Shared learning database

 
Organisation:
NHS Blood and Transplant
Published date:
August 2014

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.

Guidance the shared learning relates to:
Does the example relate to a general implementation of all NICE guidance?
No
Does the example relate to a specific implementation of a specific piece of NICE guidance?
Yes

Example

Aims and objectives

Earlier investigations have indicated that that Fresh Frozen Plasma (FFP) may be associated with high rates of inappropriate transfusion with some studies indicating rates of up to 50% non-compliance with established guidelines. The current British Committee for Standards in Haematology (BCSH) guidelines on the use of FFP aim to reinforce the message regarding avoidance of its inappropriate use. NICE guidance on the management of acute upper gastrointestinal bleeding (CG141) make similar recommendations and recent audits have shown that gastrointestinal bleeding accounts for a significant proportion of the use of this component. Evidence of the inappropriate use of this product persists however. This audit against recommended standards, was undertaken to review its use across the East Midlands region and to ascertain if there have been any changes in the use of this component following previous audits and recommendations.

Reasons for implementing your project

NHS Blood and Transplant supplies blood components to hospitals across the UK, Northern Ireland and North Wales. Transfusion of blood components is not without significant risks if these components are used incorrectly. NHSBT carries out internal and external audits of blood component use on a regional and national basis to help ensure these components are used in accordance with recommended guidelines and standards. FFP is one such component. FFP should not be used in the absence of bleeding where coagulation parameters are normal or near normal. FFP when used, should be given in adequate dosages that relate to the patients weight; although some caution should be used if the patient is obese. In 2009, a national comparative audit (NCA) of FFP use in 4635 cases was undertaken. This was complimented by regional audit activity. These earlier audits demonstrated that:
- 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

An audit sub group of the East Midlands Regional Transfusion Committee was formed. The group consisted of two consultant haematologists and Transfusion Practitioner representatives from hospitals in the East Midlands region (EMRTC). The regional transfusion practitioners elected to undertake the data collection using a hard copy data collection form. The form was a modification of a developed audit form used by a large teaching hospital in the region. In addition, an organisational audit was undertaken and issued once to each site.

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

Key findings

Nine sites completed the organisational questionnaire. Clinical data on FFP use was collected on 167 patients. 29% of cases were given FFP for massive haemorrhage. 15% of cases of FFP use associated with gastrointestinal bleeding and a further 13% of cases of FFP use were patients with liver disease. 13% were surgical cases and 7% were given FFP as a consequence of abnormal coagulation parameters. The remaining 25% of cases were associated with plasma exchange (4%), warfarin reversal (3%) and single case submissions of disseminated intravascular coagulopathy (DIC), factor deficiencies and other bleeds. The dataset indicated a mean age of 52 years (1 - 99 years), 75 (48%) female, 90 (51%) male, 2 no gender submitted. Standard 1 FFP should be used in appropriate situations as defined by current guidelines.

- 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

Improvements resulting from audit are iterative and require repeats over time. FFP continues to be transfused in the absence of bleeding or significant coagulopathy. This audit shows no improvement in this area of clinical practice since the earlier NCA audit of 2009 apart form the the use of this component for Warfarin reversal. 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. In summary, this audit shows that FFP continues to be frequently used in the absence of bleeding and / or evidence of abnormal coagulation, and thus highlights the need for concerted efforts in the education of clinicians who prescribe FFP. The use of FFP for Warfarin reversal has greatly improved. While it is not possible to directly attribute this improvement to audit, it may suggest that multiple audit coupled with education programmes directed at specific aspects of practice do influence clinical behaviour over time.

Recommendations:
- 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.

Contact details

Name:
Brian Hockley
Job:
Audit Manager
Organisation:
NHS Blood and Transplant
Email:
brian.hockley@nhsbt.nhs.uk

Sector:
Is the example industry-sponsored in any way?
No