Art & science
If you would like to contribute to the Art & science section, email [email protected] or @NSclinicalEd
The synthesis of art and science is lived by the nurse in the nursing act
Josephine G Paterson
Developing nursing practice in platelet transfusions McSporran W, Watson D (2014) Developing nursing practice in platelet transfusions. Nursing Standard. 29, 11, 35-39. Date of submission: February 27 2014; date of acceptance: September 1 2014.
Abstract The number of platelet transfusions has risen steadily over the past five years. This article addresses some of the reasons for this increase and examines current transfusion practice in relation to findings of national audits of platelet use and current research. It explores the extended role of the nurse in platelet transfusions, including nurse authorisation, and presents an overview of education material available to inform practice and to ensure judicious use of platelet transfusions with maximum benefit for the patient.
Authors Wendy McSporran Transfusion practitioner, The Royal Marsden Hospital NHS Foundation Trust, London. Denise Watson Regional lead, patient blood management team, NHS Blood and Transplant, Newcastle. Correspondence to: [email protected]
Keywords Blood component transfusion, clinical audit, educational resources, haematology, nurse authorisation, platelet transfusion, professional, education, prophylactic transfusion, thrombocytopaenia
Review All articles are subject to external double-blind peer review and checked for plagiarism using automated software.
Online For related articles visit the archive and search using the keywords above. Guidelines on writing for publication are available at: rcnpublishing.com/r/author-guidelines
THE NUMBER OF PLATELET transfusions performed in the UK has been steadily rising in recent years. In 2001-02, total issues of platelet packs from the transfusion services of the UK numbered 251,451 (Serious Hazards of Transfusion (SHOT) 2003) and remained at this level until 2008. In 2012, 311,737 platelet packs were issued to hospitals, a 21% increase since 2008 (Taylor et al 2009, Bolton-Maggs et al 2013). This article considers factors contributing to this rise in demand and indicates why it may be a cause for concern, necessitating more judicious transfusion practice. It outlines reasons for administering a platelet transfusion and addresses different ways nurses can help shape future transfusion practice and improve patient care.
Platelet transfusions Platelets are formed from megakaryocytes in the bone marrow. They are essential for clot formation and maintaining haemostasis. When, as a result of injury, platelets come into contact with tissue other than the intact lining of blood vessel walls, they become activated, and aggregate to form a plug. This plug forms an initial seal, and in turn activates coagulation factors to form a stable clot. Some treatments, such as chemotherapy, cause decreased platelet production, which is known as thrombocytopaenia. Some drugs, such as aspirin and clopidogrel, impede platelet function; so despite the presence of a healthy number of circulating platelets, the platelets do not function effectively. Platelets are given to patients either to stop active bleeding (therapeutic transfusion) or to try to prevent future bleeding (prophylactic transfusion).
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Art & science haematology Judicious use of prophylactic transfusions
Platelets are a limited resource. One concern about their increasing use is the ability of NHS Blood and Transplant (NHSBT) to fulfil increased requests and keep up with demand by recruiting more donors. Platelets may be collected via apheresis (a procedure in which blood is temporarily withdrawn, components are selectively removed and the rest of the blood is reinfused) from a single donor, or by pooling platelets from four separate whole blood donations. Collection by apheresis minimises the potential infection risk to the patient, since the patient is exposed to one donor only. Apheresis procedures take around 90 minutes, requiring dedication and commitment from donors. Platelets are therefore a precious resource, and healthcare professionals should ensure they are used judiciously.
