Transfusion of Single Unit Plasma in a Multihospital Health Care System: A Real Gap in Practice Guidelines and Clinical Use as well as Opportunity for Improvement

From the 2022 HVPA National Conference

Michael Benson M-III, MS (Ohio University Heritage College of Osteopathic Medicine), Deborah Tolich DNP, RN, Marni Dargis RN, Richard Gammon MD, Moises Auron MD

Background

Transfusion of plasma should be administered in a weight-based dosing ranging from 10-20 ml/kg of ideal body weight to be therapeutic. Its use in patients with INR < 1.8 has minimal to no impact in coagulation effectiveness. This study aimed to gain insight into the rationale for under-dosing of plasma in a multi-hospital health care system.

Objective

To identify the characteristics (e.g., patient, clinical setting, specialty) involved in the use of single unit plasma use within our multihospital health care system, in order to implement patient safety and educational efforts.

Methods

This is a descriptive study of a random sampling of 100 individuals who were transfused a single unit of plasma with discharge dates between 09/01/2020 through 01/31/2021. The exclusion criteria included pediatric population (age < 18 years), single-unit plasma for management of hereditary angioedema and convalescent plasma for treatment of COVID-19. These charts were evaluated for the following: reason for transfusion, indication for order, area where plasma was administered (Operating Room (OR), Intensive Care Unit (ICU), Post-Anesthesia Care Unit (PACU), Emergency Department (ED), and Regular Nursing Floor (RNF), as well as the INR level within 6 hours prior to transfusion and 30-day survival. An indication is required to order plasma in the EHR using one of the following: bleeding with INR ≥1.8, pre-procedural designating either high or low risk for bleeding, and other, where the provider is to specify a reason not listed (not a required field).

Results

No documented clinical reasoning for plasma transfusion was found in 57% of cases; Of those with documented reasoning, 13% were for coagulopathy, 10% were for warfarin reversal, 10% were for bleeding prophylaxis, 9% for acute blood loss, and 1% as a volume expander. The indications identified were bleeding with INR ≥1.8 was found in 32%; pre-procedural with high bleeding risk in 29%, pre-procedural with low bleeding risk in 6%, and no indication on the order in 33% of cases. The transfusions took place in the OR (42%), ICU/PACU (42%), RNF (13%) and ED (3%). In patients with INR measured within 6 hours prior to plasma transfusion, 65% had an INR <1.8. Thirty days following plasma, 84% of patients were living, while 16% had expired, of those who expired, 87.5% expired prior to discharge.

Conclusion

Single unit plasma transfusion lacks meaningful clinical impact with subtherapeutic dosing. This study demonstrates educational opportunities to enhance adherence to evidence-based criteria for plasma transfusion, as well as for accuracy in reasons for transfusion and indications for orders when documenting in the electronic health record.

Clinical Implications

Lack of concordance between practice guidelines and actual clinical use are characteristics of subtherapeutic plasma administration. Transparent and targeted dissemination of the current performance data to key stakeholders within the health care system should be done to enhance awareness, improve patient-centered care, safety, and resource conservation.

What are academic medical centers across the country doing to improve healthcare value?

Value improvement guides: Published reviews in JAMA Internal Medicine coauthored by experienced faculty from multiple leading medical centers, with safety outcomes data and an implementation blue print.

Review article detailing 25 labs to refine for high value quality improvement | July 2020

MAVEN campaign: Free 4 year high value care curriculum online.

Join the Alliance! Membership is free with institutional approval and commitment to improving value in your medical center.

Learn more about HVPA on Health Affairs Blog