red cell transfusions as outpatients.
Patients with chronic anaemia were excluded from red cell transfusion standards which used a haemoglobin threshold alone as this group may require an individualised transfusion threshold.
Only 24% (195/815) of patients who were anaemic and had no additional risk factors were transfused when their Hb was 70g/L or lower (Red cell standard 2).
Only 44% (32/72) of patients who were anaemic and had cardiovascular disease were transfused when their Hb was 80g/L or lower (Red cell standard 3).
Compliance with the standard associated with radiotherapy which used a higher Hb threshold was much better.
An algorithm was used to assess appropriateness which included all red cell transfusion episodes. Patients with chronic anaemia were assessed based on symptoms and a Hb threshold of less than 100g/L. At best 76% were considered appropriate (see Executive Summary Table 1).
Platelet transfusion
79% (1223/1553) of platelet transfusion episodes were given as prophylaxis, and within this group 51% were given to patients with chronic BMF. 9% (138/1553) were used pre-procedure and 9% (145/1553) were used to treat bleeding. For 3% (47/1553) of patients the reason for transfusion was either unclear or not stated.
Prophylactic platelet transfusion
97% (1509/1549) of patients had a platelet count measured within 24 hours if they were an inpatient or within 48 hours if they were an outpatient. In patients with reversible BMF and no other risk factors, 65% (305/469) of patients had a platelet count less than or equal to 10 x 109/L (Platelet standard 1).
94% (1144/1218) of prophylactic platelet transfusions were single units; 92% of inpatients and 97% of day patients (Platelet standard 2).
Using an appropriate use algorithm 75% of prophylactic transfusion episodes associated with reversible BMF were considered appropriate but only 42% of episodes associated with chronic BMF, not receiving intensive therapy, were considered appropriate (Platelet standard 3) (see Executive Summary Table 1).
Pre-procedure
Overall appropriate use was 27% (37/138) with 51% (29/57) compliance in patients prior to procedures where platelet transfusion was recommended up to a maximum platelet count threshold of 50 x 109/L. (Platelet standard 4).
In 7% (9/138) of patients who had a platelet transfusion prior to a procedure the only procedure being performed was a bone marrow biopsy or trephine (Platelet standard 6).
Therapeutic
Appropriate use was 88% (127/145).
Comparison with 2010 and 2016 audit results
148 sites participated in both the 2016 and 2017 audits. Direct comparison for only these sites replicated results for all participants (see Appendix F). Results provided in this report are therefore for all participants. Results from 2017 compared to 2010 and 2016 have largely shown either improved practice or little change (see Executive Summary Table 2). At best local audit to assess the use of blood within the last 12 months has continued to be achieved in only around 50% of participating hospitals.
Red cell transfusion. There has been an improvement in the percentage of single unit transfusions, including in patients with low weight. Overall appropriate use of RBC transfusions remains high although compliance with haemoglobin thresholds for patients with either no additional risk factors or with risk of cardiovascular disease is still not standard practice.
Platelet transfusion. There has been an improvement in the use of single platelet units for prophylaxis however further improvement is likely to be possible. A higher proportion of patients with reversible BMF were transfused within a threshold of 10 x 109/L and the improvement has been significant when compared to the result in 2010. This is in keeping with an overall appropriate prophylactic platelet use in this group of 75%. There has been little overall change in appropriate prophylactic platelet use since 2016 and unnecessary use in stable patients with chronic BMF remains high. The results in 2010 are not comparable as one algorithm was used and only patients with MDS, but no other causes of chronic BMF, were excluded. Compliance with pre-procedure guidance has shown a significant reduction. This is largely due to new British Society of Haematology recommendations, which were adopted by the NBTC, to lower the platelet threshold for central line insertion and prior to a lumbar puncture. This has not yet been commonly adopted in local guidance or clinical practice. Unnecessary transfusion prior to a bone marrow biopsy continues.
Conclusion
Haematological patients are high blood users and more patients with chronic BMF now receive red cells and platelets than those with reversible BMF. National audit followed by publicity and tools to promote appropriate use are likely to have made a significant contribution to the documented improvement in practice seen in this audit. Further audit and follow up work should continue to tackle both remaining and emerging areas of concern.
Local hospital guidelines continue to be discrepant and lag behind national guidelines contributing to inappropriate transfusion practice. Compliance is similar across all levels of care. Routine regular audit of use is unlikely to be achieved without an information technology solution.
Single unit red cell transfusions continue to be less common than 2 unit transfusions and multiple units continue to be given to low weight patients. This practice is unsafe because it puts patients at risk of Transfusion Associated Circulatory Overload (TACO).
The majority of platelet transfusion episodes are given for prophylaxis. Within this group more than half are given to patients with chronic BMF and most of these are outside of guidance.
Executive Summary Table 1: Reason for the transfusion and compliance with national guidelines
|Reason for transfusion |Total number |Appropriate |Outside of guidance |Unable to assess |
| |transfusions | | | |
|RED BLOOD CELL revised |3830 |76% 2924 |14% 544 |9% 362 |
|PLATELET | | | | |
|Prophylactic |1223 |58% 705 |39% 482 |3% 36 |
|Reversible BMF |590 |75% 443 |24% 141 |1% 6 |
|Chronic BMF |579 |42% 246 |57% 330 |1% 3 |
|(non-intensive therapy) | | | | |
|Chronic BMF |23 |70% 16 |30% 7 |- |
|(intensive therapy) | | | | |
|Unable to categorise |31* |- |13% 4 |87% 27 |
|Pre-procedure |138 |27% 37 |55% 76 |18% 25 |
|Therapeutic |145 |88% 127 |11% 16 |1% 2 |
|Unable to determine |42 |- |- |100% 42 |
|Not stated |5 |- |- |100% 5 |
* 27 of these cases were known to have chronic BMF but not known whether patients had intensive or non-intensive treatment
Executive Summary Table 2: Comparison of National Comparative Audit results where possible
| |2010 |2016 |2017 |
|Standards | | | |
|Organisational | | | |
|1. Written guidance available |96% |87% |89% |
|2. Local audit within last 12 months |43% |51% |49% |
|Clinical | | | |
|Red cell transfusion | | | |
|1. Timely pre-transfusion Hb check | |94% |94 % |
|Chronic anaemia cases excluded from standards 2,3,4,5 | | | |
|2. Hb threshold 70g/L, no additional risk factors | |17% |24% |
|3. Hb threshold 80g/L, cardiovascular risk | |30% |44% |
|4. Hb threshold, radiotherapy (2016:100g/L, 2017:110g/L | |100% |100% |
|Platelets prophylactic | | | |
|1. Reversible BMF, threshold of 10 x 109/L |*54% |61% |65% |
|2. One adult therapeutic dose for prophylaxis |90% |93% |94% |
|3. Chronic stable BMF no prophylaxis - % non-compliance | |56% |57% |
|Platelets pre-procedure | | | |
|4. Compliance with procedures where threshold < 50 x 109/L |81% |84% |**51% |
|5. Critical site surgery, threshold 100 x 109/L (all cases) |100% (6) |67% (3) |100% (1) |
|6. Bone marrow biopsy (BMB), platelet transfusion not required (% of cases where BMB |9% (45/497) |9% (14/160) |7% (9/138) |
|was the only procedure) | | | |
|Appropriate use | | | |
|Red blood cells | |75% |***76% |
|Platelets | | | |
|Prophylactic | |55% |58% |
|Reversible BMF | |72% |75% |
|Chronic BMF, non-intensive therapy | |43% |42% |
|Pre-procedure |64% |61% |*27% |
|Therapeutic |84% |87% |****88% |
|Transfusion episode | | | |
|Red blood cells single unit transfusion | | | |
|- all day cases (day cases weighing less than 50kg) | |13% (22%) |24% (32%) |
|- all inpatients (inpatients weighing less than 50kg) | |27% (33%) |43% (46%) |
* Calculated using same formula as in 2016 and 2017
**Introduction of new recommendations in 2017 with lower threshold platelet counts prior to some procedures
*** revised removing R4 medical anaemia with sepsis or with cerebral ischaemia
**** revised to include a lower threshold of 30 x 109/L for WHO bleeding grade 2 or above but considered non-severe
Summary of Recommendations
Key recommendations for improving local guidelines
1. Local hospital guidelines must be easily available and should reflect national guidelines for blood transfusion.
2. Local hospital guidelines should state that prophylactic platelet transfusions are not required:
a. Prior to bone marrow aspirates and trephine
b. In stable patients with chronic bone marrow failure.
3. Local hospital guidelines should state how to manage transfusions in patients at high risk of Transfusion Associated Circulatory Overload (TACO).
Key recommendation for local audit
1. Information technology (IT) solutions are required to allow regular non-labour intensive audit of transfusion practice.
2. Until IT solutions are available resource to allow staff to perform regular local audit of transfusion practice is required.
Key recommendations for improving clinical practice
1. Each patient undergoing transfusion should have a transfusion plan in the medical records that will, at minimum, include a transfusion threshold & target and document reasons that justify deviation from the existing standards. This is particularly important for patients on chronic transfusion programmes where a customized approach is recommended.
2. In the absence of active bleeding, use the minimum number of red cell units required to achieve target haemoglobin and consider a single unit transfusion.
3. One adult therapeutic dose of platelets is required for prophylaxis. Pre-procedure consider the size of the patient, previous platelet count increments and the target platelet count.
4. Risk assess the patient for transfusion-associated circulatory overload (TACO), which is the transfusion reaction most commonly associated with death.
Aims of the audit
This audit aimed to:
• examine the use of red cells and platelets in a sample of patients who had a known haematological condition
• collect information on the context in which care was delivered through the use of an organisational questionnaire
• identify variation in practice and compare practice against guidelines
• discuss reasons for variation and identify opportunities to reduce variation while not compromising treatment
Audit standards
Organisational
1. Local written guidelines are available for the management of blood component transfusions in haematology patients.
2. Regular local audits are performed to assess compliance with local blood transfusion guidelines.
Red Cell Transfusion
1. Hb is measured within 24 hours prior to the transfusion of red cells if the patient is an inpatient or within 72 hours if the patient is a day patient;
2. In normovolaemic patients without additional risk factors (defined as cardiovascular disease or signs or symptoms of cardiovascular compromise) the transfusion threshold is an Hb of 70g/L;
3. In patients with cardiovascular disease or signs or symptoms of cardiovascular compromise the threshold is raised to an Hb of 80g/L;
4. In patients receiving radiotherapy the threshold is raised to an Hb of 110g/L;
Platelet Transfusion - Prophylactic
1. In patients with a reversible cause for bone marrow failure and no other risk factors for bleeding the threshold for prophylaxis is a platelet count of 10 x 109/L;
2. When platelets are prescribed for prophylactic use, this should not be more than one adult therapeutic dose;
3. Patients with chronic bone marrow failure are not routinely given prophylactic platelet transfusions.
Platelet Transfusion - Pre-procedure
4. To prevent bleeding prior to invasive procedures the following platelet count thresholds are recommended if no other risk factors are present;
• Platelet count < 20 x 109/L for central venous line
• Platelet count < 40 x 109/L for lumbar puncture
• Platelet count < 50 x 109/L for e.g. percutaneous liver biopsy/major surgery
5. Prior to operations in critical sites such as the eye or brain the threshold platelet count is 100 x 109/L or lower;
6. Patients do not require platelet transfusion prior to a bone marrow biopsy.
Methodology
Any hospital in England that treated adult patients, aged 16 years or over, with a malignant haematological diagnosis / myeloid failure syndrome was eligible to enrol. The audit was also offered to all hospitals/Trusts in Northern Ireland, Scotland & Wales and the Republic of Ireland.
Cases could be inpatients or outpatients.
The term site is used throughout this report to refer to the hospital or Trust which participated in the audit. Sites were asked to audit patients seen in July 2017. They were asked to include up to 40 patients receiving a red cell transfusion (up to 20 inpatients and 20 outpatients).
The same number of patients receiving platelets were also eligible for audit. Sites were asked to collect consecutive cases, and while a patient could only be audited once for each component, that patient could be audited for both red cells and platelets, so one patient could fulfil 2 of the suggested quota.
