Identifying Patterns of Inappropriate Plasma Transfusion Practices Using a Novel Multicenter Electronic Data Audit: Over 80 Percent of Plasma Transfused Is Inappropriate

Abstract

Importance: Plasma is frequently transfused to patients who are bleeding or require an invasive procedure and have a deficiency of coagulation factors. Despite published guidelines delineating optimal plasma use, two recent audits have suggested that over 50% of the plasma transfused is unnecessary. Inappropriate utilization of plasma has numerous adverse consequences for the recipient, as well as the health care system. Objective: To determine the proportion of inappropriate plasma use with a multicenter electronic data audit and identify focused areas for intervention to reduce inappropriate use. Setting: 3 tertiary care academic sites across Ontario, Canada: Hamilton Health Sciences Centre (Hamilton, Ontario), Sunnybrook Health Sciences Centre (Toronto, Ontario), London Health Sciences Centre (London, Ontario). Participants: All adult inpatients receiving plasma during the time period January 1, 2017 and December 31, 2017. Design: Four areas of inappropriate plasma use in adult patients were defined: (1) patients with a normal INR <1.5 and who were not actively bleeding or moderate bleeding only (1 unit RBC transfused within 24 hours before or after plasma transfusion or 20 g/L drop in hemoglobin); (2) elevated INR >1.5, without active bleeding or procedures in 6 hours after plasma transfusion (1 calendar day when time of procedure was not available); (3) no INR drawn before or after plasma infusion; (4) inappropriate non-therapeutic plasma dose of plasma (≤ 2 units) . Results: A total 4,385 plasma transfusion events occurred in 1,844 inpatient admissions. Appropriate indication and dosing was found in 813 (18.5%) of the events. Inappropriate compliance occurred in 3,572 (81.5%) of the events: 608 (13.9%) events occurred in the pre-specified criteria (1-3) above; inappropriate dosing alone occurred in 1,583 (36.1%) events; and, a combination of inappropriate dosing in addition to any 1-3 pre-defined categories occurred in 1,381 (31.5%) transfusion events. Patients transfused with a documented INR (81.5%) in the 24 hours preceding plasma transfusion had a mean INR value 1.8+1.7 (INR + SD). The mean overall reduction after 1-24 hours of plasma transfusion was -0.5+1.6 . Conclusions and Relevance: A significant amount of plasma is transfused inappropriately, leading to potential patient harm, significant unnecessary costs, and diversion of plasma away from fractionation impacting the supply of intravenous immunoglobulin. This study will inform a large quality improvement study aimed at reducing unnecessary plasma transfusion. Disclosures Heddle: Novartis: Research Funding. Arnold:Principia: Consultancy; Bristol-Myers Squibb: Research Funding; Novartis: Honoraria, Research Funding; Rigel: Consultancy, Research Funding. Hsia:Amgen: Honoraria; Jansen: Honoraria, Membership on an entity's Board of Directors or advisory committees; Novartis: Honoraria, Membership on an entity's Board of Directors or advisory committees; Pfizer: Membership on an entity's Board of Directors or advisory committees.

Coagulation test understanding and ordering by medical trainees: Novel teaching approach

“…7,27 There are many harms associated with inappropriate coagulation testing, including increased risk of exposure to blood components and products, a cascade of additional investigations and referrals, delays to patient care, patient and physician anxiety, iatrogenic anemia, and additional, often unnecessary costs to the health care system. [3][4][5]7,[9][10][11] In a previous study conducted at our center in the emergency department, the reduction of routine use of PT/aPTT testing in unselected patients was associated with an estimated cost saving of US$56,000 per year. 28 As medical trainees order a significant proportion of laboratory tests at academic centers, this is an important group to target in clinical quality improvement interventions.…”

“…A single‐center Canadian audit of FP use identified 62.6% of FP transfusions were administered for an INR of 0.9 to 1.8 13 . A more recent Canadian audit of FP transfusions at three large tertiary care centers identified that 81.5% of FP was transfused inappropriately, with 21.5% of these transfusions administered to patients with an INR of 1.5 to 1.7 11 . The inappropriate transfusion of FP results in many negative outcomes, including the harm of transfusion reactions and increased costs to the health care system 10,11 .…”

“…9,10 FP is often transfused in patients with mild abnormalities in coagulation tests and corrects these values in only a minority of patients. 9,[11][12][13][14] A multicenter national audit in the United Kingdom identified that 41.0% of FP transfusions were administered to patients with a mildly prolonged INR and no bleeding. 12 A single-center Canadian audit of FP use identified 62.6% of FP transfusions were administered for an INR of 0.9 to 1.8.…”

Reducing use of coagulation tests in a family medicine practice setting: An implementation study

“…Conversely, an abnormal PT/INR or APTT may lead the patient down a path of unnecessary investigations, referrals, procedure delays, anxiety, and even inappropriate plasma transfusion, causing potential harm to patient and contributing toward an increased financial burden on the health care system. 1,[6][7][8] The clinical history is an important screening tool for bleeding disorders. 9 To that end, bleeding assessment tools (BATs) such as APTT tests per 100 patients per week), leading to an estimated $6000 in savings per month.…”

“…When assessing a patient with a bleeding history, a physician may be falsely reassured by a normal PT/INR and/or APTT. Conversely, an abnormal PT/INR or APTT may lead the patient down a path of unnecessary investigations, referrals, procedure delays, anxiety, and even inappropriate plasma transfusion, causing potential harm to patient and contributing toward an increased financial burden on the health care system 1,6–8 …”