Factors underlying increased demand
Several factors have contributed to an increased demand for platelet transfusions, including: the ageing population, new approaches to medical care, and advances in treatments that result in patients with thrombocytopaenia. Large-scale national audits of platelet use took place in 2007 and 2010 (Qureshi et al 2007, National Comparative Audit of Blood Transfusion 2011). Both audits investigated the use of platelet transfusions according to national guidelines (British Committee for Standards in Haematology, Blood Transfusion Task Force (BCSH) 2003). The BCSH recommendations give thresholds for platelet transfusion for routine prophylactic use; prophylactic use in the presence of risk factors for bleeding such as sepsis, antibiotic treatment and abnormalities of haemostasis; prophylactic use pre-procedure such as lumbar puncture and for therapeutic transfusion. The first audit, in 2007, looked at 4,421 platelet transfusions across a range of specialties and concluded that 43% did not comply with audit standards based on the national guidelines (Qureshi et al 2007). One criticism of the 2007 audit raised by clinicians was that not all possible clinical indications and factors for a transfusion were taken into consideration before deeming the transfusion inappropriate. In the 2010 audit when 3,293 cases were examined in haematology patients, additional reasons for transfusion were included. This audit allowed for factors such as platelets due for expiry and the setting of an individualised threshold for treatment by the clinician, providing this was documented in the patient’s records. Nonetheless, 28% of transfusions still fell outside national guidelines, and the particular area of concern highlighted
in the audits was prophylactic use (National Comparative Audit of Platelet Transfusions 2010). Important findings from these audits where the transfusion was considered outside guidelines included. Platelets were transfused before a bone marrow aspiration or trephine biopsy. Platelets were transfused to patients who were stable (no evidence of bleeding) with long-term bone marrow failure, such as myelodysplasia. Two platelet packs were administered in one episode – ‘double dosing’. A bag of platelets is often referred to as a ‘pool’ in reference to the collection method (four adult donations pooled into one bag) or as a ‘pack’ of platelets. One pack of platelets is one adult therapeutic dose (ATD), regardless of whether it is a pooled pack or an apheresis pack. Administering two adult therapeutic doses in quick succession accounted for 10% of prophylactic transfusions. A large randomised controlled trial showed that doubling the number of platelet packs had no effect on a patient’s risk of bleeding (Slichter et al 2010).
Patient benefits of limiting prophylactic transfusions
One benefit of limiting prophylactic platelet transfusions is reducing exposure to transfusion-transmitted infections. Limiting prophylactic platelet transfusions also reduces the risk of adverse transfusion reactions. Allergic reactions are more common with platelet transfusions than with red cell transfusions; the incidence of cutaneous reactions for plasma-containing blood components is 1-3% (Taylor et al 2008). The risk of bacterial sepsis from contamination of the platelet pack during collection is a rare but serious risk reported to the SHOT scheme, with 11 deaths reported to SHOT since reporting commenced in 1996 (Bolton-Maggs et al 2013). Unlike red cells, platelets have to be stored at room temperature (20-24°C), so bacteria have the opportunity to continue to grow if the pack has been contaminated. Since May 2011, a sample from all platelet donations is cultured to detect any bacterial contamination and this has allowed the NHSBT to extend the shelf life of platelet transfusions from five to seven days (MacLennan and Murphy 2011). A more subtle reason to avoid unnecessary transfusions is that each transfusion can affect the effectiveness of subsequent transfusions. Multiple transfusions can lead a patient to make antibodies against antigens present on transfused platelets, or alloimmunisation. These antibodies can cause the destruction of any platelets
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transfused in future and subsequent failure to observe an incremental platelet rise following transfusion. Even where antibodies are not detected following the first transfusion, there is evidence to suggest that the incremental platelet rise will be lower on subsequent transfusions, resulting in reduced benefit from later transfusions (Slichter et al 2005).
Assessing the effect of prophylactic transfused platelets
The Trial of Prophylactic PlateletS (TOPPS) examined the benefit of prophylactic transfusions versus no prophylactic transfusions in patients with haematological malignancies (Stanworth et al 2013). Six hundred patients were randomised to receive either a prophylactic transfusion if the platelet count fell below 10x109/L, or no prophylactic transfusion and transfusion only when a bleeding episode occurred. Patients were monitored for clinically significant bleeding using the World Health Organization (WHO) (1979) classification for bleeding, with clinically significant bleeding being grade 2 or above (Table 1). The overall rate of bleeding was reduced in the prophylactic group, and the study concluded that prophylactic transfusions are required in patients with thrombocytopaenia. The rate of WHO grade 2-4 bleeding in patients who had prophylactic transfusions was 43%, compared with 50% in the no prophylaxis group. The majority of patients with bleeding had grade 2 bleeding. Only seven patients had grade 3 or 4 bleeds, and of these only two had a platelet count below 10x109/L at the onset of grade 3 or 4 bleeding. The authors concluded that the platelet level is not the sole risk factor for major bleeds. They proposed that further studies are required to increase knowledge of the risk factors for major bleeds, and strategies are required to manage the high rates of bleeding observed even after prophylactic transfusion (Stanworth et al 2013).