The Analysis Algorithms are available in Appendix B, the Patient Audit Tool is shown in Appendix C, and the Organisational Questionnaire is shown in Appendix D.
RESULTS: STANDARDS
Organisational
1. Local written guidelines are available for the management of blood component transfusions in haematology patients.
89% of hospitals (95/107) stated that written guidelines were available and 11% (12) stated that they were not.
2. Regular local audits are performed to assess compliance with local blood transfusion guidelines.
49% of hospitals (45/91) stated that local audit had been performed within 12 months and a further 21% (19) indicated that audit had been performed within 24 months. See organisational audit results for further details.
Red Cell Transfusion
Cases associated with chronic anaemia due to bone marrow failure (BMF) were excluded from all red cell transfusion standards which relied on a threshold Hb as this is not an appropriate assessment for this population. In addition, patients transfused with a higher threshold because of severe sepsis or acute cerebral ischaemia have been excluded as this is no longer considered to be a valid indication for all patients in this category.
1. Hb is measured within 24 hours prior to the transfusion of red cells if the patient is an inpatient or within 72 hours if the patient is a day patient;
94% (3606/3829) of all patients had a pre-transfusion Hb measured within the specified time frame. For in-patients, this was 98% (1198/1217) and for day patients this was 92% (2399/2602)
2. In normovolaemic patients without additional risk factors (defined as cardiovascular disease or signs or symptoms of cardiovascular compromise, the transfusion threshold is an Hb of 70g/L;
There were 815 cases where the Hb was reported and no other standards with higher thresholds applied. 195 (24%) had an Hb less than or equal to 70g/L and 620 (76%) had an Hb greater than 70g/L.
3. In patients with cardiovascular disease or signs or symptoms of cardiovascular compromise the threshold is raised to an Hb of 80g/L;
There were 72 cases where the Hb was reported and no other standards with higher thresholds applied. 32 (44%) had an Hb less than or equal to 80g/L and 40 (56%) had an Hb greater than 80g/L.
4. In patients receiving radiotherapy the threshold is raised to an Hb of 110g/L;
There were 28 cases, all of which had a documented Hb and all had an Hb of less than or equal to 110g/L.
Platelet transfusion - Prophylactic
1. In patients with a reversible cause for bone marrow failure and no other risk factors for bleeding the threshold for prophylaxis is a platelet count of 10 x 109/L;
65% (305/469) of patients received a prophylactic platelet transfusion for reversible bone marrow failure without additional risk factors, when the count was less than or equal to 10 x 109/L.
2. When platelets are prescribed for prophylactic use, this should not be more than one adult therapeutic dose;
One adult therapeutic dose was transfused in 94% (1144/1218) of all prophylactic transfusions. This was 92% (611/667) of inpatients and 97% (528/546) of day patients.
3. Patients with chronic bone marrow failure are not routinely given prophylactic platelet transfusions.
This standard was not met in 57% (330/576) of patients with chronic bone marrow failure who were not receiving intensive therapy and did not have stated risk factors.
Platelet Transfusion - Pre-procedure
4. To prevent bleeding prior to invasive procedures the following platelet count thresholds are recommended if no other risk factors are present;
• Platelet count < 20 x 109/L for central venous line
• Platelet count < 40 x 109/L for lumbar puncture
• Platelet count < 50 x 109/L for e.g. percutaneous liver biopsy/major surgery
There were 57 patients in this standard for whom the platelet count was reported. None of these were associated with standards allowing a higher threshold. The standard was met in 29 (51%) and not met in 28 (49%). These were made up of 14 cases requiring lumbar puncture (threshold 40), 9 cases needing central line insertion (threshold 20) and 6 cases having other relevant procedures (threshold 50).
5. Prior to operations in critical sites such as the eye or brain the threshold platelet count is 100 x 109/L or lower;
There was 1 case where the platelet count was reported, which had a platelet count less than or equal to 100 x 109/L.
6. Patients do not require platelet transfusion prior to a bone marrow biopsy.
Nine patients were transfused platelets when only a bone marrow biopsy was performed.
RESULTS: ORGANISATIONAL AUDIT
A total of 159 sites participated in the combined clinical and organisational audit, 153 in the clinical audit and 107 in the organisational audit. Of sites with organisational data, 97 were from England, 6 from Wales, 2 from Scotland, and 1 each from Northern Ireland and the Republic of Ireland. There were no submissions from Independent hospitals.
To see which sites participated in the audit, please see Appendix E.
Section 1. General information
Levels of Haematology care
The vast majority of care is provided by level 2a, 2b and 3. For 3 sites no further information other than level of care was provided.
[pic]
Figure 1: Level of haematology care according to BCSH criteria
Number of in-patient beds designated as haematology beds
(includes all types of haematology patient)
The median number of designated haematology beds was 10, inter-quartile range (IQR) 4 to 18 and range 0 to 107. Around a fifth (21%, 23/107) of organisations have no designated haematology beds. The majority (87%, 20/23) of these provide level 1 or 2a care. All organisations providing level 3 care had 10 or more beds.
Under direct care of Consultant Haematologist
9% of hospitals during working hours and 18% of hospitals out of hours do not provide patient care which was directly managed by a consultant haematologist. All of these hospitals provided either level 1 or level 2a care except for three level 2b hospitals that provided direct consultant haematologist care during working hours but not out of hours.
Table 1: Are in-patients who require care, primarily because of a haematological problem, under the direct care of a Consultant Haematologist (107 hospitals)
| |National |
| |(107) |
| | | |
| During working hours |91% |97 |
| Out of hours |82% |88 |
Written guidelines
11% of hospitals (12/107) did not have written guidelines which cover haematology patients. Ten of these provided level 1 or level 2a care, however two provided level 2b care. These hospitals could not complete further sections of the organisational audit.
How guidelines are made available to medical and nursing staff
Nearly all hospitals (96%) that provide guidelines use the intranet and many (54%) have specific teaching sessions at medical staff induction.
Table 2: How guidelines are made available to medical and nursing staff (95 hospitals that provided written guidelines stated how they were made available)
|How guidelines are made available |National | |
| |(95) | |
| |27% |26 | |
|Provided in written format at hospital induction to all new junior doctors | | | |
|Provided on hospital intranet |96% |91 | |
|Displayed on wall in haematology day unit |5% |5 | |
|Displayed on wall in haematology ward |5% |5 | |
|Specific teaching sessions provided at doctors’ induction |54% |51 | |
|Provided in guideline/protocol folder on wards |16% |15 | |
|Other * |19% |18 | |
| |
|*Other predominantly identified teaching sessions outside of induction (5) or on request form/prescription chart (5). |
When the last local audit was performed to assess compliance with transfusion guidelines (This could be of one or all blood component use and include additional specialties)
70% of hospitals stated that local audit had been performed in the last 2 years: 49% (45/91) within one year and 21% (19/191) within one to two years.
Table 3: Timing of the last local audit performed to assess compliance with transfusion guidelines
|Timing of last local audit |National |
| |(91) |
|Less than 12 months |49% |45 |
|12 to 18 months |11% |10 |
|18 to 24 months |10% |9 |
|24 to 36 months |4% |4 |
|36 to 48 months |5% |5 |
|48 to 60 months |4% |4 |
|No local audit performed |15% |14 |
Information within local guidelines
Indication for transfusion
The following tables identify the patient category and threshold count, for each category, suggested by the National Blood Transfusion Committee (NBTC) Indications and Codes for transfusion. Some indication codes have been subdivided to understand if hospitals use different thresholds. Table 4 shows NBTC indications for red cell transfusion and the level of agreement in participating hospitals, while Table 6 shows NBTC indications for platelet transfusion and the level of agreement in participating hospitals.
Red cell Transfusions
95 hospitals provided details regarding the indication for red cell transfusion.
In the category of “stable acute anaemia” without additional risk factors, the main reason for non-compliance with NBTC thresholds was because a higher threshold of 80 g/L or 90 g/L was used (12 hospitals in those under 65 years and 21 hospitals in those over 65 years). In the category of “with cardiovascular disease or symptoms” similarly a higher threshold of 90 g/L or 100 g/L was stated by many non-compliant hospitals. For "radiotherapy" the main reason for disagreement was because of a lower threshold of 100 g/L (47 hospitals) and in patients with “chronic anaemia” the most common reason was not covered. “Acute blood loss in an emergency” was not covered in 20 replies (see Table 4).
There was no tendency for level 1 or 2 care organisations, compared to level 3 organisations, to be less compliant with NBTC indications. For patients with “stable acute anaemia” a higher percentage of level 3 care hospitals, compared to level 1 or 2, stated a higher haemoglobin threshold when no other risk factors were present.
Table 4: NBTC Codes for red cell transfusion
|CLINICAL INDICATION for transfusion |NBTC |NBTC threshold |Exact agreement |Disagreement |
| |Code |(g/L) |with NBTC* | |
|Acute blood loss in an emergency (when |R1 |70 |56% 51/91 |80 g/L (n=7), 90 g/L (n=4), 100 g/L (n=3), clinical decision |
|normovolaemia achieved) | | | |(n=6), not covered (n=20) |
|Stable acute anaemia | |
|Usual indication for red cell |R2 |70 |76% 72/95 |80 g/L (n=10), 90 g/L (n=2), 100 g/L (n=1), not covered (n=10) |
|transfusion, age < 65 years | | | | |
| | | | | |
|Usual indication for red cell |R2 |70 |66% 63/95 |80 g/L (n=16), 90 g/L (n=5), 100 g/L (n=2), not covered (n=9) |
|transfusion, age > 65 years | | | | |
|With cardiovascular disease or symptoms |
|History of IHD |R3 |80 |80% 76/95 |70 g/L (n=1), 90 g/L (n=6), 100 g/L (n=6), not covered (n=6) |
|Chest pain; hypotension or tachycardia |R3 |80 |69% 66/95 |70 g/L (n=2), 90 g/L (n=7), 100 g/L (n=5), not covered (n=15) |
|unresponsive to fluid resuscitation; or | | | | |
|cardiac failure | | | | |
|**With severe sepsis |Old R4 |Not covered |48% 45/93 |70 g/L (n=3),80 g/L (n=5), 90 g/L (n=37), 100 g/L (n=3) |
|**With traumatic brain injury |Old R4 |Not covered |54% 51/95 |70 g/L (n=2),80 g/L (n=2), 90 g/L (n=37), 100 g/L (n=3) |
|**With acute cerebral ischaemia |Old R4 |Not covered |57% 54/95 |80 g/L (n=2), 90 g/L (n=36), 100 g/L (n=3) |
|Radiotherapy |R5 |110 |12% 11/94 |100 g/L (n=47), 120 g/L (n=3), clinical decision (n=2), not |
| | | | |covered (n=31) |
|Chronic Anaemia | | | | |
|Chronic anaemia age < 65 years |R4 (old R6) |80 |53% 50/94 |70 g/L (n=7), 110 g/L (n=1), individualised threshold (n=17), |
| | | | |not covered (n=19) |
|Chronic anaemia age > 65 years |R4 (old R6) |80 |54% 51/94 |70 g/L (n=5), 90 g/L (n=1), 110 g/L (n=1), individualised |
| | | | |threshold (n=16), not covered (n=20) |
*If known
**Now not separate classifications in NBTC indication codes
Platelet Transfusions
93 sites provided further details regarding the indication for platelet transfusion.
51% of local guidelines specified grades of bleeding to differentiate prophylactic from therapeutic transfusion and 51% of these used the grades suggested in this audit.
Table 5: Does your guideline specify grades of bleeding to differentiate between prophylactic and therapeutic platelet transfusions? (93 hospitals)
| |National |
| | | |
| YES |51% |47/93 |
| | |
|If YES are the bleeding grades as stated in appendix D? | |
| YES |51% |23/45 |
In the “Prophylaxis for chronic BMF not receiving intensive therapy” category “indication not covered in local guidelines” was stated by 41% (39/94) of hospitals who answered this question. This was more frequently stated in level 3 care hospitals at 48% (13/27). When a threshold count was provided in this category, 20% (19/94) of hospitals indicated that they used a platelet count threshold of 10 or 20 x 109/L. In the “Pre-procedure” category for the insertion of a central line, PICC line and prior to a lumbar puncture a threshold of 50 x 109/L was most commonly stated at 54% (51/95), 45% (41/92) and 51% (48/95) respectively. In the “Therapeutic” category “bleeding but non-severe” a threshold of 50 x 109/L was also most commonly stated [31% (29/94)].
