Faculty Bibliography

Background/Case Studies: Because platelet usage is driven by the types of services offered and the diagnoses treated in a given hospital, benchmarking usage is hard. Although single-donor platelet (SDP) transfusion (TXN) numbers are small, SDPs are a major cost. In 2Q10, new TXN triggers were introduced in the hospital's CPOE system, and the blood bank initiated prospective (PST) auditing of SDP orders. All SDP orders including a numeric platelet count (PLTC) as a part of the TXN trigger underwent PST audit, and SDPs were not issued if the most recent PLTC did not satisfy the selected trigger. A post-TXN PLTC was required prior to the release of a 2nd SDP unit in a non-rapidly bleeding patient. In 2011, we first evaluated the impact of the changes and noted that many orders were placed by using "other" as the TXN trigger. In 3Q13, PST auditing was expanded to include the reason provided when placing an order using "other" as the TXN trigger. In 2014, we sought to evaluate the impact of PST auditing and the expansion to include "other" orders on SDP usage. Study Design/Methods: The number of SDPs transfused from 1Q07 through 1Q10 was compared to SDP usage from 2Q10 through 3Q12. The results were then compared to SDP usage from 3Q13 through 1Q14. 4Q12 through 2Q13 were excluded because of the impact of Hurricane Sandy. The results were analyzed by using the Student's T-test. Results/Findings: From 1Q07 to 1Q10, a mean of 555.9 SDPs (range 393-801) were transfused per quarter. From 2Q10 to 3Q12, a mean of 450 SDPs (range 370-557) were transfused per quarter. From 3Q13 to 1Q14, a mean of 363.7 SDPs were transfused per quarter. PST auditing of the PLTC alone significantly decreased mean usage by 105.2 units per quarter (P value 0.041) and reduced spending by $55,756 per quarter (assuming a mean SDP cost of $530 per unit). Although not statistically significant, the addition of PST auditing of "other" orders further decreased mean usage by 87 units per quarter (P value 0.098) and provided a mean addi!

Background/Case Studies: Roughly 25% of the 15 million RBC transfusions (TXN) in the United States are medically unnecessary. Many studies have demonstrated the safety of using lower hemoglobin (Hgb) TXN thresholds. In 2010, our hospital adopted more restrictive RBC TXN triggers and began prospective auditing of orders, which specified a particular Hgb level, to minimize unnecessary RBC TXN. The adult triggers were A) Hgb <7 g/dl and symptomatic anemia, B) Hgb <9 g/dl with significant cardiac, neurological, or respiratory disease, C) Blood loss >20% refractory to fluid resuscitation, D) Pre-op for major surgery with anticipated blood loss >1000 ml and Hgb <7 g/dl, and E) "Other." Education was part of the roll-out of the new triggers and auditing process. In 2011, we saw an 8.7% reduction but discovered that 25% of all RBC orders were placed on the basis of "Other," likely to avoid prospective auditing. In 2013, we began prospectively evaluating the "Other" orders in addition to those placed using triggers A and B. In 2014, we evaluated the impact of this addition of prospective auditing of "Other" orders to determine whether it led to a further decrease in RBC TXN. Study Design/Methods: The number of RBC units and patients transfused from 1Q12 to 3Q12 was compared to the number transfused from 3Q13 to 1Q14. 4Q12 through 2Q13 were excluded due to the impact of Hurricane Sandy. The results were analyzed by using the Student's T-test. Results/ Findings: From 1Q12 to 3Q12, a mean of 692 patients (range 621-829) were transfused a mean of 1901 (range 1854-1950) RBC units per quarter. From 3Q13 to 1Q14, a mean of 681 patients (range 615-740) were transfused a mean of 1483 (range 1392-1566) RBC units per quarter. Although the number of patients transfused did not differ between the two time periods, there was a statistically significant reduction (mean 418 units) in the number of RBC units transfused (P value 0.002) per quarter (Table). The reduction led to a savings of $96,976 (mean RBC cost of $232 !

