Frozen Plasma Transfusion Practices in Ontario-an Electronic Audit at Five Tertiary Care Hospitals to Inform a Knowledge Translation Strategy to Reduce Inappropriate Plasma Transfusions

Frozen plasma transfusions are blood components that are frequently transfused to patients who are bleeding or require an invasive procedure and have a deficiency of coagulation factors detected on abnormal coagulation testing as inferred by a prolonged prothrombin time (PT), partial thromboplastin time (PTT), or increased international normalized ratio (INR). Despite published guidelines, supporting optimal plasma use, two recent provincial audits have suggested that 50% of the plasma transfused in the Province of Ontario is inappropriate. Inappropriate utilization of plasma has numerous adverse consequences for the recipient, including transfusion associated lung overload, allergic reactions, and delays necessary procedures while awaiting completion of the transfusion. In addition to the direct risks that inappropriate utilization of plasma has on the patient, it also has adverse consequences for the health care system; Given 98,521 units transfused in Canada in 2017, of which 50% are unnecessary, the annual revenue loss is estimated to be CAN$1.7 million.

We will include all adult Inpatients receiving plasma during the time period January 1, 2017 and December 31, 2017. The study population will be subdivided into 5 groups of inappropriate plasma use that include: (1) patients with a normal INR≤1.5 and who were not actively bleeding, as indicated by no RBC transfusion; (2) patients with normal INR≤1.5 with moderate bleeding only; (3) elevated INR>1.5, without active bleeding or procedures; (4) no INR drawn before or after plasma infusion; or, (5) transfused a non-therapeutic dose of plasma, defined by less than or equal to 2 units. RBC transfusion requirement and the quantitative drop in hemoglobin will be used as a surrogate marker for bleeding. We plan to analyze the number and proportion of unnecessary plasma transfusions at five tertiary care centres by patient demographics, by triggering INR, and by the presence or absence of bleeding.

As part of preliminary work to facilitate future audits and monitor appropriate plasma utilization in Ontario, there has been an Ontario Blood Utilization Data Strategy (ONBUDS) data extraction project where preliminary data has been extracted from blood transfusion databases, laboratory databases, and the discharge abstract database (DAD) for four institutions. We expect to confirm previous findings that 50% of the plasma transfused in Ontario is transfused inappropriately. Based on the preliminary ONBUDS data, it was found that the majority of inappropriate plasma transfusions were in the areas of cardiac surgery, orthopedic surgery, intensive care and gastroenterology.

This study will inform a large quality improvement study aimed at reducing unnecessary plasma transfusion. The long-term goal is to develop an alternative electronic auditing strategy that is more comprehensive, faster, and more cost efficient than the historical annual Provincial audit which requires manual chart reviews by physicians, nurses and technologists.