Table 6 : NBTC codes for platelet transfusion
|CLINICAL INDICATION for transfusion |NBTC |NBTC threshold |Exact agreement with|Disagreement |
| |Code |(X109) |NBTC* | |
|Prophylactic use in the absence of risk factors for bleeding |
|Reversible BMF e.g. disease/treatment including allogeneic|P1 |10 |89% 85/95 |Not covered (n=10) |
|BMT but excluding autologous BMT | | | | |
|Reversible BMF associated with autologous BMT |P1 |10 |71% 67/95 |20 x109 (n=1), consider not giving (n=3), Not covered |
| | | | |(n=24) |
|Chronic BMF receiving intensive therapy |P1 |10 |65% 60/92 |20 x109 (n=2), clinical decision (n=5), No threshold/Not|
| | | | |indicated (n=8), Not covered (n=17) |
|Chronic BMF not receiving intensive therapy |P1 |Not indicated |28% 26/94 |10 x109 (n=16), 20 x109 (n=3), clinical decision (n=9), |
| | | | |individual threshold (n=1), Not covered (n=39) |
|Prophylactic use in the presence of risk factors for bleeding |
|Reversible BMF |P2 |20 |70% 66/94 |10 x109 (n=19), 50 x109 (n=2), Not covered (n=7) |
|Chronic BMF |P2 |20 |63% 59/94 |10 x109 (n=8), 50 x109 (n=2), Individualised threshold |
| | | | |(n=5), no threshold/not indicated (n=5), not covered |
| | | | |(n=15) |
|Prophylactic use prior to a procedure |
|Central venous line insertion (tunnelled or untunnelled) |P3 |20 |29% 28/95 |10 x109 (n=2), 40 x109 (n=2), 50 x109 (n=51), 75 x109 |
|excluding PICC line | | | |(n=1), 80 x109 (n=1), not covered (n=10) |
|PICC line |P3 |Not indicated |14% 13/92 |10 x109 (n=1), 20 x109 (n=14), 40 x109 (n=1), 50 x109 |
| | | | |(n=41), 75 x109 (n=1), not covered (n=21) |
|Lumbar puncture |P3 |40 |33% 31/95 |10 x109 (n=1), 20 x109 (n=1), 50 x109 (n=48), 70 x109 |
| | | | |(n=1), 75 x109 (n=4), 100 x109 (n=1), not covered (n=8) |
|Percutaneous liver biopsy |P3 |50 |86% 82/95 |75 x109 (n=2) not covered (n=11) |
|Major surgery |P3 |50 |80% 76/95 |75 x109 (n=2), 80 x109 (n=5), 100 x109 (n=1), dependent |
| | | | |on surgery (n=2), not covered (n=9) |
|Epidural anaesthesia |P3 |80 |65% 62/95 |40 x109 (n=1), 50 x109 (n=14), 70 x109 (n=1), 75 x109 |
| | | | |(n=2), 100 x109 (n=4), individual threshold (n=1), not |
| | | | |covered (n=10) |
|Spinal anaesthesia |P3 |40 |13% 12/95 |50 x109 (n=18), 70 x109 (n=1), 75 x109 (n=2), 80 x109 |
| | | | |(n=39), 100 x109 (n=4), No threshold/Not indicated |
| | | | |(n=1), not covered (n=18) |
|CNS surgery (including posterior segment of eye) |P3 |100 |86% 82/95 |Not covered (n=13) |
|Major haemorrhage |P4 |50 |30% 28/94 |75 x109 (n=47), 80 x109 (n=5), 100 x109 (n=12), not |
| | | | |covered (n=2) |
|Bleeding with multiple trauma, or brain/eye injury, or |P4 |100 |91% 86/95 |50 x109 (n=1), 75 x109 (n=1), 80 x109 (n=2), not covered|
|spontaneous intracerebral haemorrhage | | | |(n=5) |
|Bleeding |P4 |50 |55% 52/95 |10 x109 (n=1), 20 x109 (n=1), 30 x109 (n=22), 75 x109 |
| | | | |(n=1), 80 x109 (n=2), 100 x109 (n=4), clinical decision |
| | | | |(n=2), No threshold/not indicated (n=1), not covered |
| | | | |(n=9) |
|Bleeding but considered non severe |P4 |30 |29% 27/94 |10 x109 (n=1), 20 x109 (n=3), 50 x109 (n=29), 70 x109 |
| | | | |(n=1), clinical decision (n=3), No threshold/not |
| | | | |indicated (n=2), not covered (n=28) |
| | | | | |
|*if known and applicable | | | | |
CLINICAL AUDIT
Data Collection
We received data from 4296 patients. We removed 198 patient records because of: duplication (5), no red cell or platelet transfusion (2), no data other than episode number (52) or found to be ineligible during the data cleaning process (139).
This provided 4098 patient records for analysis, submitted by 153 sites, median 27, inter-quartile range (IQR) 16 to 37, range 1 to 61. There were 4050 patients from 150 NHS hospitals in the United Kingdom, 38 patients from 2 hospitals in the Republic of Ireland and 10 patients from one English Independent hospital.
31% (1285/4098) of patients received both red cell and platelet transfusions. A total of 5383 transfusion episodes were analysed, 3830 red cell transfusion episodes and 1553 platelet transfusion episodes.
To see which sites participated in the audit, please see Appendix E.
Patient characteristics
Median age at the time of transfusion was 73 years (IQR 63 to 81), range 16 to 102 years.
40% were female (1653), 60% were male (2444), and 1 was unknown.
Weight was known for 68% (2805/4098), with a median of 72 kg (IQR 63 to 83). When weight was known 5% (150/2805) of patients weighed less than 50Kg.
Diagnosis
Myelodysplasia was the largest diagnostic category of patients requiring blood component transfusion at 29.7%. This increased to 36% if myelodysplastic/myeloproliferative neoplasms were included.
Table 7: Haematological diagnosis (4098 patients)
|Haematological Diagnosis |National |
| |(N=4098) |
|Acute leukaemia |22.4% |916 |
|Acute myeloid leukaemia excluding APML |18.8% |770 |
|Acute promyelocytic leukaemia (APML) |0.4% |17 |
|Acute lymphocytic leukaemia |2.5% |104 |
|Other acute leukaemia |0.7% |28 |
|Aplastic anaemia |4.0% |162 |
|Chronic leukaemia |6.3% |259 |
|Chronic lymphocytic leukaemia (CLL) |4.1% |170 |
|Chronic myeloid leukaemia (CML) |1.5% |61 |
|Other chronic leukaemia |0.7% |29 |
|Lymphoma |14.5% |594 |
|Burkitt’s lymphoma |0.5% |22 |
|Diffuse large B cell lymphoma (DLBCL) |5.3% |217 |
|Follicular lymphoma |1.2% |51 |
|Hodgkin’s lymphoma (HL) |1.6% |66 |
|Other lymphoma |5.9% |242 |
|Myelodysplasia |29.7% |1216 |
|Myelodysplastic/myeloproliferative neoplasms (includes CMML, JMML) |6.8% |279 |
|Myeloproliferative neoplasms including myelofibrosis |6.2% |254 |
|Myeloma/Plasma cell dyscrasia |12.1% |497 |
|Other stated* |1.4% |58 |
Treatment
44% of patients were managed by blood component transfusion alone and 56% were receiving treatment in addition to transfusion.
28% of all patients were receiving intensive treatment for their haematological malignancy.
In 23% of all patients this was intensive chemotherapy, in 2.6% this was allogeneic stem cell transplant (SCT) and in 2.6% this was autologous SCT.
28% of all patients were therefore receiving low dose chemotherapy.
Table 8: Treatment for haematological diagnosis
| |National | |
| |(4098) | |
|Was the patient receiving treatment (excluding transfusion) for their underlying current haematological diagnosis? |
| YES |56% |2308/4093 | | | |
| |
|If YES, was the patient undergoing allogeneic stem cell transplant? |
| YES |2.6% |108/4093 | | | |
| |
|If NO, was the patient undergoing autologous stem cell transplant? |
| YES |2.6% |107/4093 | | | |
| |
|NO, Was the patient on an intensive chemotherapy programme in the last 6 weeks? |
|(excluding low dose chemotherapy e.g. azacitidine) |
| YES |23% |941/4093 | | |
Participation in clinical trials
Many (339) of the patients audited were participating in clinical trials, however none of these trials included a transfusion threshold for either RBC or platelet transfusion that deviated from the NBTC standards used in this audit. Three were in the REAL study investigating threshold Hb.
SECTION A: RED CELL TRANSFUSION
3830 patients received a red cell transfusion (defined as all units transfused within a 24-hour period). One transfusion episode occurred in August and the date of transfusion was unknown for 5. All other transfusion episodes occurred in July 2017 (Appendix A, Figure 1).
There were 2602-day patient and 1217 inpatient red cell transfusion episodes. In 11 cases the location was unknown.
Indication for red cell transfusion
Principal reason for red cell transfusion
Table 9 identifies the main reason for transfusion. Hospitals were asked to select only one category. When more than one category was selected the reason for transfusion was prioritised to chronic transfusion programme, then symptomatic anaemia, then Hb level less than local threshold, in that order.
The largest category selected was symptomatic anaemia; however, 42% of this group were reported to have mild symptoms only. One-third of transfusions were given as part of a chronic transfusion programme.
Table 9: Main reason for red cell transfusion (3830 patients)
| |National |
| |(N=3830) |
|A. Symptomatic anaemia |40% |1537 |
|Mild (Chronic fatigue, loss of energy) |17% |646 |
|Moderate (Palpitations; Shortness of breath on exertion etc.) |18% |679 |
|Severe (Shortness of breath at rest; symptoms of ischaemic heart disease, |3% |134 |
|such as chest pain; hypotension or tachycardia unresponsive to fluid | | |
|resuscitation; cardiac failure) | | |
|Unspecified |2% |78 |
|B. Hb level less than the local threshold |22% |834 |
|C. Chronic transfusion programme |34% |1313 |
|D. Cannot determine reason for transfusion |3% |128 |
|Not stated |0.5% |18 |
Although the majority of patients receiving red cells as part of a chronic transfusion programme had a diagnosis of myelodysplasia, around 40% did not.
Table 10: Diagnosis of patients transfused as part of chronic transfusion programme
|Diagnosis |National figures |
| |(1313 patients) |
|Acute leukaemia |11.6% |152 |
|Aplastic anaemia |6.2% |82 |
|Chronic leukaemia |5.1% |67 |
|Lymphoma |5.3% |70 |
|Myelodysplasia |49.7% |652 |
|Myelodysplastic/myeloproliferative neoplasms (includes CMML, JMML) |9.7% |127 |
|Myeloproliferative neoplasms including myelofibrosis |9.7% |128 |
|Myeloma/Plasma cell dyscrasia |5.3% |70 |
|Other stated |0.9% |12 |
Clinical indication for transfusion
More than one category could be selected. The NBTC codes are shown after each option
Chronic anaemia was the indication for transfusion in 58% of all red cell transfusion episodes and the largest single category was chronic anaemia with bone marrow failure (37%).
Table 11: Clinical Indication for Transfusion (3780 patients)
|Indication for Transfusion |National |
| |(N=3780) |
|Acute blood loss |1.8% |69 |
|Medical anaemia, age 65 years |27.2% |1028 |
|Medical anaemia in patients with cardiovascular disease |3.8% |142 |
|Medical anaemia with sepsis |5.8% |219 |
|Medical anaemia with CNS complications |0.4% |14 |
|Anaemia in a patient receiving radiotherapy |0.9% |33 |
|Chronic anaemia with bone marrow failure (BMF) due to MDS/AA/PNH |36.7% |1387 |
|Chronic anaemia with BMF due to bone marrow infiltration |21.6% |817 |
|Other stated* |3.2% |120 |
| |
|* in 73 % of cases the reason provided in other was “not stated”. |
Transfusion Episode
Number of units transfused
One unit transfusions were given to 43% of inpatients and 24% of outpatients whereas 2 or 3 unit transfusions were given to 75% of day patients and 55% of inpatients. Fewer single unit transfusions were given to patients as part of a chronic transfusion programme (inpatients 34%, 37/109 and day patients 20%, 241/1200). Patients weighing less than 50kg received more single unit transfusions; however, five day patients were given 3-unit transfusions.
