Platelets should not be squandered: hospitals can use a range of strategies to become more efficient in the way they use this precious blood component. This article is accompanied by a self-assessment questionnaire so you can test your knowledge after reading it
Abstract
Platelets are expensive and their use is increasing, so the question of their supply is becoming an issue. In some instances platelet transfusions are administered unnecessarily, wasting a precious resource. This article explores ways of making sure platelets are used appropriately. It covers the most basic methods, such as respecting the indications for use and following transfusion procedures, to newer and more-innovative strategies, such as applying the principles of patient blood management, using indication codes or sharing stocks.
Citation: Cowan K [2017] Strategies to reduce inappropriate use of platelet transfusions. Nursing Times [online]; 113: 2, 18-21.
Author: Katy Cowan is patient blood management practitioner, NHS Blood and Transplant, Devon.
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Introduction
Over the past decade, the number of platelet units issued by NHS Blood and Transplant [NHSBT] to hospitals has steadily increased; it has risen by just over 25% in the nine years to April 2016 [Fig 1; Estcourt et al, 2016]. Platelets are the most expensive commonly used component supplied by NHSBT; one unit costs £193.15 [NHSBT, 2016] and, according to NHSBT figures, issuing platelets cost the NHS at least £52m in 2015/16.
There are many reasons for the increasing use of platelets, including an ageing population, improved treatments for people with cancer and improved trauma management. However, there is also evidence that the inappropriate use of platelets is an ongoing problem [Moss, 2015; North West Regional Transfusion Committee, 2013]. The national comparative audit estimated that, in 2010, 28% of platelet transfusions could have been avoided [NHSBT, 2011].
Platelets can only be obtained from donors willing to go through donation process that can be last up to 90 minutes, so maintaining an adequate supply of these blood components – and using them in the patient’s best interest – has become a priority. This article discusses the appropriate use of platelets, referring to existing guidance as well as guidelines written by Estcourt et al [2016] and published by the British Society for Haematology – formerly the British Committee for Standards in Haematology.
Indications for use
Platelets – or thrombocytes – are blood components derived from megakaryocytes in the bone marrow; the normal platelet count in healthy individuals is 150-400x109/L. They circulate in the blood in an inactive state and become activated in response to a breach in the lining of a blood vessel wall. Their main function is to stop bleeding at the site of an injury.
When an injury occurs, a series of reactions is initiated: platelets stick to the damaged endothelium, change shape and release chemicals into the circulation that encourage more platelets to adhere, resulting in a platelet plug at the site of injury. The coagulation cascade is activated and a fibrin mesh forms around the platelet plug, trapping red and white cells, which further strengthens the plug.
Although transfusions can be necessary for a variety of reasons the three main indications for platelet transfusions in adults are:
- Prophylactic use – to prevent spontaneous bleeding in people with a low platelet count;
- Pre-emptive use – in patients with a low platelet count who are undergoing an invasive procedure;
- Therapeutic use – to treat active bleeding in patients who have a low platelet count or platelets that do not function properly.
The new BSH guidelines for platelet use contain a more comprehensive list of indications for platelet transfusions [Estcourt et al, 2016]. To help clinicians make decisions when prescribing blood components, NHSBT has produced a bookmark, based on the National Blood Transfusion Committee’s indication codes for transfusion.
Prophylactic use
Certain individuals should receive a transfusion when their platelet count is