Appropriate or not?
Matthew Etchells appreciates better than most the advantages of electronic health records. To collect data for his research project, he has to dig into patient charts to find out why a platelet transfusion was ordered. “It definitely helps my job when everything is put into electronic format,” he says.
Etchells is working with Dr. Jeannie Callum as part of the D+H SRI Summer Student Research Program. Callum is a transfusion specialist and an associate scientist in the Trauma, Emergency & Critical Care Research Program at Sunnybrook Research Institute (SRI) whose work focuses on improving transfusion practices within the hospital setting. Last summer she led an audit of red blood cell transfusions in 10 hospitals across Ontario to determine whether the procedure was being used appropriately. Etchells is extending that work by undertaking a pilot study of platelet transfusions at four academic hospitals in Toronto—Sunnybrook, Toronto General, Toronto Western and Princess Margaret.
For every unit of blood donated—480 millilitres (mL) or just under two cups—over half is made up of red blood cells, which deliver oxygen to the tissues. Platelets are one of the less abundant components of blood, comprising just 70 mL of each unit. These cellular fragments help stop bleeding by gathering at the site of an injury and forming a surface that allows blood to clot and coagulate. Unlike red blood cells that can be kept for 35 to 42 days in the refrigerator, platelets can only be stored at room temperature, an optimal setting for bacterial growth that limits platelet shelf life to just five days. As a result platelets are often in short supply at many hospitals, making their appropriate use a significant concern for clinicians.
As part of the pilot study, Etchells is examining records for 50 platelet transfusions from each hospital. For each procedure, he collects patient- and transfusion-related data such as the patient’s diagnosis, medications and laboratory results. The information is then passed on to Callum and fellow transfusion specialist Dr. Yulia Lin for evaluation. Based on a criterion that they developed specifically for platelet transfusions, Callum and Lin determine whether or not each procedure was appropriate. “With that data we can look at where the inappropriate transfusions tend to happen,” says Etchells, who will be starting his second year at McGill University in the fall. This knowledge will allow the researchers to identify medical specialties and departments that might benefit from better education on platelet transfusion.
The results of this study will also help guide the design and implementation of a province-wide audit of platelet transfusion practices in Ontario, the first such survey in Canada. “The goal is to improve transfusion practice,” says Etchells. “It could be reducing wastage. There are also concerns about patient safety.” Because platelets are stored at room temperature, they are more susceptible to bacterial contamination than other blood products. “There’s an increased risk of giving patients a bacterial infection through the transfusion of platelets versus other blood products because of the room temperature storage,” he says. “You always have to ask yourself, is this necessary? Because there are risks and costs associated with it.”
A 2007 audit of 187 hospitals in the U.K. found that 43% of platelet transfusions were inappropriate. While he is still analyzing the data, Etchells is optimistic that the four hospitals he surveyed will have a higher rate of appropriate transfusions than that seen in the U.K. “This is the starting point,” he says. “It will give us an idea of where we are compared to other hospitals and other countries.”
Matthew Etchells received a D+H Summer Studentship Award.
