This audit describes current use of Fresh Frozen Plasma in hospitals in the East Midlands Region. Its use is audited against current guidelines from the British Committee for Standards in Haematology and NICE guidance on the management of acute upper gastrointestinal bleeding. It describes a prospective case audit of 167 patients in this region.
Aims and objectives
Reasons for implementing your project
- FFP was used for warfarin reversal in 26% of the cases audited
- 43% of cases given FFP had no indication of active bleeding
- 8% of cases given FFP had no record of pre-transfusion coagulation data
- 14% of cases given FFP had no record of post-transfusion coagulation data
- 40% of adults received inadequate doses of FFP as determined by body weight Following this work, dissemination coupled with education was undertaken across the regions. This audit was undertaken to determine current use of FFP and to see if any improvements in the use of this component in relation to recommended guidance, had occurred.
How did you implement the project
Appropriate governance arrangements were implemented and approval to participate in the audit obtained. Caldicott Guardians in each participating site were also informed. One hospital elected not to take part on practical grounds. Each site that elected to participate in the audit was asked to collect information on FFP use for a total of 20 cases per site using the data collection tool. A pragmatic time frame was adopted which was later extended.
Data collection was undertaken by local transfusion practitioners and took place during the summer of 2013 until November of the same year. Completed forms were returned to the RTC data analyst and audit facilitator. Information was manually entered into an Excel spreadsheet and analysed proportionately (n, %). Data anomalies were discussed and followed up at a subsequent RTC meeting before final analysis. No overt identifying patient details were taken and hospitals have been anonymised in the report. Where data anomalies could not be resolved, the data was discarded. The data collection form was designed to collect information to enable comparison to guideline standards. The organisational questionnaire gathered information regarding local policy on FFP use, size of hospital, type(s) of FFP used and access to specialised coagulopathy assessment tools. The principle clinical audit standards that were applied to this project were: 1. FFP should be used in appropriate situations as defined by BCSH guidelines and recent NICE guidance on the management of acute upper gastrointestinal bleeding (CG141) 2. FFP dosage should be based on the weight of the patient 3. Coagulation screening should be performed pre and post transfusion
- 52% of patients with GI bleeding had FFP where the pre transfusion prothrombin time was less than 18 seconds. Prothrombin time was the principle assessment made (92% of cases with GI bleeds).
- In 46% of cases, FFP was transfused in the absence of any bleeding. The NCA in 2009 reported this figure as 43%, indicating no improvement in clinical practice.
- FFP is used where there is little or no evidence of abnormal coagulation in over 30% of cases and these figures have not changed substantially since the NCA in 2009 Standard 2 FFP dosage should be based on the weight of the patient.
- Where data was available (132/167, 79% of cases), 39% were under transfused and 17% were over transfused based on weight (Kg) and volume given (mls). Standard 3 Coagulation screening should be performed pre and post transfusion.
- 88% of patients receiving FFP had a pre-transfusion blood coagulation assessment with appropriate tests. However only 37% had these tests carried out within 3 hours after the transfusion.
- The NCA 2009 reported that FFP was used to reverse warfarin in 14% of cases audited. In our audit this figure was 3%, indicating a significant improvement in this region.
- This audit also shows a significant variation in the dose of FFP transfused. There was evidence of both under and over-transfusion based on the dosage recommended in the BCSH guideline.
- Pre transfusion coagulation parameters were reported for the majority (98%) of cases. However post-transfusion coagulation parameters were reported for 62% of cases, and only 37 % had coagulation checked within 3 hours FFP transfusion.
Key learning points
- Hospitals should have locally agreed speciality specific, guidelines for the use of FFP. As a minimum, specific local guidelines should address the use of FFP in liver patients, cardiac surgery, trauma, Intensive Care Units and Neonatal units.
- These guidelines should define appropriate dose (mls /Kg) of FFP.
- Hospitals should have local guidelines on the reversal of anticoagulation with warfarin and other vitamin K antagonists. This guideline should clearly define exceptions where the use of FFP may be appropriate in addition to vitamin K, when Prothrombin Complex Concentrates (PCCs) are contra-indicated.
- Clinicians who prescribe FFP should be familiar with the guidelines for their specialty (e.g. NICE guideline CG141).
- Each high user clinical specialty should perform regular (annual) audits of compliance with local and national guidelines.