Table 12: Number of red cell units transfused
|Units transfused |Day patient |Inpatient |Unknown |
| |(2602) |(1217) |(11) |
|One |24% |629 |43% |527 |9% |1 |
|Two |67% |1746 |51% |621 |82% |10 |
|Three |8% |212 |4% |49 |- |- |
|Four to Eight |0.5% |14 |2% |20 |- |- |
|Not stated |2 |15.4% |239 | | |
|Prophylactic indication not described above |1.7% |27 | | |
|b) Prophylactic use in the presence of currently existing risk factors for bleeding (e.g. sepsis, antibiotic treatment, abnormalities of haemostasis) |
|(modified WHO bleeding grade 0 or 1) |
|Reversible BMF |16.5% |257 | | |
|Chronic BMF |13.4% |208 | | |
|c) Pre-procedure platelet transfusion | | | | |
|Central venous line insertion (tunnelled or untunnelled) excluding PICC line |1.9% |30 | | |
|Lumbar puncture |1.6% |25 | | |
|Percutaneous liver biopsy |0.1% |1 | | |
|Major surgery (not involving eye or brain) |0.5% |8 | | |
|Epidural anaesthesia |- |- | | |
|CNS surgery (including posterior segment of eye) |0.1% |1 | | |
|Bone marrow aspirate and or trephine |0.6% |9 | | |
|PICC line insertion |0.9% |14 | | |
|Other organ biopsy (e.g. lung, splenic, renal) |0.2% |3 | | |
|Endoscopy only |0.2% |3 | | |
|Endoscopy and biopsy |0.2% |3 | | |
|Other procedures not described above* |3.4 |53 | | |
|d) Therapeutic Platelet transfusion – modified WHO bleeding grade > 2 |
|Major haemorrhage (WHO grade 3 or 4) |1.7% |27 | | |
|Multiple trauma, or brain/eye injury, or spontaneous intracerebral haemorrhage |1.1% |17 | | |
|Bleeding considered non-severe |6.8% |106 | | |
|Bleeding outside of categories above |0.6% |10 | | |
|e) In addition to the haematological malignancy or myeloid failure syndrome, please indicate if the patient has any of the specific conditions |
|identified below |
|Platelet function defect – acquired |0.6% |9 | | |
|Disseminated intravascular coagulation (DIC) |0.3% |5 | | |
|Congenital platelet function defect |0.1% |2 | | |
|Heparin induced thrombocytopenia (HIT) |- |- | | |
|Primary immune thrombocytopenia (ITP) |0.4% |6 | | |
|Post transfusion purpura (PTP) |- |- | | |
|Thrombotic thrombocytopenic purpura (TTP) |0.1% |2 | | |
| |
|*Pre-procedure indication not described included: dental surgery, cataract surgery, minor surgery, pleural tap and central line removal. |
Transfusion Episode
Number of units transfused
One unit transfusions were most common and given to 96% of all day patients and 88% of all inpatients. Prophylactic transfusions were associated with the highest percentage of single unit episodes with 94% (1144/1218) overall: 97% (528/546) for day patients and 92% (611/667)for inpatients (Platelet Standard 2). A lower percentage of single units were given when the indication was pre-procedure or therapeutic.
Table 20: Number of units transfused
|Units transfused |Day patient (660) |Inpatient (887) |Unknown (6) |
|One |96% |632 |88% |784 |83% |5 |
|Two |3% |22 |10% |86 |17% |1 |
|Three |0.2% |1 |0.8% |7 |- |- |
|Four to Seven |0.3% |2 |0.8% |7 |- |- |
|Not stated |0.5% |3 |0.3% |3 |- |- |
Table 21: Single unit transfusion episodes according to indication
| |Day patient |Inpatient |Unknown |
|All indications (1553) |96% (632/657) |89% (784/884) |83% (5/6) |
|Prophylactic (1223) |97% (528/546) |92% (611/667) |100% (5/5) |
|Pre-procedure (137) |93% (38/41) |71% (67/94) |0% (0/1) |
|Therapeutic (146) |91% (41/45) |85% (86/101) |- |
|Cannot determine reason (42) |100% (23/23) |89% (17/19) |- |
|Not stated (5) |100% (2/2) |100% (3/3) | |
Were the platelets HLA matched?
7.1% (109/1541) of platelets transfusion episodes were HLA matched.
Pre-transfusion platelet count
97% of all patients had a pre-transfusion platelet count measured within 24 hours of the transfusion if they were an inpatient or within 48 hours of the transfusion if they were a day patient. For inpatients this was 99% and for day patients this was 95%.
Table 22: Pre-transfusion platelet count performed within 24 hours if patient was an inpatient or within 48 hours if patient was a day patient
| |National |
| |(1553) |
|Day patients |95% |626/657 |
|Inpatients |99% |877/886 |
|ALL patients |97% |1509/1549 |
Was the pre-transfusion platelet count above the threshold stated in local guidelines?
In 25% of transfusion episodes the pre-transfusion platelet count was known to be above the threshold stated. A reason for non-compliance was provided for 78% of these cases and the most common reasons were: systemic infection (20%); fever (18%); platelet count anticipated to fall below threshold before next visit (17%) and previous significant bleed (16%). In only 37% was a higher threshold specified in the patient record.
Table 23: Was the pre-transfusion platelet count above the threshold stated in the local guidelines (1553 patients)
| |National | |
| |(1553) | |
|Platelet count above the threshold stated in local guidelines |
| YES |25% |381/1495 | | | |
|If YES, was there a reason for a higher threshold |
| YES |78% |294/375 | | | |
|If YES, reason/s for a higher threshold: |
|Fever |18% |53 | | | |
|Systemic infection |20% |60 | | | |
|Abnormality of haemostasis |6% |17 | | | |
|Therapeutic anticoagulation |9% |25 | | | |
|Anti-platelet agent |1% |4 | | | |
|Previous significant bleed |16% |47 | | | |
|Recent major surgery (within one week) |1% |2 | | | |
|Participation in a trial where higher threshold specified |1% |3 | | | |
|On medication where higher threshold specified – please state medication and threshold* |4% |11 | | | |
|Platelet concentrate due to expire at midnight of day of transfusion |0.3% |1 | | | |
|Platelet count anticipated to fall below threshold before next visit to outpatients |17% |49 | | | |
|Other stated** |7% |22 | | | |
|If platelet count was above threshold (n=381), was a higher threshold specified in the notes? |
| YES |37% |121/329 | | | |
|*medication stated to require a higher platelet threshold included: anticoagulation, velcade, desatinib, ATG, Bortezomib. | |
|**other reason for a higher threshold included: advised by consultant haematologist, risk of/possible cerebral bleeding, minor bleeding, mucositis, | |
|recent trauma | |
Platelet count assessment in between transfused units
When more than one unit was transfused 42% (38/91) of inpatients and 19% (4/21) of day patients had a platelet count measured in between units.
When the indication was limited to prophylaxis 39% (20/51) of inpatients and 13% (2/15) of day patients had a platelet count measured in between units.
Table 24: If more than one unit was given was a platelet count checked in between transfused units?
| |National | |
| |(126) | |
| |
| Day patients |19% |4/21 | | | |
| Inpatients |42% |38/91 | | | |
| ALL patients |37% |42/113 | | | |
Post-transfusion platelet count
91% of inpatients and 25% of day patients had a post-transfusion platelet count taken within 24 hours of the end of the transfusion episode.
When the indication was limited to prophylaxis the median increment was 15 x 109/L (n=960) with 22% (215/960) of transfusion episodes obtaining an increment of < 5 x 109/L. There was no obvious difference in increment or refractoriness when calculated for each unit transfused (when more than one unit was given) and no obvious difference between inpatients and day patients.
Table 25: Was a post-transfusion platelet count taken within 24 hours of the transfusion?
| |National | |
| |(1553) | |
| |
| Day patients: |25% |165/654 | | | |
| Inpatients: |91% |801/884 | | | |
| ALL patients: |63% |970/1544 | | | |
|For those who received prophylactic platelets: |
|POST minus PRE-platelet count (x 109/L) | |
| ALL patients: median (IQR) |15 |(6-25), n=960 | |
|Change of 5 or less |22% (215/960) | | |
Total number of platelet concentrates given during the audit period
A total of 7703 platelet units were calculated to have been transfused during July to the patients audited. 1717 of these were transfused during the audited episodes (1547 patients) and 5986 additional units were transfused (1525 patients) during this month. This is an underestimate as 6 audited transfusion episodes did not provide the number of units transfused and additional unit information was not provided for 28 patients. Correction for the whole sample of 1553 patients provides an estimate of 7820 platelet units and this equates to around 39% (7820/19803) of all platelet units received by participating hospitals during this month (Appendix A, Table 2).
Appropriate use algorithm
To evaluate the appropriateness of platelet transfusion algorithms for prophylactic use, pre-procedure and therapeutic use were devised. The prophylactic use was further divided into 3 groups – patients with reversible bone marrow failure (BMF), patients with chronic BMF receiving non-intensive treatment and patients with chronic BMF receiving intensive treatment. The latter group were receiving treatment in an attempt to reverse BMF therefore a threshold platelet count of 10 was applied. For the prophylactic and pre-procedure algorithms, the following were considered: pre-transfusion platelet count, the time at which this was performed, NBTC Indications and individual patient thresholds. For the therapeutic algorithm the pre-transfusion platelet count, the time at which this was performed and the grade of bleeding were considered (see table 26 and Appendix B).
Prophylactic transfusions
Overall a total of 1223 platelet transfusions were assessed. 58% (705/1223) were considered appropriate, 39% (482/1223) outside of guidance and in 3% (36/1223) appropriateness could not be determined. In 4 cases, the transfusions were given to patients with ITP and in 27 cases the transfusions were given to patients with chronic BMF but a timely baseline platelet count was unavailable. This left 590 episodes to be assessed in patients with reversible BMF and 629 episodes to be assessed in patients with chronic BMF. Within the chronic BMF category 579 were managed with non-intensive treatment and 23 with intensive treatment.
Reversible Bone Marrow Failure
75% (443/590) were considered appropriate, 24% (141/590) outside of guidance and in 1% (6/590) appropriateness could not be determined.
Of note 133 transfusions, with a pre-transfusion platelet count greater than 10 x 109/L, were stated by auditors to be within their local guidelines. In 67 of these 133 episodes however no additional risk factors for bleeding were documented and they were classified as outside of guidance.
Where the count was documented to be above local guidelines, 54% (67/123) were accepted as appropriate as an additional risk factor was documented. This was likely to have been lenient.
65% (305/469) of patients received a prophylactic platelet transfusion for reversible bone marrow failure without additional risk factors, when the count was less than or equal to 10 x 109/L (Platelet Standard 1).
Chronic Bone Marrow Failure receiving intensive therapy.
This group accounted for only 2% (23/1223) of all prophylactic platelet transfusion episodes. 70% (16/23) were judged appropriate and 30% (7/23) outside of guidance. 7 transfusions, with a pre-transfusion platelet count of more than 10 x 109//L were stated by auditors to be within their local guidelines. In 5 of these 7 episodes however no additional risk factor for bleeding was stated and they were classified as outside of guidance.
Chronic Bone Marrow Failure receiving non-intensive therapy.
42% (246/579) were judged appropriate, 57% (330/579) outside of guidance (Platelet Standard 3) and in 1% (3/579) appropriateness could not be determined. 423 transfusions were stated by auditors to be within their local guidelines. In 272 of these 423 episodes (64%) however no risk factor for bleeding was stated and they were classified as outside of guidance.
Level of Care
Overall, assessment according to level of care identified no trend towards improved appropriate prophylactic use and a higher level of care. There was no improved practice in level 2b or level 3 care units for the management of patients with chronic BMF receiving non-intensive treatment – (see table 27).