Background/Case Studies: Patients on vitamin K antagonist (VKA) anticoagulants such as warfarin have reduced levels of functional coagulation factors II, VII, IX, and X. Although highly efficient at reducing the risk of thrombosis, these drugs are associated with an increased risk of bleeding. The warfarin-related bleeding can be catastrophic, but it is reversible. The factors can be slowly replenished by administering vitamin K or more rapidly replenished by plasma transfusion and/or prothrombin complex concentrates (PCCs) infusion. In 2008, we began stocking Bebulin, a three-factor PCC, as an off-label option for rapid reversal of VKA. Because of the high cost and the risk of thrombotic events, each clinical service was required to submit guidelines for appropriate use of PCCs in 2010. Once Kcentra, a four-factor PCC, received FDA approval for urgent VKA reversal in 2013, both Bebulin and Kcentra were stocked by the blood bank. We sought to evaluate the impact of adding Kcentra on our institution's use of PCCs. Study Design/Methods: Bebulin and Kcentra usage from 1/1/12 to 4/20/14 was analyzed. The specific derivative orders, indications, and clinical cases were reviewed as part of quality assurance. Bebulin was administered at a dose of 40 IU/per kg, and Kcentra was dosed as per the manufacturer's package insert. Use of Bebulin also required the transfusion of 2 units of plasma to provide factor VII The de-identified tabulated data were analyzed. Results/Findings: Forty-four patients received Bebulin, and three patients received Kcentra. The mean doses of Bebulin and Kcentra were 3288.4 IU and 1600 IU, respectively. The mean INR before infusion was 3.57 for Bebulin and 3.11 for Kcentra. The mean IRN after infusion was 1.66 for Bebulin and 1.26 for Kcentra. Bebulin was used nine times outside of the approved clinical service guidelines. Bebulin administration did not prevent the death of 12 (27.3%) patients. Only 1 patient who received Bebulin had CT evidence of a thrombotic event. The mean c!

Background/Case Studies: Wastage of group AB plasma is a problem for Level I trauma centers. To ensure the 1:1:1 (RBC : plasma : platelet) MTP ratio, plasmas must be kept liquid. In an attempt to reduce expiration and transfusion of group AB plasma to non-AB patients, our MTP called for only 2 units of group AB to be kept thawed. Group AB units not used within 4 d are issued to other patients requiring plasma. On January 1, 2014, our blood supplier began offering group A plasma with low-titer anti-B (<1:100) as an alternative to group AB plasma. After receiving approval from the hospital transfusion committee, we began stocking group A plasma with low-titer anti-B (low-titer A plasma) to try to reduce our wastage of group AB plasma. Study Design/Methods: The implementation process and usage of low-titer A plasma was evaluated from March 15, 2014 to April 30, 2014. The number of units thawed and used was tabulated, and the recipients' clinical information was assessed, as part of routine QA, via the EMR. Results/Findings: Although the substitution of low-titer A plasma appears easy, in practice it was challenging. HCLL Transfusion (the browser-based blood bank software system) cannot differentiate the low-titer A units from regular type A plasmas. No field exists within which to scan and capture the titer information. Our HCLL truth tables only permit AB plasma to be issued until 2 ABO types are resulted even using the emergency release function. HCLL permits a given unit of plasma to be thawed only once, and thus a unit cannot first be labeled as FP24 or FFP and then, after 24 h, be relabeled as thawed plasma. New procedures needed to be created. By using an ISBT label-duplication program, a thawed unit can first be labeled outside of HCLL as PF24 or FFP and then later labeled via HCLL as thawed plasma. The ISBT labelduplication program is also able to read the additional titer barcode label. Until a patient has 2 ABO types resulted, the low-titer A plasmas must be issued manually and then late!

BACKGROUND: Testing of platelets (PLTs) for bacterial contamination is required by the AABB Standards but is not fully standardized. On January 31, 2011, a new AABB Standard, 5.1.5.1.1, specified that bacterial detection methods for PLT components shall use assays either approved by the Food and Drug Administration (FDA) or validated to provide sensitivity equivalent to these FDA-approved methods. METHODS: An Internet-based survey of AABB member institutions was conducted from May to June 2012, to document current practices used in 2011 for bacterial detection in different PLT products and to assess the impact of the new standard. RESULTS: Of 1053 AABB member institutions surveyed, 40 of 99 blood centers (40.4%) and 184 of 954 hospital blood banks or transfusion services (19.3%) responded. Sixty-four respondents manufactured PLTs. Apheresis PLTs (APs) were predominantly screened with the BacT/ALERT system (89.5%); the majority (95.2%) were cultured with at least 8 mL of product. There was substantial variation in the minimum incubation time of cultures before release of PLTs (range, 0 to >24 hr). Recalls of released AP for possible bacterial contamination were largely successful (67.3%); successful interdiction before transfusion was associated with incubation for more than 12 hours before release (p < 0.01). After Standard 5.1.5.1.1 took effect, there was a decrease in production of whole blood-derived PLT concentrates (WBPCs). Point-of-issue ("rapid") immunoassays were used to screen a substantial proportion of WBPC PLTs, but were rarely used as secondary tests for previously cultured APs. CONCLUSION: The survey identified variability in culture methods and release times with AP, while use of WBPC decreased after AABB Standard 5.1.5.1.1 became effective.