Intention to comply does not equal compliance with evidence-based transfusion algorithms.

Abstract

Patient blood management (PBM) can decrease transfusion rates, mortality and major complications [1]. Sustainability of the blood supply in the face of increasingly complex surgeries on an aging population is imperative. PBM on Randwick campus incorporates the ROTEM algorithms, as well as a cardiothoracic protamine and tranexamic acid (TXA) guideline. The compliance with these guidelines was analysed at the local level. Methods A voluntary QR code linked REDCap questionnaire was used to capture the transfusion decision following a ROTEM test during a critical bleed. It was implemented across the Randwick Campus, which includes the Prince of Wales Hospital, Royal Hospital for Women, Sydney Children’s Hospital, and Prince of Wales Private Hospital. Data collection occurred from September 2023 to August 2024. The questions focused on the blood products administered and whether the clinician agreed that they had followed the ROTEM algorithms and the protamine and TXA guidelines. The ROTEM results were used to calculate recommended cryoprecipitate doses based on FIBTEM and patient weight. These were compared to actual doses given, considering compliance as ±50% of the recommendation. We also analysed the cryoprecipitate dose ratio between administered and recommended. Platelet transfusion was evaluated against platelet count and EXTEM A5. Results There were 59 data entry points for our audit. Cardiothoracic compromised 70% of the data, 20% were in intensive care, and only 10% general theatre and obstetrics. Regarding ROTEM algorithm cryoprecipitate dosages, overall only 42/59 (71%) participants were compliant, and while most participants 49/59 (83%) agreed that they were compliant to our ROTEM algorithm, only 39 (80%) actually were. Analysis of cryoprecipitate dose ratio included 34 patients with FIBTEM A5 result below 12, with a mean dose ratio of 1.04, median 0.914 with a few significant outliers that will be discussed below. There was only one patient meeting platelet count criterion, and no cases meeting ROTEM EXTEM platelet transfusion criterion, but 27/59 (46%) patients received platelets. For protamine in cardiac patients, 35/41 (85%) cases were compliant, and for TXA, 38/41 (93%) cases. Discussion The voluntary nature of this survey might have skewed the results to show better compliance, as participants may be more likely to follow the guidelines. There remain barriers to clinicians correctly following the algorithms. In six instances, cryoprecipitate was not administered despite FIBTEM criterion. These cases were logged non-compliant; however, upon further examination, three of them reported bleeding cessation. ROTEM is indicated in critical bleeding but is sometimes done in anticipation of bleeding before separation from cardiopulmonary bypass. These patients could be excluded from future analyses. Three patients received more than twice the recommended dose of cryoprecipitate with one even receiving a fivefold dose. This could indicate severe bleeding with more loss in the minutes between test and result but also poses a risk of overcorrection and thrombotic complications. Contemporary ROTEM testing cannot detect platelet function disorders, so clinicians often use intuition to decide on platelet transfusions. There is evolving data that the Multiplate™ platelet function test can assist with this decision, and improved testing at the point of care for platelet inhibitors would also be beneficial. Improving PBM can enhance patient outcomes, sustain blood supply, benefit health economics, and uphold ethical standards. Our audit has identified two critical areas in blood transfusion practices on our campus. Firstly, there is an opportunity to enhance compliance. Secondly, additional education on the ROTEM algorithm is necessary, as some clinicians who reported being compliant were found not to be.