Pre-procedure transfusions
A total of 138 platelet transfusions were assessed. 27% (37/138) were considered appropriate, 55% (76/138) outside of guidance and in 18% (25/138) appropriateness could not be determined. (Using 2016 thresholds 54% (75/138) were considered appropriate, 28% (38/138) outside of guidance and in 18% (25/138) appropriateness could not be determined)
In cases assessed against the NBTC indications, where up to a maximum count of 50 was recommended (e.g. 50 x 109/L prior to a laparotomy, liver biopsy, transbronchial biopsy etc., 40 x 109/L prior to lumbar puncture, 20 x 109/L prior to central line insertion), with no other risk factors for bleeding stated, 51% (29/57) were considered appropriate, and 49% (28/57) outside of guidelines. (Using threshold of 50 for this group as in 2016 - 70% (40/57) were considered appropriate, and 30% (17/57) outside of guidelines) (Platelet standard 4).
1 case was reported prior to an operation in a critical site such as the eye or brain, which had a platelet count < 100 x 109/L. (Platelet standard 5).
Within the transfusion episodes considered to be outside of guidance were 9 (7% of all pre-procedure cases) given prior to a bone marrow biopsy (Platelet Standard 6).
There was no clear difference between levels of care and appropriate use (see table 27).
Therapeutic transfusions
145 platelet transfusions were assessed. 88% (127/145) were considered appropriate, 11% (16/145) outside of guidance and in 1% (2/145) appropriateness could not be determined. Using the 2016 algorithm there was no clear difference in the results (92%, 7% and 1% respectively. Out of the 127 transfusions considered appropriate 12% (15/127) were associated with CNS bleeding, 18% (23/127) with major haemorrhage, 6% (7/127) with other bleeding; however the majority 65% (82/127) were associated with lower grades of bleeding and judged appropriate with a platelet count of less than or equal to 30 x 109/L.
There was no clear difference between levels of care and appropriate use (see table 27).
Table 26: Appropriate use of platelet transfusions (1553 patients)
|Reason for transfusion |Total number |Appropriate |Outside of guidance |Unable to assess |
| |transfusions | | | |
| |(% of 1553) | | | |
| | | | | |
|PLATELET | | | | |
|Prophylactic |1223 (79%) |58% (705) |39% (482) |3% (36) |
|Reversible BMF |590 (38%) |75% (443) |24% (141) |1% (6) |
|Chronic BMF (non-intensive therapy) |579 (37%) |42% (246) |57% (330) |1% (3) |
|Chronic BMF (intensive therapy) |23 (1%) |70% (16) |30% (7) |- |
|Unable to categorise |31 (2%) |- |13% (4) |87% (27) |
|Pre-procedure |138 (9%) |27% (37) |55% (76) |18% (25) |
|Therapeutic |145 (9%) |88% (127) |11% (16) |1% (2) |
|Unable to determine |42 (3%) |- |- |100% (42) |
|Not stated |5 (0.3%) |- |- |100% (5) |
Table 27: Appropriate use (excluding cases which could not be assessed) and level of care (where known)
| |Level 1 |Level 2a |Level 2b |Level 3 |
|Prophylactic appropriate use |67% (2/3) |61% (74/122) |64% (138/214) |60% (210/351) |
|Reversible BMF |100% (1/1) |63% (19/30) |86% (87/102) |74% (145/195) |
|Chronic BMF (non- intensive therapy) |50% (1/2) |61% (54/89) |44% (47/107) |40% (59/148) |
|Chronic BMF (intensive therapy) |- |33% (1/3) |80% (4/5) |75% (6/8) |
|Pre-procedure |- |13% (1/8) |48% (10/21) |42% (18/43) |
|Therapeutic |- |90% (19/21) |88% (21/24) |92% (33/36) |
Discussion
This was a large audit with participation from 107 hospitals in the organisational audit and 153 hospitals in the clinical audit. This represented 127/138 (92%) of eligible English NHS Trusts. A total of 4098 patient records were analysed providing 5383 transfusion episodes. When additional units received by audited patients during the audit period were included this accounted for around 13% (14484/111567) of all red cell and 39% (7820/19803) of all platelet concentrates requested by participating hospitals.
Organisational audit
Standards
Two standards were defined for the organisational audit – the availability of written guidelines and the implementation of local audit to assess compliance. It is essential for all hospitals to have access to written guidelines so that clinical staff are aware of best practice and therefore disappointing to identify in this audit that 11% (12/107) did not (Standard 1). 49% (45/91) of hospitals stated that local audit had been performed within the last 12 months (Standard 2). Regular audit of practice remains a problem and most likely reflects the fact that audit is very labour intensive, the work load in hospitals is increasing and there is currently no IT solution.
Local guidelines
When guidelines were available the most common method of access was the intranet and this was stated by 96% of hospitals. Overall there was poor compliance with NBTC indications for transfusion in local hospital guidelines. This was most marked for some platelet pre-procedure thresholds, recently revised by the British Society of Haematology but also noticeable for longstanding national guidance indicating that prophylactic platelet transfusion was not required for stable patients with chronic BMF. There was also a lack of compliance with the NBTC higher recommended red cell threshold for patients receiving radiotherapy. It is acknowledged that the latter has no good evidence base. Without clear guidance to the contrary unnecessary transfusion is a likely consequence and is demonstrated in the clinical section of this audit report.
Level of care and organisational information
58% (62/107) of all hospitals who took part in this audit provided either level 2b or level 3 care. There was a clear relationship between inpatient bed numbers and the level of care, and direct consultant haematology management and the level of care. 87% (20/23) of organisations without designated beds, and the vast majority of hospitals who did not provide direct consultant haematology management provided either level 1 or 2a care. In contrast level 3 care was associated with a minimum of 10 designated beds and provided both working hours and out of hours direct consultant haematology supervision.
Conversely there was no tendency for level 1 or 2a care organisations, compared to organisations with a higher level of care, to be less compliant with either red cell or platelet transfusion NBTC indications. In fact, a larger proportion of level 3 hospitals used a higher threshold for red cell transfusion when no other risk factors were present (36% if aged < 65 and 45% if aged ≥ 65).
Clinical Audit
The patient population was largely elderly with a median age of 73 years. Myelodysplasia, largely a disease of the elderly, was the single most common diagnostic category at 29.7% and 72% of all patients audited were managed without curative intent by either transfusion alone or with the addition of low dose chemotherapy. In 58% of red cell transfusion episodes the indication was chronic anaemia and at least 34% of episodes were associated with a chronic red cell transfusion programme. In 79% of platelet transfusion episodes the indication was prophylactic and within this group 51% (629/1223) were given to patients with chronic BMF.
As the number of elderly people in the population is increasing blood use within the haematology patient population would also be expected to increase making compliance with best practice and limiting transfusion to only those who are likely to benefit essential if availability is to continue to meet demand.
Red blood cell transfusion
Process
6% (223/3829) of transfusion episodes did not have a pre-transfusion Hb measured within 24 hours in inpatients or 72 hours in day patients (Red cell standard 1). As was predictable more one unit transfusions were given to inpatients (43%) compared to day patients (24%.). 5% (150/2805) of all patients weighed less than 50 kg and although this group received more single unit transfusions, in keeping with all patients, very few patients had an Hb check when further units were given (weight less than 50 kg 10%, 3/31 of inpatients and no day patient, 0/58). Five patients weighing less than 50 kg received 3 unit transfusions as day patients. This practice is unsafe because it puts patients at risk of Transfusion Associated Circulatory Overload (TACO).
Appropriate use
Standards
Four red cell specific standards were used to assess compliance with NBTC Hb thresholds. As there is no Hb threshold to define appropriate transfusion in chronic anaemia these standards were limited to patients with reversible BMF. Patients transfused with a higher threshold because of severe sepsis or acute cerebral ischaemia were also excluded as this is no longer a valid indication for all patients in this category. The results highlighted significant deviation with only 24% (195/815) compliance for use of a threshold of 70g/L for patients without additional risk factors (Red cell standard 2). There was also poor compliance for patient with risk factors of cardiovascular disease with only 44% (32/72) having an Hb of less than 80g/L (Red cell standard 3). These results are in keeping with the organisational audit results which identified that the most common reason for deviation from the NBTC guidance in these groups was use of a higher threshold. Compliance was 100% for those receiving radiotherapy (Red cell standard 4) and no cases were transfused above an Hb of 100g/L.
Appropriate Use Algorithm
The construction of an appropriate use algorithm allowed the inclusion of all patients and assessed symptoms of anaemia.
A threshold Hb of 100g/L to define appropriate use in patients with chronic anaemia is in keeping with a feasibility study which aims to assess quality of life and transfusion thresholds in patients with myelodysplastic syndromes. Despite this more generous approach only 63% to 76% of all red cell transfusions were considered to be appropriate, depending upon whether only those known to be on a chronic transfusion programme or all those with chronic anaemia were allowed a higher threshold.
The inappropriate use of RBCs is mainly due to transfusion of patients with both reversible and chronic BMF at liberal thresholds without a clear indication. Although in some patients this may have been appropriate, easily identified transfusion plans for all patients are required when existing standards are not followed. This is particularly important for patients on chronic transfusion programmes where a customized approach is recommended.
Platelet transfusion
Process
3% (40/1549) of transfusion episodes did not have a pre-transfusion platelet count measured within 24 hours in inpatients or 48 hours in day patients. One unit transfusions were usual and given on 92% of all occasions (96% day patients and 88% inpatients). Predictably more single units were used as prophylaxis at 94% (Platelet standard 2). Prophylactic platelets are routinely given to stable patients and therefore allow analysis of everyday practice. In this group when more than one unit was transfused, it would be reasonable to expect a platelet count measured in between units.
However, only 39% (20/51) of inpatients and 13% (2/15) of day patients had this performed which demonstrates that this procedure is not yet standard. When a post prophylactic transfusion platelet count was performed 22% had an increment of less than or equal to 5 x 109/L indicating little benefit.
Appropriate use
Standards
Six platelet specific standards were used to assess compliance with NBTC indications for transfusion. In patients with a reversible cause for BMF and no other risk factors for bleeding the platelet count was less than or equal to 10 x 109/L in 65% (305/469) of all episodes (Platelet standard 1). This was a significant improvement compared to 2010 when compliance was 54% using the same algorithm as used in 2016 and 2017. A small improvement compared to the 2016 audit was noted (61%). There was probably also an improvement in prophylactic single unit transfusions compared to results in 2016 and 2010 (94% v 93% v 90%).
Pre-procedure with a threshold platelet count of 50 x 109/L or below, compliance was significantly reduced at 27%. This was due to new recommendations for a lower platelet count threshold for central line insertion and prior to a lumbar puncture. As stated above this change has not yet been commonly adopted in local hospital guidance and reflected in clinical practice. (Platelet standard 4). There was little difference in the percentage of platelet transfusions pre-procedure where the only indication was to prior to a bone marrow biopsy (Platelet standard 6).
In this audit, stable patients with chronic bone marrow failure were assessed (Platelet standard 3). In this group 57% (330/579) were given prophylactic transfusions outside of guidance. This is in keeping with the organisational audit findings that hospital guidance frequently does not specify that transfusion is not necessary in these patients.
Appropriate Use Algorithms
Appropriate use algorithms were constructed for prophylactic, pre-procedure and therapeutic platelet use. Within the prophylactic group appropriate use remains comparable to 2016 - 75% associated with reversible BMF, 42% associated with chronic BMF not receiving intensive therapy (as above) and 70% associated with chronic BMF receiving intensive therapy.
There was no observable association between level of care and appropriate use, including use in chronic BMF. Appropriate use algorithms for prophylaxis are not comparable to the 2010 audit results as only one algorithm was used then and only patients with MDS, but no other causes of chronic BMF, were excluded.
Pre-procedure appropriate use has seen a dramatic drop likely because of a change in recommendations as described above for platelet standard 4. This was predicted in the 2016 audit by analysing the results then but using the 2017 guidance. This contrasts with a similar level of compliance for therapeutic transfusion despite a recent lower threshold of 30 x 109/L for bleeding considered to be non-severe. Of disappointment is the lack of a clear improvement in the use of platelet transfusion prior to bone marrow biopsy.