Education in transfusion practice Nurses have an important role in the education of patients and colleagues. Educational resources developed by the NHSBT patient blood management team and other transfusion specialists are available. The team was established to ensure patients receive the best possible evidence-based transfusion care, and to promote the safe and appropriate use of blood components and their alternatives. The educational resources developed by the team are listed in Box 1. The patient blood management team has been involved in a series of ‘Let’s talk platelets’
workshops, which enabled the NHSBT and hospital users to discuss issues relating to platelets, ensuring good transfusion care for the patient. Delegates discussed platelet stock management within hospitals, issue and wastage data, appropriate usage, empowerment of biomedical scientists to offer advice and challenge requests, and the timing of routine and ad hoc deliveries. Exploring every opportunity to use platelets appropriately and ensuring good stock management minimises the possibility of shortages and ensures that all patients can have a transfusion when required. A national platelet working group, formed after the audits, produced a number of additional resources (Box 2). Some of this work by the patient blood management teams is starting to take effect, as demand appears to be increasing at a much lower rate than in previous years.
TABLE 1 Classification for bleeding Grade
Description
Grade 0
No bleeding.
Grade 1
Petechial bleeding.
Grade 2
Mild blood loss, clinically significant.
Grade 3
Gross blood loss, required transfusion.
Grade 4
Debilitating blood loss, retinal or cerebral, associated with fatality.
(World Health Organization 1979)
BOX 1 NHS Blood and Transplant (NHSBT) patient blood management team educational resources ‘HLA (human leukocyte antigen) matched platelets’ poster: Information for healthcare professionals on why a post-transfusion platelet count is necessary following an HLA-matched platelet transfusion, when the blood sample should be taken, and why it is necessary for the NHSBT to be informed. ‘Transfusion of platelets across blood groups’ poster: Alternatives to the first choice ABO blood group and Rh blood group, D antigen (RhD) identical platelets are identified to maximise use and minimise wastage. ‘Don’t use two… when one will do’ poster: Information on helping to reduce the use of double-dose platelets for prophylactic transfusions. Transfusion Matters ninth edition: A newsletter that focuses on the safe and appropriate use of platelets. Platelet transfusion mobile site: The site works in a similar way to an app, and has been designed to give quick and easy access to the national guidelines on platelet transfusion. It is designed specifically for smartphones and tablets, so it can be accessed wherever needed (http://goo.gl/PHnpVH). (NHSBT 2014)
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Art & science haematology BOX 2 National platelet working group educational resources PowerPoint presentation ‘Platelet transfusion – scope to improve practice’: Provides facts and figures for healthcare professionals and assists hospital transfusion practitioners to raise awareness within their local trusts. ‘Platelet transfusion: principles, risks, alternatives and best practice’: A factsheet for doctors and senior nurses, based on national and international guidance. (NHS Blood and Transplant 2014)
Nursing role Nurses have an important role in good transfusion practice and should stay well informed by attending face-to-face updates on blood transfusions provided in-house, or by working through the available e-learning packages, depending on their local trust policy. Such practice updates alert nurses to current issues and changes to guidelines, and encourages them to reflect on their practice. The nurse can inform the patient of the need for the transfusion, explain the alternatives available and, in some trusts, gain informed valid consent from the patient, once trained and competent to do so. Nurses are the patient’s advocate and should question and seek clarification for a request for a platelet transfusion if they feel this may be inappropriate.
Nurses can influence the practice of prophylactic transfusions by educating patients and colleagues, and by becoming responsible for writing the instruction to transfuse through role development. A framework to support nurses and midwives in making the clinical decision and providing the written instruction for blood component transfusion was developed in 2009 (Pirie and Green 2009). The authors established the legality of nurse ‘prescribing’ for blood components, and the absence of barriers to extending the nurse’s role in this area. Blood components are excluded from the legal definition of medicinal products, so strictly speaking they cannot be ‘prescribed’ by any practitioner. The term ‘authorisation’ was therefore adopted as an alternative, and it was established that there is no legal barrier to nurses authorising a blood transfusion. Since the release of the framework, several hospitals have implemented nurse authorisation of blood component transfusions for specific groups of nurses, mainly for advanced nurse practitioners. The hospital policy must state which groups of staff are eligible to authorise blood component transfusions, how they are supported and what additional education is required. Nurse authorisation is an extended role for nurses, who should attend specific
References Bolton-Maggs P, Thomas D, Cohen H et al (2013) Annual SHOT Report 2012. www.shotuk. org/wp-content/uploads/ 2013/08/SHOT-Annual-Report2012.pdf (Last accessed: October 10 2014.) British Committee for Standards in Haematology, Blood Transfusion Task Force (2003) Guidelines for the use of platelet transfusions. British Journal of Haematology. 122, 1, 10-23.
