ATLANTA — Inappropriate blood transfusions given in the emergency department (ED) to individuals with iron deficiency anemia was reduced by implementing a set of relatively simple strategies.
“We were able to show that we improved the appropriateness of red cell transfusion for iron deficiency in the emergency department,” said Yulia Lin, MD, an associate professor in the Department of Clinical Pathology at Sunnybrook Health Science Centre/Research Institute, Toronto, Ontario, Canada. “And that it can be achieved and maintained at least over a couple of years with the implementation of several practical and simple interventions.”
The main keys to success, Dr Lin noted, were the “engagement of the emergency physicians and the teams in developing our algorithm and toolkit, and really the recognition of iron as a more effective treatment in stable patients.”
“We have also had some local hospitals implementing elements of this program with some success so we think this is really an example of a scalable intervention,” said Dr Lin.
She presented the results of this quality improvement project here at the at the American Society of Hematology (ASH) 2017 Annual Meeting.
Last year, the American Board of Internal Medicine Foundation launched a new component of the Choosing Wisely campaign — the Choosing Wisely Champions program, which is a national initiative to recognize the clinicians who are leading efforts to reduce overuse and waste in medicine.
More than a dozen leading medical specialty societies are participating in the program, including ASH.
Dr Lin was selected as an ASH Choosing Wisely Champion, and the findings from her project were selected to be presented at this year’s meeting at a special session where “champions” could share the details of their work.
“Underdiagnosed and Overtransfused”
“Iron deficiency is common, and when its severe, patients are referred to emergency departments in some cases and transfused,” said Dr Lin. “But the literature suggests that iron deficiency anemia in the ED is underdiagnosed and overtransfused.”
This issue has been recognized by the AABB (previously American Association of Blood Banks), and one of their own Choosing Wisely statements says, “Don’t transfuse red blood cells for iron deficiency without hemodynamic instability.”
The AABB points out that blood transfusion has become a routine medical response even though cheaper and safer alternatives exist in some settings. Oral and/or intravenous iron should be given for preoperative patients with iron deficiency and patients with chronic iron deficiency who are hemodynamically stable.
Iron deficiency anemia is common, Dr Lin pointed out, ranging from 1% in men to 5% in women and up to 30% during pregnancy.
Overtransfusion is a problem not only for the patient but for the ED and healthcare system.
“For the patient, there may be a better therapy — in this case iron supplementation,” she said. “They are exposed to the unnecessary risk of transfusion complications, and many of these patients are women of childbearing age, so this increases the risk of alloimmunization, which can impact future pregnancy.”
For the ED, there is an impact on patient flow, as transfusion and testing take up more time and resources than do intravenous and oral iron supplementation.
For the healthcare system overall, this can lead to poor use of a limited resource and increased cost.
“In Canada it cost $425 for red blood cells, and this is before it goes through the hospital processes, while iron is $145,” Dr Lin pointed out.
Multipronged Approach
The quality improvement project reported by Dr Lin at the meeting involved several steps: first identifying the problem and then developing interventions that could be easily used in the real-world setting.
The first step was finding a way to recognize patients coming into the ED at their institution with iron deficiency anemia. “It’s not that common, and this was actually quite challenging…as we didn’t have a triage screening tool,” she commented.
There is a rapid turnaround ferritin test, but this was not available in their facility’s lab. The solution that was finally agreed upon was to focus on the ability of clinicians to recognize iron deficiency anemia from the use of simple lab tests that they might be ordering.
The second step was in managing the patients, and Dr Lin emphasized that many of the ED physicians had — surprisingly — never heard of alternatives, such as infusing iron. “This was new to them and something they needed more comfort with and to be educated about,” she said.
The third step was the intervention. An education session was held in November 2013 for the ED physicians, and then from December to March 2014, intravenous iron was made readily available in the ED.
Further interventions included access to a transfusion specialist for guidance (April 2015), an emergency medicine podcast (May 2015), the development of an algorithm on iron deficiency anemia management in the ED (April to October 2015), and finally the development of the ED iron deficiency anemia toolkit (July to November 2015).
“We had an education podcast which was quite popular,” said Dr Lin. “And our toolkit included patient education, preprinted orders to make it easy for doctors, an oral iron prescription to give to patients on their way out, and a note to send to the family doctor to recheck and follow up, and to investigate the cause of the anemia.”
“We are trying to spread and disseminate information that there are alternatives to sending the patient to the [emergency room],” she added.
Transfusion Declined, Iron Use Increased
The appropriateness of treatment was determined by using an algorithm that was developed by two transfusion specialists with input from ED staff at their facility. The process measure for their evaluation of the project was monthly Intravenous iron use in patients with iron deficiency anemia who were managed exclusively by ED staff.
Balancing measures included use of intravenous iron as per the algorithm and undertransfusion, which was defined as a patient with a hemoglobin level less than 6 g/L who did not receive a transfusion.
The authors then assessed quality improvement, looking at the rate of appropriate transfusion in patients with iron deficiency anemia who presented to the ED between January 2014 and December 2015.
“We were able to maintain appropriateness of transfusion to 91%, which was above our target of 80%,” said Dr Lin.
The use of iron in patients with iron deficiency anemia increased from only one dose between August and October 2013 to an average of 2.6 per month in 2014 and 4.7 per month in 2015. “We are now at 10 iron infusions a month,” she said.
Regarding the other side of the coin — potential undertransfusion —18 of 90 patients with a hemoglobin level less than 6 g/L were not transfused. In this group, 7 declined a transfusion, 6 were admitted/referred to an inpatient team, and 4 were asymptomatic and received intravenous iron.
“One patient was mildly symptomatic and received iron, but we heard later on that she went to a different hospital and was transfused,” said Dr Lin.
As for adverse events, 1 patient who received a transfusion had circulatory overload and was admitted to the hospital, and 1 patient who received iron had syncope, which may have been partly due to the anemia, she added.
Dr Lin disclosed relationships with CSL Behring, Grifols, Novartis, Pfizer, and Octapharma.
American Society of Hematology (ASH) 2017 Annual Meeting. Presented December 11, 2017. No abstract
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