Limitations
The credibility of audit data is important. This report is based upon standardised case identification and data collection and analyses have followed defined statistical plans. Unexpected findings at individual hospitals could occur because of chance effects, in which case readers should examine any shortfalls in achievement in the light of national data. Unusual case mix may also account for apparent shortfalls although the audit standards have been designed as far as possible to reflect individual patient needs.
There has been a change in use of red cell and platelet guidance between 2016 and 2017 therefore direct comparison for some standards was not possible. The audit results also depend on the quality of documentation in the medical notes and, in the absence of appropriate documentation, may underestimate clinical performance. Readers should take account of these limitations, but accept several strengths of the audit, including comparative analysis of a large sample size across many hospitals.
Appendix A – Additional Figures
Figure 1: Date of red cell transfusion audited
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Figure 2a: Histogram for post transfusion Hb for inpatients.
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Figure 2b: Histogram for post transfusion Hb increment for inpatients.
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One outlier (-80 g/L) excluded from graphic.
Figure 2c: Histogram for post transfusion Hb increment per unit transfused for inpatients.
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Figure 3: Date of platelet transfusion audited
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Table 1: Number of additional red cells patients received in July 2017
| |National | |
| |(3722) | |
| |
| Median (IQR) |1 |0 to 3 | |
| |
| None |44.5% |1656 | | |
| One |8.3% |308 | | |
| Two |20.3% |754 | | |
| Three |7.6% |284 | | |
| Four |6.7% |249 | | |
| Five |3.5% |131 | | |
| Six |3.1% |117 | | |
| Seven |1.4% |52 | | |
| Eight |1.1% |42 | | |
| Nine |0.8% |31 | | |
| Ten or more (10-74) |2.6% |98 | | |
Table 2: Number of additional platelets received in July 2017
| |National | |
| |(1525) | |
| |
| Median (IQR) |2 |1 to 5 | |
| |
| None |24.8% |378 | | |
| One |14.3% |218 | | |
| Two |13.0% |199 | | |
| Three |10.4% |158 | | |
| Four |8.6% |131 | | |
| Five |5.1% |78 | | |
| Six |4.9% |75 | | |
| Seven |3.4% |52 | | |
| Eight |3.1% |47 | | |
| Nine |1.8% |27 | | |
| Ten to nineteen |8.6% |131 | | |
| Twenty or more (20 - 53) |2.0% |31 | | |
Appendix B – Analysis Algorithms
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Appendix C – Patient Audit Tool
Patient Characteristics
1. What is the patient’s gender? ( Male ( Female
2. What was the patient’s age at the time you audited this transfusion episode
3. What was the patient’s weight (kilograms)?
Diagnosis
4. What is the current haematological diagnosis? (occasionally more than one may apply)
Acute leukaemia (tick one of the options below)
( Acute myeloid leukaemia excluding APML
( Acute promyelocytic leukaemia (APML)
( Acute lymphocytic leukaemia
( Other acute leukaemia
( Aplastic anaemia
Chronic leukaemia (tick one of the options below)
( Chronic lymphocytic leukaemia (CLL)
( Chronic myeloid leukaemia (CML)
( Other chronic leukaemia
Lymphoma (tick one of the options below)
( Burkitt’s lymphoma
( Diffuse large B cell lymphoma (DLBCL)
( Follicular lymphoma
( Hodgkin’s lymphoma (HL)
( Other lymphoma
( Myelodysplasia
( Myelodysplastic/myeloproliferative neoplasms (includes CMML, JMML)
( Myeloproliferative neoplasms including myelofibrosis
( Myeloma/Plasma cell dyscrasia
( Other (please state)
Treatment
5. Was the patient receiving treatment (excluding transfusion)
for their underlying current haematological diagnosis? ( Yes ( No
If yes, go to Q6. If no, go to Q9
6. Was the patient undergoing allogeneic stem cell transplant? ( Yes ( No
If yes, go to Q9. If no, go to Q7
7. Was the patient undergoing autologous stem cell transplant? ( Yes ( No
If yes, go to Q9. If no, go to Q8
8. Was the patient on an intensive chemotherapy programme in
the last 6 weeks? (excluding low dose chemotherapy e.g. azacitidine) ( Yes ( No
9. Was the patient participating in a clinical study? ( Yes ( No
If yes, please state the name of the study
10. Did this patient have a red cell transfusion in July 2017? ( Yes ( No
If yes, go to Q11. If no, go to Q22
Red Cell Transfusion
11. Was the patient an ( Inpatient? or a ( Day patient?
Indication for the Red Cell Transfusion that you are auditing
12. Please select one of the 4 broad categories (a, b, c, d) below which best
describes the reason for transfusion.
a) ( Symptomatic anaemia
If yes, please indicate severity grade
( Mild (Chronic fatigue, loss of energy)
( Moderate (Palpitations; Shortness of breath on exertion etc.)
( Severe (Shortness of breath at rest; symptoms of ischaemic
heart disease, such as chest pain; hypotension or tachycardia
unresponsive to fluid resuscitation; cardiac failure)
( Unspecified
b) ( Hb level less than the local threshold
c) ( Chronic transfusion programme
d) ( Cannot determine reason for transfusion
13. What was the clinical indication for transfusion?
(More than 1 code may be used. NBTC 2016 codes are shown after each option,
where applicable)
( Acute bleeding (R1)
( Medical anaemia, age 65 years (R2)
( Medical anaemia in patients with cardiovascular disease (R3)
( Medical anaemia with sepsis
( Medical anaemia with CNS complications (R2)
( Anaemia in a patient receiving radiotherapy (R5)
( Chronic anaemia with bone marrow failure (BMF) due to MDS/AA/PNH (R4)
( Chronic anaemia with BMF due to bone marrow infiltration (R4)
( Other, please specify
14. What was the date of the red cell transfusion that you are auditing? (dd:mm)
2017
15. How many units were given in this transfusion episode?
(A transfusion episode is defined as all units transfused within a 24 hour period)
16. Was a pre-transfusion Hb count performed within 24 hours ( Yes ( No
of the start of the transfusion if the patient was an inpatient,
or within 72 hours of the transfusion if the patient was a day patient?
17. If yes to Q16, what was the Hb? g/L
If only one unit was given go to Q19, if more than one unit was given please answer Q18
18. Was the Hb measured after each unit transfused? ( Yes ( No
19. Was a post-transfusion Hb taken within 24 hours of ( Yes ( No
the end of the transfusion episode?
20. If yes to Q19, what was the Hb? g/L
21. How many additional red cells units did this patient receive in the month of
July 2017?
22. Did the patient receive a platelet transfusion in July 2017? ( Yes ( No
If yes, go to Q23. If no, you have finished this questionnaire
Platelet transfusion
23. Was the patient an ( Inpatient? or a ( Day patient?
Indication for the platelet transfusion that you are auditing
To assist you in completing this section, please refer to the bleeding grade definitions shown on page 11
24. Please select one of the 4 broad categories (a,b,c,d) below which best describes the reason for transfusion. If therapeutic to treat bleeding (modified WHO bleeding grade 2 or above) please indicate grade.
a). Prophylactic platelet transfusion to prevent bleeding and not having a procedure
Modified WHO bleeding grade 0 or 1 ( Now go to Q25
b). Pre-procedure
Modified WHO bleeding grade 0 or 1 ( Now go to Q25
c). Therapeutic to treat bleeding
Modified WHO bleeding grade 2 ( Now go to Q25
Modified WHO bleeding grade 3 ( Now go to Q25
Modified WHO bleeding grade 4 ( Now go to Q25
d). Cannot determine the reason for transfusion ( Now go to Q26
25. What was the clinical indication for transfusion (a,b,c,d,e)?
(please tick all codes that apply. NBTC 2016 codes are shown after each
option, where applicable)
a) Prophylactic - modified WHO bleeding grade 0 or 1
( Reversible bone marrow failure due to haematological disease or treatment (P1)
( Allogeneic stem cell transplant (P1)
( Autologous stem cell transplant (P1)
( Chronic BMF receiving intensive therapy (excluding low dose chemotherapy e.g.
azacitidine) (P1)
( Chronic BMF e.g. MDS, AA to prevent recurrence of previous bleed of modified
WHO grade >2
( Prophylactic indication not described above (please state) (P1)
b) Prophylactic use in the presence of currently existing risk factors for bleeding (e.g. sepsis, antibiotic treatment, abnormalities of haemostasis) (P2) modified WHO bleeding grade 0 or 1
( Reversible BMF
( Chronic BMF
c) Pre-procedure platelet transfusion (P3)
( Central venous line insertion (tunnelled or untunnelled) excluding PICC line (P3a)
( Lumbar puncture (P3b)
( Percutaneous liver biopsy (P3c)
( Major surgery (not involving eye or brain) (P3c)
( Epidural anaesthesia (P3d)
( CNS surgery (including posterior segment of eye) (P3e)
( Bone marrow aspirate and or trephine
( PICC line insertion
( Other organ biopsy (e.g. lung, splenic, renal)
( Endoscopy only
( Endoscopy and biopsy
( Other procedures not described above (Please state)
d) Therapeutic Platelet transfusion (P4) – modified WHO bleeding grade > 2
( Major haemorrhage (WHO grade 3 or 4) (P4a)
( Multiple trauma, or brain/eye injury, or spontaneous intracerebral haemorrhage (P4b)
( Bleeding considered non severe (P4c)
( Bleeding outside of categories above
e) In addition to the haematological malignancy or myeloid failure syndrome, please indicate if the patient has any of the specific conditions identified below
( Platelet function defect – acquired (P6a)
( Disseminated intravascular coagulation (DIC) (P5)
( Congenital platelet function defect (P6b)
( Heparin induced thrombocytopenia (HIT)
( Primary immune thrombocytopenia (ITP) (P5b)
( Post transfusion purpura (PTP)
( Thrombotic thrombocytopenic purpura (TTP)
Platelet transfusion episode
26. What was the date of the platelet transfusion 2017
that you are auditing? (dd:mm)
27. How many units of platelets were given in this transfusion episode?
(A transfusion episode is defined as all units transfused within a 24 hour period)
28. Were the platelets HLA matched? ( Yes ( No
29. Was a pre-transfusion platelet count performed within 24 hours of the transfusion if the patient was an inpatient, or within 48 hours of the transfusion if the patient was a day patient?
( Yes ( No
If yes, go to Q30. If no, go to Q36
30. If yes to Q30, what was the platelet count? x 109/L
31. Was the platelet count above the
threshold stated in local guidelines? ( Yes ( No
If yes, go to Q32. If no, go to Q36
32. Was there a reason for a higher threshold? ( Yes ( No
If yes, go to Q33. If no, go to Q36
33. Please select from the list below reason/s for a higher threshold:
( Fever
( Systemic infection
( Abnormality of haemostasis
( Therapeutic anticoagulation
( Anti-platelet agent
( Previous significant bleed
( Recent major surgery (within one week)
( Participation in a trial where higher threshold specified
( On medication where higher threshold specified – please state medication and
threshold
( Platelet concentrate due to expire at midnight of day of transfusion
( Platelet count anticipated to fall below threshold before next visit to outpatients
( Other, please state
34. Was a higher threshold specified in the notes? ( Yes ( No
35. If yes to Q34, please state threshold specified
If only one unit was given (see Q27) go to question 37, if more than one unit was given please answer question 36.
36. Was a platelet count checked in between transfused units? ( Yes ( No
37. Was a post-transfusion platelet count taken within ( Yes ( No
24 hours of the transfusion?
38. If yes to Q37, what was the platelet count? x 109/L
39. How many additional platelet units did this patient receive
within the month of July 2017?
END OF AUDIT TOOL
MODIFIED WHO BLEEDING GRADES
Modified WHO bleeding grade 0 or 1
Type of bleeding included:
• No evidence of bleeding
• Mild/moderate petechiae, purpura
• Mild/moderate oropharyngeal bleeding, epistaxis 30 minutes in continuous duration
• Symptomatic oral blood blisters i.e. bleeding or causing discomfort
• Extensive petechiae, purpura i.e. numerous in number and/or positioned on either face or abdomen and/or spreading by comparison to previous assessment
• Visible blood in urine
• Bleeding from invasive sites requiring 2 ≥ changes of dressings in a 24 hr period
• Unexpected vaginal bleeding saturating 2 ≥ pads with blood in a 24 hr period
• Red cells in body cavity fluids obvious macroscopically
• Retinal haemorrhage with/without visual impairment
Modified WHO bleeding grade 3
Type of bleeding included:
• Melaena, haematemesis, haemoptysis, haematuria – including intermittent gross bleeding without clots, abnormal vaginal bleeding, fresh blood in stool, epistaxis, and oropharyngeal bleeding, bleeding from invasive sites, musculoskeletal bleeding, or soft tissue bleeding requiring red cell transfusion specifically for support of bleeding within 24 hours of onset and without haemodynamic instability.
