Bridging evidence and practice: the role of implementation science to optimize plasma transfusion in cirrhosis

Despite growing evidence and updated clinical practice guidelines discouraging routine plasma transfusions in patients with cirrhosis, real-world practice is inconsistent with current recommendations. Inappropriate use of fresh frozen plasma remains a common challenge, often driven by multiple factors including misinterpretation of coagulation tests such as the prothrombin time and International Normalized Ratio. Unnecessary plasma use is particularly prevalent as prophylaxis in the periprocedural setting. In this perspective article, we summarize current understanding of hemostasis in cirrhosis, highlighting the limited efficacy and potential harms of prophylactic fresh frozen plasma transfusions and the rationale underlying recent guideline recommendations. We then examine how the field of implementation science can be used to address the persistent evidence-practice gap in plasma transfusion. We propose a structured, stepwise roadmap to support implementation of plasma transfusion guidelines in cirrhosis, encompassing environmental scanning and precise clinical behavior specification, followed by identification of barriers and enablers, selection of tailored implementation strategies, and evaluation of implementation outcomes. This roadmap translates established implementation science frameworks into a clinically focused approach tailored to transfusion practice. Specific strategies such as audit and feedback, clinical decision support systems, education, and institutional policy reform are discussed as context-dependent approaches that can be aligned with locally identified barriers and enablers. Applying structured, theory-informed implementation approaches can help translate guideline recommendations into consistent clinical practices.