Loyola University Medical Center, Illinois, United States
Background/Case Studies: Only a small proportion of platelet refractoriness can be attributed to immune mediated mechanisms such as HLA antibodies. The workup for evaluating immune mediated refractoriness requires a 1-hour post-transfusion platelet count and evaluation for HLA antibodies by a panel reactive antigen (PRA) assay with antibody identification based on a positive result for class I HLA on PRA. At our institution, post-transfusion platelet counts were not regularly obtained and many clinicians order either crossmatched (XM) or HLA matched (HLA) platelets prior to completing an appropriate workup. A grand rounds presentation was provided to the Hematology/Oncology Department regarding platelet refractoriness, appropriate workup, cost and challenges to obtain HLA or XM platelets, and an algorithm developed by the Transfusion Medicine Service. The objective of this study was to determine the effectiveness of the education in changing ordering practices, refractoriness workups, and wastage of HLA and XM platelets.
Study
Design/Methods: Grand rounds presented August 25, 2023. Platelet orders from January 2023 to February 2024 were sorted for HLA and XM platelet orders, which were reviewed for appropriateness based on Class I PRA of >70%. Utilization of post-transfusion platelet counts and their timing after completion of the platelet transfusion were evaluated. Finally, wastage was determined based on ordered HLA and XM platelets and allocation to patient other than the intended patient from January 2023 to April 2024. All data was analyzed using R Studio and SPSS (one-tailed t-test).
Results/Findings: Upon review of the workup for HLA and XM platelet orders, PRAs were ordered for almost all HLA platelet orders, but only half of XM platelet orders. Order appropriateness occurred in the majority of HLA platelet orders, but in less than 20% of XM platelet orders. Post-transfusion platelet counts performed in approximately 25% of all HLA and XM platelet orders. The impact of grand rounds showed only a relative slight decrease in HLA platelet orders, but no change or decrease in PRAs and post-transfusion platelet counts within 1 hour (see Table 1). Platelet wastage was significantly decreased from 19%±12.1% before and 10.2%±6.3% after grand rounds (p=0.045). Conclusions: There was no improvement in ordering practices. A relative decrease in HLA platelet orders was seen, but inappropriate orders were unchanged. Wastage of HLA and XM platelets decreased significantly since the education occurred, but was likely related to interactions between blood bank and the hematology/oncology nurses. There seems to be a lack of understanding on XM platelet utilization. Ultimately, education is needed for non-hematology/oncology clinicians where HLA and XM platelets are concerned as they likely more involved in ordering.