• Body cavity fluids reported as grossly bloody in laboratory, nursing, or medical notes.
• CNS bleeding noted on CT (computerized tomography) without clinic consequences
Modified WHO bleeding grade 4
Type of bleeding included:
• Debilitating bleeding including retinal bleeding with visual impairment*
• Non-fatal CNS bleeding with neurological signs and symptoms
• Bleeding associated with haemodynamic instability (hypotension, > 30mm Hg change in systolic or diastolic BP)
• Fatal bleeding from any source.
*visual impairment is defined as a field deficit, and patients with suspected visual impairment require an ophthalmologic consultation
Appendix D – Organisational Questionnaire
Section 1: General Information
What level of haematology care does your hospital provide? (according to BCSH criteria - see definitions in appendix 1)
Level 1 ( Level 2a ( Level 2b ( Level 3 (
At your hospital how many in-patient beds have been designated haematology beds (includes all types of haematology patient)?
Are in-patients who require care, primarily because of a haematological problem, under the direct care of a Consultant Haematologist:
During working hours? Yes ( No (
Out of hours? Yes ( No (
Do you provide written guidelines for the use of blood component transfusion in haematology patients? These may be the same as national and used for all other patients in the hospital.
Yes ( No (
If No, this is the end of the questionnaire.
If Yes, please complete the Red Blood Cell and Platelet tables below.
The tables below indicate the patient category and threshold count suggested in the National Blood Transfusion Committee (NBTC) Indications and Codes for transfusion. Sometimes we have subdivided indication codes to understand if hospitals use different thresholds. Please identify in the “Your Threshold column” the count in your guideline which is used for each indication. If your guideline does not cover the indication state “not covered”.
|Red Blood Cells |
|CLINICAL INDICATION for transfusion |NBTC |NBTC INDICATION |PLEASE STATE YOUR THRESHOLD OR |
| |Code |THRESHOLD (g/L) |STATE “NOT COVERED” |
|Acute bleeding |R1 |70 | |
|Surgery / medical / critical care | |
| Usual indication for red cell transfusion, age < 65 years |R2 |70 | |
| Usual indication for red cell transfusion, age > 65 years |R2 |70 | |
| With cardiovascular disease or symptoms |R3 | |
| History of ischaemic heart disease | |80 | |
| Chest pain; hypotension or tachycardia unresponsive to fluid resuscitation; or | |80 | |
|cardiac failure | | | |
| With severe sepsis | |90 | |
| With traumatic brain injury |R2 |90 | |
| With acute cerebral ischaemia |R2 |90 | |
|Radiotherapy |R5 |100 | |
|Chronic Anaemia |R4 | |
|Chronic anaemia age < 65 years | |80 | |
|Chronic anaemia age > 65 years | |80 | |
|Platelets |
|Does your guideline specify grades of bleeding to differentiate Yes ( No ( |
|prophylactic from therapeutic transfusion? |
| |
|If yes are the bleeding grades as stated in appendix 2? Yes ( No ( |
|CLINICAL INDICATION for transfusion (NBTC indication code shown in brackets) |NBTC INDICATION |PLEASE STATE YOUR THRESHOLD|
| |THRESHOLD |OR STATE “NOT COVERED” |
|Prophylactic use in the absence of risk factors for bleeding (P1) |
|Reversible BMF e.g. disease/treatment including allogeneic BMT but excluding autologous BMT | | |
| |10 x 109 | |
|Reversible BMF associated with autologous BMT | | |
| |10 x 109 | |
|Chronic BMF receiving intensive therapy | | |
| |10 x 109 | |
|Chronic BMF not receiving intensive therapy |Not indicated | |
|Prophylactic use if risk factors for bleeding present [e.g. sepsis, antibiotic treatment, abnormalities of haemostasis] (P2) |
|Reversible BMF |20 x 109 | |
|Chronic BMF |20 x 109 | |
| | | |
|Pre-invasive procedure or surgery (P3) |
|Central venous line insertion (tunnelled or untunnelled) excluding PICC line | | |
| |20 x 109 | |
| PICC line | | |
|Lumbar puncture |40 x 109 | |
| | | |
| | | |
|Percutaneous liver biopsy |50 x 109 | |
|Major surgery |50 x 109 | |
|Epidural anaesthesia |80 x 109 | |
| Spinal anaesthesia |80 x 109 | |
|CNS surgery (including posterior segment of eye) |100 x 109 | |
|Bone marrow aspirate and or trephine |Not indicated | |
| | | |
| | | |
|Therapeutic Platelet transfusion (P4) |
|Major haemorrhage |50 x 109 | |
|Bleeding with multiple trauma, or brain/eye injury, or spontaneous intracerebral haemorrhage | | |
| |100 x 109 | |
|Bleeding |30 x 109 | |
|Bleeding but considered non severe | | |
How are your guidelines made available to medical and nursing staff?
( Provided in written format at hospital induction to all new junior doctors
( Provided on hospital intranet
( Displayed on wall in haematology day unit
( Displayed on wall in haematology ward
( Specific teaching sessions provided at doctors’ induction
( Provided in guideline/protocol folder on wards
( Other (please state)
When was your last local audit performed to assess compliance with transfusion
guidelines? (This could be of one or all blood component use and include additional
specialties)
( < 12 months
( 12-18 months
( 18-24 months
( 24-36 months
( 36-48 months
( 48-60 months
( No local audit performed
Definitions
Levels of Haematology Care
Level 1 care requires facilities for delivering treatment that would not normally be expected to result in significant neutropenia, although this might occur for a brief period (less than 7 days). Such treatment can be given on an out-patient basis, either orally or intravenously. Examples of this level of treatment include oral hydroxycarbamide and melphalan.
Level 2a care requires facilities for delivering treatment that more predictably results in short periods of bone marrow suppression, with neutropenia of usually less than 7 days duration. Examples include CHOP, ABVD, rituximab containing combinations (FCR, R-CVP, R-CHOP etc.), bortezomib therapies and non-intensive treatment for acute myeloid leukaemia (AML).
Level 2b care requires facilities for delivering treatment that will predictably cause prolonged periods of neutropenia, would normally be given on an in-patient basis, and which may need to be given at weekends as well as during the week. These regimens are more complex to administer than at level 1 or 2a (for example, in terms of drug scheduling) and have a greater likelihood of resulting in medical complications in addition to predictable prolonged neutropenia. Consequently, the resources required to deliver these more complex regimens are greater than at level 1 or 2a. Such regimens include those used to treat AML with curative intent, and salvage chemotherapy regimens for relapsed aggressive histology lymphomas (for example DHAP, IVE).
Level 3 care requires facilities for delivering complex treatment regimens and, as with level 2b, may have a high incidence of complications. In addition these treatments are designed for rare haematological malignancies where centralisation of care at regional centres is considered to be advantageous, for example in terms of the familiarity of the biology of the rare diseases and the treatment protocols used. An example of this is the modern in-patient management phase of acute lymphoblastic leukaemia (ALL).
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Appendix E – Sites that participated in the audit
The figures for 2017 refer to the numbers available at the time of analysis during October 2017.
| |Analysed cases|Analysed cases|Excluded from |Participation in |Participation in |
| | |2017 audit |2017 analysis*|Organisational audit|Organisational audit|
| |2016 | | |2016 |2017 |
| |audit | | | | |
|Addenbrooke's Hospital |26 |40 |- |- |- |
|Airedale NHS Foundation Trust |31 |19 |6 |Yes |Yes |
|Altnagelvin Area Hospital |25 |30 |3 |Yes |Yes |
|Barnet Hospital |32 |34 |2 |Yes |Yes |
|Barnsley Hospital NHS Foundation Trust |33 |25 |- |Yes |Yes |
|Barts Health NHS Trust |28 |38 |2 |Yes |- |
|Basildon and Thurrock University Hospitals |37 |36 |- |- |Yes |
|NHS Foundation Trust | | | | | |
|Basingstoke & North Hampshire Hospital |8 |25 |- |Yes |Yes |
|Belfast Health and Social Care Trust |41 | |- |Yes |- |
|Betsi Cadwaladr University Health Board |26 |17 |3 |Yes |- |
|Birmingham City Hospital |20 |10 |- |Yes |Yes |
|Birmingham Heartlands Hospital |51 |11 |- |Yes |Yes |
|Bishop Auckland Hospital |5 | |- |Yes |Yes |
|Blackpool Victoria Hospital |0 | |- |Yes |Yes |
|Bradford Teaching Hospitals NHS Foundation Trust |26 |34 |1 |Yes |- |
|Bronglais Hospital |6 |10 |- |Yes |- |
|Buckinghamshire Healthcare NHS Trust |57 |52 |16 |Yes |Yes |
|Calderdale and Huddersfield NHS Foundation Trust |31 |27 |- |- |Yes |
|Central Manchester University Hospitals |39 | |- |Yes |- |
|NHS Foundation Trust | | | | | |
|Chelsea & Westminster Hospital |16 |13 |- |Yes |Yes |
|Chesterfield Royal Hospital |38 |37 |4 |Yes |Yes |
|City Hospital Campus Nottingham |49 |23 |- |Yes |Yes |
|Colchester Hospital University NHS Foundation Trust |54 |53 |1 |Yes |Yes |
|Conquest Hospital |25 |21 |2 |Yes |Yes |
|Countess of Chester Hospital NHS Foundation Trust |12 | |- |- |- |
|County Hospital (Stafford) |24 | |- |Yes |- |
|Craigavon Area Hospital |27 | |- |Yes |- |
|Croydon Health Services NHS Trust |16 |15 |- |Yes |Yes |
|Darlington Memorial Hospital |11 |32 |4 |Yes |Yes |
|Dartford and Gravesham NHS Trust |33 |38 |3 |- |- |
|Derriford Hospital |58 |36 |2 |- |- |
|Doncaster and Bassetlaw Hospitals |31 | |- |Yes |- |
|NHS Foundation Trust | | | | | |
|Dorset County Hospital NHS Foundation Trust |20 |5 |- |Yes |Yes |
|East and North Hertfordshire NHS Trust |18 |7 |- |Yes |- |
|East Cheshire NHS Trust |9 |16 |- |- |Yes |
|East Lancashire Hospitals NHS Trust |26 |37 |- |Yes |Yes |
|Eastbourne Hospital |33 |24 |- |Yes |Yes |
|Epsom Hospital |19 |19 |- |Yes |- |
|Forth Valley Royal Hospital |14 |33 |- |Yes |Yes |
|Frimley Park Hospital |24 |19 |- |Yes |- |
|Furness General Hospital |9 |14 |- |Yes |Yes |
|George Eliot Hospital |17 |19 |2 |- |- |