MacLennan S, Murphy M (2011) Introduction of Bacterial Screening of Platelet Components: Information for Hospital Transfusion Teams. http://hospital.blood.co.uk/ media/1918/2f291133-4143-4 2b6-8705-11823fdb6f8d.pdf (Last accessed: October 10 2014.) National Comparative Audit of Platelet Transfusions (2010) Key Findings of the Audit with Regard to the Inappropriate Use of Platelet Transfusions. http:// hospital.blood.co.uk/media/26976/
key-findings.pdf (Last accessed: October 10 2014.) National Comparative Audit of Blood Transfusion (2011) 2010 Re-audit of the Use of Platelets in Haematology. http:// hospital.blood.co.uk/media/26866/ nca-platelet_re-audit_report-st_ elsewheres_nhs_foundation_ trust_2010.pdf (Last accessed: October 10 2014.) NHS Blood and Transplant (2014) Platelet Resources. http://hospital.
blood.co.uk/patient-services/ patient-blood-managementresources/platelet-resources (Last accessed: October 10 2014.) Pirie E, Green J (2010) A framework to support safe blood transfusion practice. Nursing Standard. 24, 48, 35-40. Qureshi H, Lowe D, Dobson P et al (2007) National comparative audit of the use of platelet transfusions in the UK. Transfusions Clinique et Biologique. 14, 6, 509-513.
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non-medical authorisation education and be assessed as competent by their clinical mentors before they can authorise a blood component transfusion. The education programmes available vary. In Wales, an accredited programme of education is available at graduate and postgraduate level at Swansea University (Shreeve and Benton 2013). The NHSBT also runs education programmes (http://hospital. blood.co.uk/training/programmes/ programme_diary/). A survey showed that, for nurse authorisation to be integrated effectively into healthcare practice, enough time – usually at least three months – was required to allow practitioners an opportunity to authorise blood component transfusions under supervision, and to complete their competency assessments (Watson 2013). When nurses are considered competent, they can assess their patient and organise their transfusions, which enables the care pathway to be much more streamlined. Patients are benefitting from nurses authorising blood components. Nurse authorisation gives nurses the ability to influence the practice of prophylactic platelet transfusions and increase judicious use of platelet transfusions. Future audits will illustrate how effectively this is achieved.
Serious Hazards of Transfusion (2003) Serious Hazards of Transfusion Annual Report 2001-2002. www.shotuk.org/ wp-content/uploads/2010/ 03/SHOT-Report-01-02.pdf (Last accessed: October 10 2014.) Shreeve K, Benton A (2013) All Wales Policy. Non-Medical Authorisation of Blood Component Transfusion. www.wales.nhs.uk/ sites3/documents/428/Joint%20 CMO%20CNO%20CPhO%20 Letter.pdf (Last accessed: October 10 2014.)
Conclusion The number of platelet transfusions has been steadily rising for the past five years. Platelets are a limited resource, requiring considerable commitment from donors, so more judicious use of platelets is required. The latest national audit has shown that 28% of platelet transfusions fell outside of the recommendations of the BCSH (2003) guidelines (National Comparative Audit of Platelet Transfusions 2010), and therefore may be unnecessary transfusions. This is of concern because platelet transfusions carry potential risks for the patient, including allergic reactions and bacterial sepsis. Using platelets judiciously has the potential to ensure patients are well supported for longer periods, because the effectiveness of subsequent transfusions is protected. Nurses have an important role in colleague and patient education, promoting the safe and effective use of platelet transfusions, acting as patient advocates and ensuring their practice is up-to-date. Some trusts have implemented nurse authorisation of blood components for transfusion, permitting nurses who have satisfactorily undertaken a non-medical authorisation education programme to assess patients and organise their transfusions in a streamlined process NS
Slichter SJ, Davis K, Enright H et al (2005) Factors affecting posttransfusion platelet increments, platelet refractoriness, and platelet transfusion intervals in thrombocytopenic patients. Blood. 105, 10, 4106-4114. Slichter SJ, Kaufmann RM, Assman SF et al (2010) Dose of prophylactic platelet transfusions and prevention of hemorrhage. The New England Journal of Medicine. 362, 7, 600-613.
