Reduction in plasma transfusion after enforcement of transfusion guidelines

The majority of fresh-frozen plasma (FFP) is transfused in the United States in the management of acquired bleeding disorders. The prothrombin time (PT), and its derivative the international normalized ratio (INR), is the most common test used to detect the presence and gauge the severity of these disorders. Observation studies have shown that the PT correlates poorly with clinical bleeding and that transfusion of plasma often achieves no measurable change in the INR nor is of any known clinical benefit.

Data on FFP and red blood cell transfusions and measures of hospital activity and mortality were collected over a 12-year period. The first 3 years were baseline years, the next 3 years were physician education years, and in the last 6 years all requests for FFP were screened. Orders were discouraged if the INR was less than 2.0 in the absence of active bleeding and the use of vitamin K was encouraged if the patient was taking warfarin.

This program ultimately resulted in an approximate 80% reduction in transfused FFP using the average of the baseline years compared to the average of the last 3 years (157 ± 19 units FFP/1000 discharges vs. 30 ± 15, p < 0.01, respectively). Overall, hospital activity remained largely unchanged or increased. No unexpected bleeding was reported, which was attributed to a failure to transfuse FFP, and inpatient mortality rate decreased during these 12 years.

A program of engagement and interdiction using evidence-based guidelines can successfully decrease the use of FFP without any observable increase in unexpected bleeding.