|Glangwili General Hospital |17 |6 |- |Yes |Yes |
|Gloucestershire Hospitals NHS Foundation Trust |28 |27 |- |Yes |Yes |
|Guys and St Thomas' NHS Foundation Trust |32 |39 |2 |Yes |Yes |
|Harrogate and District NHS Foundation Trust |23 |35 |- |Yes |Yes |
|Hinchingbrooke Hospital |23 |17 |2 |Yes |Yes |
|Homerton University Hospital |2 |1 |- |Yes |- |
|Hull Royal Infirmary |39 |27 |2 |- |- |
|Imperial College Healthcare NHS Trust |43 |19 |1 |Yes |- |
|James Paget University Hospital |34 |32 |1 |Yes |Yes |
|Kent & Canterbury Hospital |28 |25 |2 |Yes |- |
|Kettering General Hospital |36 |41 |6 |Yes |Yes |
|King's College Hospital |40 |60 |- |Yes |Yes |
|Kingston Hospital |36 |37 |- |Yes |- |
|Lancashire Teaching Hospitals NHS |27 |19 |3 |- |Yes |
|Foundation Trust | | | | | |
|Leighton Hospital |14 |14 |- |Yes |Yes |
|London North West Healthcare NHS Trust |41 |37 |- |Yes |Yes |
|Luton and Dunstable Hospital NHS Foundation Trust |21 |19 |1 |Yes |Yes |
|Maidstone and Tunbridge Wells NHS Trust |44 |39 |1 |Yes |Yes |
|Medway NHS Foundation Trust |24 | |- |- |- |
|Mid Essex Hospital Services NHS Trust |36 |33 |2 |Yes |Yes |
|Milton Keynes NHS Foundation Trust |33 | |- |Yes |- |
|Musgrove Park Hospital |24 |24 |- |Yes |Yes |
|Nevill Hall Hospital |17 |23 |- |Yes |- |
|Norfolk & Norwich University Hospital |43 |47 |- |Yes |Yes |
|North Bristol NHS Trust |30 |23 |- |Yes |Yes |
|North Cumbria University Hospitals NHS Trust |14 | |- |Yes |- |
|North Middlesex University Hospital NHS Trust |17 |17 |- |Yes |Yes |
|North Tees and Hartlepool NHS Foundation Trust |47 |22 |1 |Yes |Yes |
|Northampton General Hospital |22 |28 |3 |- |- |
|Northern Devon Healthcare NHS Trust |22 |29 |2 |Yes |- |
|Northern Lincolnshire and Goole NHS |0 |37 |5 |- |- |
|Foundation Trust | | | | | |
|Northumbria Healthcare NHS Foundation Trust |18 |33 |- |- |Yes |
|Our Lady's Hospital Navan |2 |1 |- |Yes |Yes |
|Oxford University Hospitals NHS Foundation Trust |42 | |- |Yes |- |
|Peterborough and Stamford Hospitals NHS |28 |29 |- |Yes |Yes |
|Foundation Trust | | | | | |
|Poole Hospital NHS Foundation Trust |27 |24 |- |Yes |- |
|Prince Charles Hospital |17 |14 |1 |Yes |Yes |
|Prince Philip Hospital |15 |14 |2 |Yes |Yes |
|Princess Alexandra Hospital |16 |16 |- |- |- |
|Princess Royal University Hospital Farnborough |24 | |- |Yes |Yes |
|Queen Alexandra Hospital |42 |34 |2 |Yes |Yes |
|Queen Elizabeth Hospital Birmingham |66 |48 |- |Yes |- |
|Queen Elizabeth Hospital Gateshead |25 |25 |- |Yes |- |
|Queen Elizabeth Hospital Woolwich |20 |19 |4 |Yes |- |
|Queen Elizabeth The Queen Mother Hospital |4 |7 |- |Yes |- |
|Queen's Hospital Burton |6 |11 |1 |Yes |Yes |
|Queen's Hospital Romford |27 |37 |3 |- |- |
|Raigmore Hospital |13 | |- |Yes |- |
|Royal Berkshire Hospital |34 |41 |- |Yes |- |
|Royal Bolton Hospital |33 |26 |4 |Yes |Yes |
|Royal Cornwall Hospital |32 |39 |2 |- |Yes |
|Royal Derby Hospital |57 |40 |- |Yes |Yes |
|Royal Devon and Exeter NHS Foundation Trust |45 |38 |2 |Yes |Yes |
|Royal Glamorgan Hospital |8 |2 |- |Yes |- |
|Royal Gwent Hospital |18 |8 |2 |Yes |Yes |
|Royal Hampshire County Hospital |13 |16 |- |Yes |- |
|Royal Lancaster Infirmary |14 |15 |- |Yes |Yes |
|Royal Marsden Hospital Chelsea |4 | |- |Yes |- |
|Royal Marsden Hospital Sutton |44 |34 |- |Yes |Yes |
|Royal Stoke University Hospital |49 |54 |1 |Yes |Yes |
|Royal Surrey County Hospital |17 |32 |- |Yes |Yes |
|Royal Sussex County Hospital |0 |16 |- |- |- |
|Royal United Hospital |34 |33 |1 |Yes |Yes |
|Salford Royal NHS Foundation Trust |25 |24 |1 |Yes |Yes |
|Salisbury NHS Foundation Trust |24 | |- |Yes |Yes |
|Sandwell General Hospital |29 |35 |- |Yes |Yes |
|Scarborough General Hospital |17 |9 |- |Yes |Yes |
|Sherwood Forest Hospitals NHS Foundation Trust |34 | |- |Yes |- |
|Singleton Hospital |29 | |- |- |- |
|South Tees Hospitals NHS Foundation Trust |40 |35 |- |Yes |- |
|South Tyneside District Hospital |7 |9 |- |- |Yes |
|South Warwickshire NHS Foundation Trust |27 |32 |- |Yes |Yes |
|Southend University Hospital NHS Foundation Trust |0 |38 |2 |- |- |
|Southport and Ormskirk Hospital NHS Trust |33 |33 |6 |Yes |- |
|St. George's Hospital |29 |27 |- |Yes |Yes |
|St. Helens and Knowsley Teaching Hospitals |36 |33 |- |Yes |Yes |
|NHS Trust | | | | | |
|St. Helier Hospital |24 |12 |- |Yes |- |
|St. Mary's Hospital Isle of Wight |8 |11 |- |Yes |Yes |
|St. Peter's Hospital |22 |24 |- |Yes |- |
|St. Richard's Hospital |10 |21 |1 |Yes |Yes |
|St. Vincent's University Hospital Dublin |30 |37 |2 |Yes |- |
|Stockport NHS Foundation Trust |14 |11 |2 |Yes |Yes |
|Sunderland Royal Hospital |52 |42 |5 |- |Yes |
|Surrey and Sussex Healthcare NHS Trust |24 |21 |- |Yes |- |
|Tameside Hospital NHS Foundation Trust |11 |11 |3 |Yes |Yes |
|The Christie NHS Foundation Trust |49 |61 |- |Yes |Yes |
|The Dudley Group of Hospitals NHS Foundation Trust |39 |40 |- |Yes |Yes |
|The Great Western Hospital |35 |34 |2 |Yes |Yes |
|The Hillingdon Hospitals NHS Foundation Trust |27 |31 |1 |Yes |Yes |
|The Ipswich Hospital NHS Trust |37 |42 |1 |Yes |Yes |
|The Leeds Teaching Hospitals NHS Trust |55 |38 |2 |Yes |Yes |
|The London Clinic |9 |10 |- |- |- |
|The Mid Yorkshire Hospitals NHS Trust |40 |48 |- |Yes |Yes |
|The Newcastle upon Tyne Hospitals NHS |53 |53 |- |Yes |- |
|Foundation Trust | | | | | |
|The Pennine Acute Hospitals NHS Trust |33 |12 |- |Yes |- |
|The Queen Elizabeth Hospital Kings Lynn |0 |33 |1 |- |- |
|NHS Foundation Trust | | | | | |
|The Rotherham NHS Foundation Trust |29 |27 |- |Yes |Yes |
|The Royal Bournemouth Hospital |34 |42 |1 |Yes |Yes |
|The Royal Hallamshire Hospital |58 | |- |Yes |Yes |
|The Royal Liverpool and Broadgreen University |55 |2 |- |Yes |- |
|Hospitals NHS Trust | | | | | |
|The Royal Wolverhampton Hospitals NHS Trust |48 |45 |- |Yes |Yes |
|The Shrewsbury and Telford Hospital NHS Trust |26 |36 |1 |Yes |Yes |
|The Whittington Hospital NHS Trust |7 |4 |- |Yes |Yes |
|The York Hospital |27 |24 |1 |Yes |Yes |
|Torbay and South Devon NHS Foundation Trust |23 |29 |2 |Yes |- |
|United Lincolnshire Hospitals NHS Trust |39 | |- |Yes |Yes |
|University College London Hospitals NHS |34 |42 |- |Yes |Yes |
|Foundation Trust | | | | | |
|University Hospital Aintree |22 |34 |6 |Yes |Yes |
|University Hospital Ayr |0 |13 |2 |- |Yes |
|University Hospital Lewisham |6 |17 |- |Yes |- |
|University Hospital Llandough |20 |16 |- |Yes |Yes |
|University Hospital of North Durham |24 |22 |- |Yes |Yes |
|University Hospital of South Manchester NHS |14 |11 |1 |Yes |Yes |
|Foundation Trust | | | | | |
|University Hospital of Wales |40 |37 |3 |Yes |Yes |
|University Hospital Southampton NHS |46 |50 |3 |- |Yes |
|Foundation Trust | | | | | |
|University Hospitals Bristol NHS Foundation Trust |43 |58 |8 |Yes |- |
|University Hospitals Coventry and |29 |44 |- |Yes |- |
|Warwickshire NHS Trust | | | | | |
|University Hospitals of Leicester NHS Trust |35 |37 |2 |Yes |- |
|Walsall Healthcare NHS Trust |17 |21 |3 |Yes |- |
|Warrington and Halton Hospitals NHS |27 |23 |- |Yes |Yes |
|Foundation Trust | | | | | |
|West Hertfordshire Hospitals NHS Trust |30 |41 |7 |Yes |Yes |
|West Middlesex University Hospital |19 |16 |4 |Yes |Yes |
|West Suffolk NHS Foundation Trust |22 |17 |- |Yes |Yes |
|Westmorland General Hospital |3 |6 |- |Yes |Yes |
|Weston Area Health NHS Trust |7 | |- |Yes |- |
|Wexham Park Hospital |27 |35 |- |Yes |Yes |
|William Harvey Hospital |5 |11 |1 |Yes |- |
|Wirral University Teaching Hospital NHS |37 | |- |- |- |
|Foundation Trust | | | | | |
|Withybush General Hospital |20 | |- |Yes |- |
|Worcestershire Acute Hospitals NHS Trust |48 |34 |2 |Yes |- |
|Worthing Hospital |9 |18 |3 |Yes |Yes |
|Wrightington, Wigan and Leigh NHS Foundation Trust |22 |30 |8 |Yes |- |
|Wye Valley NHS Trust |19 |23 |1 |Yes |Yes |
|Yeovil District Hospital |20 |14 |- |Yes |Yes |
*We received data from 4296 patients. We removed 198 patient records because of: duplication (5), no red cell or platelet transfusion (2), no data other than episode number (52) or found to be ineligible during the data cleaning process (139). This provided 4098 patient records for analysis
Appendix F– Comparative results for the 148 sites participating in both rounds of the audit
There were 170 sites that participated in the first round of the clinical audit and 153 that participated in the second round. There were 148 sites that participated in both rounds. The results for the 170 sites in round one and the results for the 153 sites in round two provide the best national results at the time each audit was conducted. The main part of this report focuses on the overall results in the current round of audit but occasionally does make temporal comparisons by reporting the overall results from both previous rounds. A more precise assessment of temporal change between the 2016 and 2017 audit rounds will come from selecting only those sites participating in both rounds and a selection of such results are shown in this appendix. The results here support the overall comparisons and interpretations made in the main body of the report and in the executive summary.
| | |2016 Audit |2017 Audit | |
|Cases | |4096 | |3961 | |
|Red cell transfusions | |3833 | |3694 | |
|Platelet transfusions | |1528 | |1516 | |
|Age |Median (IQR) |72 |(64-80) |73 |63-81 |
|Gender |% Female |40% |1628/4092 |41% |1604/3960 |
|Weight |% known |70% |2868 |69% |2736 |
| |% Weighttwo units |9% |110/1267 |6% |68/1187 | |
|Number of transfusions (day cases) |% single unit |13% |335/2544 |24% |595/2497 | |
| |% two units |74% |1888/2544 |67% |1680/2497 | |
| |% >two units |13% |321/2544 |9% |222/2497 | |
|On Chronic transfusion programme: |% single unit |11% |113/1010 |20% |250/1236 | |
|Number of transfusions (Inpatients) |% single unit |24% |21/87 |35% |37/107 | |
|Number of transfusions (day cases) |% single unit |10% |92/917 |19% |213/1127 | |
| | | | | | | |
|Weighing ................
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