Peridischarge prophylactic platelet transfusions after stem cell transplant: is a tranfusion trigger needed?

BACKGROUND: We examined the appropriateness of prophylactic peridischarge platelet (PLT) transfusions and the feasibility of lowering the prophylactic PLT transfusion threshold in transplant recipients within 24 hours of discharge at a National Cancer Institute-designated comprehensive cancer center. STUDY DESIGN AND METHODS: From April 2011 to June 2014, each prophylactic PLT transfusion that was administered to transplant recipients within 24 hours of discharge was identified. Each transfusion was reviewed to identify the indication and to determine if the transfusion adhered to institutional guidelines. RESULTS: Of the 187 transplant patients identified, 44 patients received a prophylactic PLT transfusion within 24 hours of discharge. Of these 44 patients, transfusions were administered to fulfill a PLT count of 20 × 10(9) /L required for discharge (n = 25 patients), for the removal of a tunneled central venous catheter (n = 16 patients), for active bleeding (n = 1 patient), or due to active anticoagulation (n = 2 patients). CONCLUSIONS: The majority of PLT transfusions (95%) were appropriate, and only 5% were avoidable. If the prophylactic PLT transfusion threshold was decreased to 15 × 10(9) /L from 20 × 10(9) /L for central line removal and to fulfill discharge PLT count criteria, 41% of the currently appropriate PLT transfusions could have been avoided. These results suggest that a risk-adapted method to select autologous transplant recipients for prophylactic PLT transfusions may be beneficial. A future study is needed to address this issue.

Hospital readmission following transplantation: identifying risk factors and designing preventive measures.

BACKGROUND: About 1 in 7 of all hospitalized patients is readmitted within 30 days of discharge. The cost of readmissions is significant, with Medicare readmissions alone costing the health care system an estimated $28 billion a year. OBJECTIVE: To identify the rates of and causes for readmission within 100 days of patients receiving a hematopoietic stem cell transplant. METHODS: We performed a retrospective review of 235 consecutive transplant recipients (autologous, n = 144; allogeneic, n = 91) to determine rates and causes for readmission within 100 days of patients receiving a transplant. Medical records and hospital readmissions were reviewed for each patient. RESULTS: 36 allogeneic patients accounted for 56 readmissions. 23 autologous patients accounted for 26 readmissions. Autologous transplant recipients were most commonly readmitted for the development of a fever (n = 15 patients) or cardiopulmonary issues (n = 4). The most prevalent reasons for readmission in the allogeneic recipients included a fever (n = 21) or the development or exacerbation of graft-versus-host disease (n = 5). The readmission length of stay was 6 days (median range, 1-91 days) for allogeneic patients and 4 days (median range, 1-22 days) for autologous patients. There was no difference in survival between the readmitted and the non-readmitted cohorts (𝑃 = .55 for allogeneic patients; 𝑃 = .24 for autologous patients). Although allogeneic graft recipients demonstrated a higher readmission rate (39.6%) compared with autologous recipients (16%), none of the variables examined, including age, gender, performance status, diagnosis, remission status at the time of transplant, comorbidities, type of preparative chemotherapy regimen or donor type, identified patients at increased risk for readmission. LIMITATIONS: Variations in clinical care, physician practices, and patient characteristics need to be considered when examining readmission rates. Most of the allogeneic patient population included unrelated donor recipients (65%) who received nonmyeloablative conditioning regimens (81% of allogeneic recipients). These features may not be characteristic of other centers. CONCLUSIONS: In these high-risk patients, readmissions following a transplant are common. Enhanced predischarge education by nurses and pharmacists, along with ongoing outpatient education and rigorous outpatient follow-up through phone calls or social media may decrease readmission rates.