Stanworth SJ, Estcoutr LJ, Powter G et al (2013) A no-prophylaxis platelet-transfusion strategy for hematologic cancers. The New England Journal of Medicine. 368, 19, 1771-1780. Taylor C, Navarrete C, Contreras M (2008) Immunological complications of blood transfusion. Transfusion Alternatives in Transfusion Medicine. 10, 3, 112-126. Taylor C, Cohen H, Mold D et al (2009) The 2008 Annual SHOT
Report. www.shotuk.org/ wp-content/uploads/ 2010/03/SHOT-Report2008.pdf (Last accessed: October 10 2014.) Watson D (2013) Implementing nurse authorisation of blood components. Blood and Transplant Matters. 39, 5-7. World Health Organization (1979) WHO Handbook for Reporting Results of Cancer Treatment. WHO, Geneva.
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If you would like to contribute to the Art & science section, email [email protected] or @NSclinicalEd
The synthesis of art and science is lived by the nurse in the nursing act
Josephine G Paterson
Developing nursing practice in platelet transfusions McSporran W, Watson D (2014) Developing nursing practice in platelet transfusions. Nursing Standard. 29, 11, 35-39. Date of submission: February 27 2014; date of acceptance: September 1 2014.
Abstract The number of platelet transfusions has risen steadily over the past five years. This article addresses some of the reasons for this increase and examines current transfusion practice in relation to findings of national audits of platelet use and current research. It explores the extended role of the nurse in platelet transfusions, including nurse authorisation, and presents an overview of education material available to inform practice and to ensure judicious use of platelet transfusions with maximum benefit for the patient.
Authors Wendy McSporran Transfusion practitioner, The Royal Marsden Hospital NHS Foundation Trust, London. Denise Watson Regional lead, patient blood management team, NHS Blood and Transplant, Newcastle. Correspondence to: [email protected]
Keywords Blood component transfusion, clinical audit, educational resources, haematology, nurse authorisation, platelet transfusion, professional, education, prophylactic transfusion, thrombocytopaenia
Review All articles are subject to external double-blind peer review and checked for plagiarism using automated software.
Online For related articles visit the archive and search using the keywords above. Guidelines on writing for publication are available at: rcnpublishing.com/r/author-guidelines
THE NUMBER OF PLATELET transfusions performed in the UK has been steadily rising in recent years. In 2001-02, total issues of platelet packs from the transfusion services of the UK numbered 251,451 (Serious Hazards of Transfusion (SHOT) 2003) and remained at this level until 2008. In 2012, 311,737 platelet packs were issued to hospitals, a 21% increase since 2008 (Taylor et al 2009, Bolton-Maggs et al 2013). This article considers factors contributing to this rise in demand and indicates why it may be a cause for concern, necessitating more judicious transfusion practice. It outlines reasons for administering a platelet transfusion and addresses different ways nurses can help shape future transfusion practice and improve patient care.
Platelet transfusions Platelets are formed from megakaryocytes in the bone marrow. They are essential for clot formation and maintaining haemostasis. When, as a result of injury, platelets come into contact with tissue other than the intact lining of blood vessel walls, they become activated, and aggregate to form a plug. This plug forms an initial seal, and in turn activates coagulation factors to form a stable clot. Some treatments, such as chemotherapy, cause decreased platelet production, which is known as thrombocytopaenia. Some drugs, such as aspirin and clopidogrel, impede platelet function; so despite the presence of a healthy number of circulating platelets, the platelets do not function effectively. Platelets are given to patients either to stop active bleeding (therapeutic transfusion) or to try to prevent future bleeding (prophylactic transfusion).
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Art & science haematology Judicious use of prophylactic transfusions
Platelets are a limited resource. One concern about their increasing use is the ability of NHS Blood and Transplant (NHSBT) to fulfil increased requests and keep up with demand by recruiting more donors. Platelets may be collected via apheresis (a procedure in which blood is temporarily withdrawn, components are selectively removed and the rest of the blood is reinfused) from a single donor, or by pooling platelets from four separate whole blood donations. Collection by apheresis minimises the potential infection risk to the patient, since the patient is exposed to one donor only. Apheresis procedures take around 90 minutes, requiring dedication and commitment from donors. Platelets are therefore a precious resource, and healthcare professionals should ensure they are used judiciously.
