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Data Entry - Clinical Audit of Platelet Use

During the study period please complete a form for each of 30 consecutive transfusion episodes where the patient has received
platelets. For hospitals who transfuse platelets very regularly, every third platelet transfusion may be audited instead.
Definition of transfusion episode: An episode will be defined as each time the participating blood bank issue one or more therapeutic doses of platelets to a patient. The same patient can only be entered into the database twice.

* = Mandatory


Transfusion Date*
/ /
dd mm yyyy
Hospital Code:*
Sex:* Male Female Audit ID:*
Age:*

Hospitals Contact Email
to receive confirmation report on data submitted electronically to Blood Matters.


Pathology
If a pathology result is not provided it will be assumed that the test was not done.

Pre Transfusion (dd/mm/yyyy)*
Platelet Count x 109/L   Date:

Post Transfusion (dd/mm/yyyy)*
Platelet Count   Date:

Platelets
Transfused * 
No of
Bags:
Type of bags *




Active Bleeding up to 24 hours before transfusion *
incl. Petechiae or mucosal bleeding		 Yes No  
If Yes, did the bleeding cease within 6 hours of transfusion? * Yes No Unable to determine
Surgery/Invasive Procedure 24 hours before, during, or after transfusion*
(refer to instructions sheet for definitions) 		Yes No

 
Patient location in hospital * Theatre  
  ICU  
  Ward  
  Other, please specify
Fever *
(> or equivalent to 38°C) *		 Yes No  
Laboratory *
coagulation abnormality
(greater than 1.5 x upper limit reference range)		 Yes No  
Anti-platelet drugs *
Eg Aspirin, ReoPro, Clopidogrel (Plavix)
in the 5 days prior to transfusion		 Yes, please state
No
Uraemia *
(creatinine is >200μmol/l)		 Yes No  
Cardiopulmonary Bypass *
(longer than 2 hours or with deep hypothermic arrest or ECMO)		 Yes No  
IV Antibiotics or antifungals * Yes No  


Patient Diagnosis (also use for other relevant comments, e.g., risks details):*



Is the indication for Transfusion recorded in the medical record?* Yes No
Recorded Indication:
Prophylaxis bone marrow failure (Platelets <10)
Prophylaxis bone marrow failure & risk factors (Platelets <20)
Massive haemorrhage/transfusion & platelets <50
Prophylaxis for surgery/invasive procedure (Platelets<50)
Abnormal microvascular bleeding & platelets <100
Documented platelet function disorder
Other (Please specify):

     

Email questions or comments: BestAudit@dhs.vic.gov.au

  
 

Contact:

Karen Botting (Program Manager)
Tel: (61 3) 9096 9037
Address: Clinical Information & Knowledge Management Unit
Statewide Quality Branch
Level 17, 50 Lonsdale Street
Melbourne Vic 3001

 Lisa Stevenson (Transfusion Nurse)
Tel: (61 3) 9096 0476
Mobile: 0417 519 023
Address: Clinical Information & Knowledge Management Unit
Statewide Quality Branch
Level 17, 50 Lonsdale Street
Melbourne Vic 3001

Email questions or comments: BestAudit@dhs.vic.gov.au

  
Last updated: 8 April, 2008
This web site is managed and authorised by the Quality Improvement Unit, Quality & Safety Branch, Rural & Regional Health & Aged Care Services Division of the Victorian State Government, Department of Human Services, Australia

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