Guideline Compliance for Plasma and Platelets Before and After Patient Blood Management

From the 2021 HVPAA National Conference

Nicolas Cruz (Department of Anesthesiology/Critical Care Medicine, Johns Hopkins Medicine, Baltimore MD), Brian D. Lo, Brian C. Cho, Nadia B. Hensley, Paul M. Ness, Steven M. Frank

Background

Historically, patient blood management (PBM) programs have primarily focused on reducing red blood cell utilization, without consideration for the “yellow” products, namely plasma (FFP) and platelets (PLT).

Objective

The purpose of this study was to assess the impact of a PBM program on FFP and PLT utilization, as well as guideline compliance, at a tertiary academic center.

Methods

After IRB approval, patients admitted to the Johns Hopkins Hospital between January 2009 and May 2016 were stratified into Pre-PBM (2009-2013) and Post-PBM (2014-2016) cohorts. We selected the 8 hospital services with the greatest number of FFP-transfused patients and PLT-transfused patients, respectively, for the analysis. For each blood component, we compared blood product utilization, transfusion triggers, and transfusion targets between the Pre-PBM and Post-PBM patient populations. For the FFP analysis, the INR trigger was defined as the highest INR obtained during the hospitalization, while the INR target was defined as the last INR measured prior to discharge. For the PLT analysis, the PLT trigger was defined as the lowest PLT count obtained during the hospitalization, while the PLT target was the last PLT count measured prior to discharge. One-way ANOVA, Kruskal-Wallis, nonparametric Wilcoxon, and Student’s t-tests were used as appropriate for the analysis.

Results

251,128 patients were included in the FFP analysis, of which 66.2% (n = 166,216) were in the Pre-PBM cohort and 33.8% (n = 84,842) were in the Post-PBM cohort. There was a significant decrease in the percentage of patients receiving FFP after the implementation of PBM (Pre-PBM: 5.7% vs. Post-PBM: 5.3%; P<0.0001). Most departments had mean INR triggers that were higher than the institutional INR guidelines of 1.5-1.7 (Figure 1). These INR triggers decreased for most departments after implementation of PBM (P<0.0001) (Figure 1). When analyzing median and interquartile range for INR triggers, appropriate implementation of institutional guidelines in the Post-PBM time period would have avoided FFP transfusion in 25-50% of patients, depending on the service. For the PLT analysis, 243,923 patients were included, of which 66.0% (n = 161,010) were in the Pre-PBM cohort and 34.0% (n = 82,913) were in the Post-PBM cohort. Overall, the percentage of patients receiving PLT transfusion increased after implementation of PBM (Pre-PBM: 6.8% vs. Post-PBM: 7.1%; P=0.0045). For most departments, PLT triggers and targets increased in the Post-PBM period, with many transfusions occurring outside the institutional guidelines of 10,000-50,000 PLT/uL (Figure 2). There was also significant variation in the PLT trigger of up to 100,000 PLT/uL between departments (Figure 2). Appropriate implementation of institutional guidelines in the Post-PBM time period would have avoided PLT transfusion in 50-75% of patients, depending on the service.

Conclusions

The implementation of a multidisciplinary PBM program improved FFP, but not PLT utilization. This overuse of both FFP and PLTS highlights the need for a renewed focus on promoting guideline compliance for the “yellow” blood components.

Clinical Implementation

While PBM has played an integral role in reducing RBC utilization, there exists continued room for improvement with respect to FFP and PLT transfusions.

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