Factors underlying increased demand
Several factors have contributed to an increased demand for platelet transfusions, including: the ageing population, new approaches to medical care, and advances in treatments that result in patients with thrombocytopaenia. Large-scale national audits of platelet use took place in 2007 and 2010 (Qureshi et al 2007, National Comparative Audit of Blood Transfusion 2011). Both audits investigated the use of platelet transfusions according to national guidelines (British Committee for Standards in Haematology, Blood Transfusion Task Force (BCSH) 2003). The BCSH recommendations give thresholds for platelet transfusion for routine prophylactic use; prophylactic use in the presence of risk factors for bleeding such as sepsis, antibiotic treatment and abnormalities of haemostasis; prophylactic use pre-procedure such as lumbar puncture and for therapeutic transfusion. The first audit, in 2007, looked at 4,421 platelet transfusions across a range of specialties and concluded that 43% did not comply with audit standards based on the national guidelines (Qureshi et al 2007). One criticism of the 2007 audit raised by clinicians was that not all possible clinical indications and factors for a transfusion were taken into consideration before deeming the transfusion inappropriate. In the 2010 audit when 3,293 cases were examined in haematology patients, additional reasons for transfusion were included. This audit allowed for factors such as platelets due for expiry and the setting of an individualised threshold for treatment by the clinician, providing this was documented in the patient’s records. Nonetheless, 28% of transfusions still fell outside national guidelines, and the particular area of concern highlighted
in the audits was prophylactic use (National Comparative Audit of Platelet Transfusions 2010). Important findings from these audits where the transfusion was considered outside guidelines included. Platelets were transfused before a bone marrow aspiration or trephine biopsy. Platelets were transfused to patients who were stable (no evidence of bleeding) with long-term bone marrow failure, such as myelodysplasia. Two platelet packs were administered in one episode – ‘double dosing’. A bag of platelets is often referred to as a ‘pool’ in reference to the collection method (four adult donations pooled into one bag) or as a ‘pack’ of platelets. One pack of platelets is one adult therapeutic dose (ATD), regardless of whether it is a pooled pack or an apheresis pack. Administering two adult therapeutic doses in quick succession accounted for 10% of prophylactic transfusions. A large randomised controlled trial showed that doubling the number of platelet packs had no effect on a patient’s risk of bleeding (Slichter et al 2010).
Patient benefits of limiting prophylactic transfusions
One benefit of limiting prophylactic platelet transfusions is reducing exposure to transfusion-transmitted infections. Limiting prophylactic platelet transfusions also reduces the risk of adverse transfusion reactions. Allergic reactions are more common with platelet transfusions than with red cell transfusions; the incidence of cutaneous reactions for plasma-containing blood components is 1-3% (Taylor et al 2008). The risk of bacterial sepsis from contamination of the platelet pack during collection is a rare but serious risk reported to the SHOT scheme, with 11 deaths reported to SHOT since reporting commenced in 1996 (Bolton-Maggs et al 2013). Unlike red cells, platelets have to be stored at room temperature (20-24°C), so bacteria have the opportunity to continue to grow if the pack has been contaminated. Since May 2011, a sample from all platelet donations is cultured to detect any bacterial contamination and this has allowed the NHSBT to extend the shelf life of platelet transfusions from five to seven days (MacLennan and Murphy 2011). A more subtle reason to avoid unnecessary transfusions is that each transfusion can affect the effectiveness of subsequent transfusions. Multiple transfusions can lead a patient to make antibodies against antigens present on transfused platelets, or alloimmunisation. These antibodies can cause the destruction of any platelets
36 november 12from :: volRCNi.com 29 no 11by:: 2014 NURSING STANDARD / RCN Downloaded ${individualUser.displayName} on Dec 06, 2015.©For personal use only. No other usesPUBLISHING without permission. Copyright © 2015 RCNi Ltd. All rights reserved.
transfused in future and subsequent failure to observe an incremental platelet rise following transfusion. Even where antibodies are not detected following the first transfusion, there is evidence to suggest that the incremental platelet rise will be lower on subsequent transfusions, resulting in reduced benefit from later transfusions (Slichter et al 2005).
Assessing the effect of prophylactic transfused platelets
The Trial of Prophylactic PlateletS (TOPPS) examined the benefit of prophylactic transfusions versus no prophylactic transfusions in patients with haematological malignancies (Stanworth et al 2013). Six hundred patients were randomised to receive either a prophylactic transfusion if the platelet count fell below 10x109/L, or no prophylactic transfusion and transfusion only when a bleeding episode occurred. Patients were monitored for clinically significant bleeding using the World Health Organization (WHO) (1979) classification for bleeding, with clinically significant bleeding being grade 2 or above (Table 1). The overall rate of bleeding was reduced in the prophylactic group, and the study concluded that prophylactic transfusions are required in patients with thrombocytopaenia. The rate of WHO grade 2-4 bleeding in patients who had prophylactic transfusions was 43%, compared with 50% in the no prophylaxis group. The majority of patients with bleeding had grade 2 bleeding. Only seven patients had grade 3 or 4 bleeds, and of these only two had a platelet count below 10x109/L at the onset of grade 3 or 4 bleeding. The authors concluded that the platelet level is not the sole risk factor for major bleeds. They proposed that further studies are required to increase knowledge of the risk factors for major bleeds, and strategies are required to manage the high rates of bleeding observed even after prophylactic transfusion (Stanworth et al 2013).
