Hospital variation in adoption of balanced transfusion practices among injured patients requiring blood transfusions

Background: This study sought to measure hospital variability in adoption of balanced transfusion following the Pragmatic, Randomized Optimal Platelet and Plasma Ratios (PROPPR) guidelines. We hypothesized hospital adoption rates of balanced transfusion would be low, and vary significantly among hospitals after controlling for patient, injury and hospital characteristics. Study Design and Methods: This was an observational cohort study of injured adult patients (≥16 years) in Trauma Quality Improvement Program hospitals 2016–2021. Inclusion criteria were hypotensive patients receiving one transfusion of packed red blood cells, fresh frozen plasma, platelets, or cryoprecipitate. Balanced transfusion was defined as ≥1 ratio of plasma to packed red blood cells or platelets to packed red blood cells or whole blood use at 4 hours. Hierarchical multivariable logistic regression quantified residual hospital-level variability in balanced transfusion rates after adjusting for patient and hospital characteristics. Results: Among 172,457 injured patients who received transfusions, 30,386 (17.6%) underwent balanced transfusion. Patient-level balanced transfusion rates were 11% in 2016, rose to 14.0% in 2019, and jumped up once whole blood transfusions were measured to 24.0% in 2020 and to 25.9% in 2021. Approximately 26% of the variability in balanced transfusion rates was attributable to the hospital. Verified level I hospitals had a 2.09 increased adjusted odds of balanced transfusion (95% CI 1.88–2.21) compared to nonverified hospitals. University teaching status had a 1.29 increased adjusted odds of balanced transfusion (95% CI 1.08–1.54) compared with community hospitals. Overall, 150 (23.5%) hospitals were high outliers (high performing) in balanced transfusion adoption and 124 (19.4%) hospitals were low outliers. Conclusion: There was significant variability in hospital adoption of balanced transfusion.