Education in transfusion practice Nurses have an important role in the education of patients and colleagues. Educational resources developed by the NHSBT patient blood management team and other transfusion specialists are available. The team was established to ensure patients receive the best possible evidence-based transfusion care, and to promote the safe and appropriate use of blood components and their alternatives. The educational resources developed by the team are listed in Box 1. The patient blood management team has been involved in a series of ‘Let’s talk platelets’
workshops, which enabled the NHSBT and hospital users to discuss issues relating to platelets, ensuring good transfusion care for the patient. Delegates discussed platelet stock management within hospitals, issue and wastage data, appropriate usage, empowerment of biomedical scientists to offer advice and challenge requests, and the timing of routine and ad hoc deliveries. Exploring every opportunity to use platelets appropriately and ensuring good stock management minimises the possibility of shortages and ensures that all patients can have a transfusion when required. A national platelet working group, formed after the audits, produced a number of additional resources (Box 2). Some of this work by the patient blood management teams is starting to take effect, as demand appears to be increasing at a much lower rate than in previous years.
TABLE 1 Classification for bleeding Grade
Description
Grade 0
No bleeding.
Grade 1
Petechial bleeding.
Grade 2
Mild blood loss, clinically significant.
Grade 3
Gross blood loss, required transfusion.
Grade 4
Debilitating blood loss, retinal or cerebral, associated with fatality.
(World Health Organization 1979)
BOX 1 NHS Blood and Transplant (NHSBT) patient blood management team educational resources ‘HLA (human leukocyte antigen) matched platelets’ poster: Information for healthcare professionals on why a post-transfusion platelet count is necessary following an HLA-matched platelet transfusion, when the blood sample should be taken, and why it is necessary for the NHSBT to be informed. ‘Transfusion of platelets across blood groups’ poster: Alternatives to the first choice ABO blood group and Rh blood group, D antigen (RhD) identical platelets are identified to maximise use and minimise wastage. ‘Don’t use two… when one will do’ poster: Information on helping to reduce the use of double-dose platelets for prophylactic transfusions. Transfusion Matters ninth edition: A newsletter that focuses on the safe and appropriate use of platelets. Platelet transfusion mobile site: The site works in a similar way to an app, and has been designed to give quick and easy access to the national guidelines on platelet transfusion. It is designed specifically for smartphones and tablets, so it can be accessed wherever needed (http://goo.gl/PHnpVH). (NHSBT 2014)
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Art & science haematology BOX 2 National platelet working group educational resources PowerPoint presentation ‘Platelet transfusion – scope to improve practice’: Provides facts and figures for healthcare professionals and assists hospital transfusion practitioners to raise awareness within their local trusts. ‘Platelet transfusion: principles, risks, alternatives and best practice’: A factsheet for doctors and senior nurses, based on national and international guidance. (NHS Blood and Transplant 2014)
Nursing role Nurses have an important role in good transfusion practice and should stay well informed by attending face-to-face updates on blood transfusions provided in-house, or by working through the available e-learning packages, depending on their local trust policy. Such practice updates alert nurses to current issues and changes to guidelines, and encourages them to reflect on their practice. The nurse can inform the patient of the need for the transfusion, explain the alternatives available and, in some trusts, gain informed valid consent from the patient, once trained and competent to do so. Nurses are the patient’s advocate and should question and seek clarification for a request for a platelet transfusion if they feel this may be inappropriate.
Nurses can influence the practice of prophylactic transfusions by educating patients and colleagues, and by becoming responsible for writing the instruction to transfuse through role development. A framework to support nurses and midwives in making the clinical decision and providing the written instruction for blood component transfusion was developed in 2009 (Pirie and Green 2009). The authors established the legality of nurse ‘prescribing’ for blood components, and the absence of barriers to extending the nurse’s role in this area. Blood components are excluded from the legal definition of medicinal products, so strictly speaking they cannot be ‘prescribed’ by any practitioner. The term ‘authorisation’ was therefore adopted as an alternative, and it was established that there is no legal barrier to nurses authorising a blood transfusion. Since the release of the framework, several hospitals have implemented nurse authorisation of blood component transfusions for specific groups of nurses, mainly for advanced nurse practitioners. The hospital policy must state which groups of staff are eligible to authorise blood component transfusions, how they are supported and what additional education is required. Nurse authorisation is an extended role for nurses, who should attend specific
References Bolton-Maggs P, Thomas D, Cohen H et al (2013) Annual SHOT Report 2012. www.shotuk. org/wp-content/uploads/ 2013/08/SHOT-Annual-Report2012.pdf (Last accessed: October 10 2014.) British Committee for Standards in Haematology, Blood Transfusion Task Force (2003) Guidelines for the use of platelet transfusions. British Journal of Haematology. 122, 1, 10-23.
MacLennan S, Murphy M (2011) Introduction of Bacterial Screening of Platelet Components: Information for Hospital Transfusion Teams. http://hospital.blood.co.uk/ media/1918/2f291133-4143-4 2b6-8705-11823fdb6f8d.pdf (Last accessed: October 10 2014.) National Comparative Audit of Platelet Transfusions (2010) Key Findings of the Audit with Regard to the Inappropriate Use of Platelet Transfusions. http:// hospital.blood.co.uk/media/26976/
key-findings.pdf (Last accessed: October 10 2014.) National Comparative Audit of Blood Transfusion (2011) 2010 Re-audit of the Use of Platelets in Haematology. http:// hospital.blood.co.uk/media/26866/ nca-platelet_re-audit_report-st_ elsewheres_nhs_foundation_ trust_2010.pdf (Last accessed: October 10 2014.) NHS Blood and Transplant (2014) Platelet Resources. http://hospital.
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38 november 12from :: volRCNi.com 29 no 11by:: 2014 NURSING STANDARD / RCN Downloaded ${individualUser.displayName} on Dec 06, 2015.©For personal use only. No other usesPUBLISHING without permission. Copyright © 2015 RCNi Ltd. All rights reserved.
non-medical authorisation education and be assessed as competent by their clinical mentors before they can authorise a blood component transfusion. The education programmes available vary. In Wales, an accredited programme of education is available at graduate and postgraduate level at Swansea University (Shreeve and Benton 2013). The NHSBT also runs education programmes (http://hospital. blood.co.uk/training/programmes/ programme_diary/). A survey showed that, for nurse authorisation to be integrated effectively into healthcare practice, enough time – usually at least three months – was required to allow practitioners an opportunity to authorise blood component transfusions under supervision, and to complete their competency assessments (Watson 2013). When nurses are considered competent, they can assess their patient and organise their transfusions, which enables the care pathway to be much more streamlined. Patients are benefitting from nurses authorising blood components. Nurse authorisation gives nurses the ability to influence the practice of prophylactic platelet transfusions and increase judicious use of platelet transfusions. Future audits will illustrate how effectively this is achieved.
Serious Hazards of Transfusion (2003) Serious Hazards of Transfusion Annual Report 2001-2002. www.shotuk.org/ wp-content/uploads/2010/ 03/SHOT-Report-01-02.pdf (Last accessed: October 10 2014.) Shreeve K, Benton A (2013) All Wales Policy. Non-Medical Authorisation of Blood Component Transfusion. www.wales.nhs.uk/ sites3/documents/428/Joint%20 CMO%20CNO%20CPhO%20 Letter.pdf (Last accessed: October 10 2014.)
Conclusion The number of platelet transfusions has been steadily rising for the past five years. Platelets are a limited resource, requiring considerable commitment from donors, so more judicious use of platelets is required. The latest national audit has shown that 28% of platelet transfusions fell outside of the recommendations of the BCSH (2003) guidelines (National Comparative Audit of Platelet Transfusions 2010), and therefore may be unnecessary transfusions. This is of concern because platelet transfusions carry potential risks for the patient, including allergic reactions and bacterial sepsis. Using platelets judiciously has the potential to ensure patients are well supported for longer periods, because the effectiveness of subsequent transfusions is protected. Nurses have an important role in colleague and patient education, promoting the safe and effective use of platelet transfusions, acting as patient advocates and ensuring their practice is up-to-date. Some trusts have implemented nurse authorisation of blood components for transfusion, permitting nurses who have satisfactorily undertaken a non-medical authorisation education programme to assess patients and organise their transfusions in a streamlined process NS
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