Iron-deficiency anemia: a medically treatable chronic anemia as a model for transfusion overuse

Improving quality of care for patients with iron deficiency anemia presenting to the emergency department

BACKGROUND

Patients presenting to the emergency department (ED) with iron deficiency anemia (IDA) are underrecognized, undertreated with iron, and overtransfused. A 3-month audit of red blood cell (RBC) transfusions at the Sunnybrook Health Sciences Centre ED in 2013 showed that only 53% of transfusions for IDA were appropriate. The aim of this quality improvement project was to increase the rate of appropriate transfusion to greater than 80%.

STUDY DESIGN AND METHODS

Since November 2013, several quality improvement interventions have been implemented, including educational presentations, development of an algorithm on IDA management in the ED, and development of an ED IDA toolkit. The primary outcome was appropriateness of RBC transfusions per month. The process measure was monthly intravenous (IV) iron use in IDA patients managed exclusively by ED staff. Balancing measures included IV iron use according to the algorithm and undertransfusion.

RESULTS

Over a 24-month period beginning January 2014, assessment of 193 units transfused in the ED showed an improvement of RBC appropriateness to 91% (range 50%-100%). IV iron use increased from one dose in the 3-month audit to an average of 2.6 and 4.7 per month in 2014 and 2015, respectively. IV iron use did not follow the algorithm in 19% (18 of 93) of cases: 12 were given to patients with less severe iron deficiency or bleeding.

CONCLUSION

Improved RBC transfusion appropriateness for IDA in the ED can be achieved and maintained with the implementation of simple educational and practical interventions.

Iron deficiency anemia in the emergency department: over-utilization of red blood cell transfusion and infrequent use of iron supplementation

Objectives

Three are no clinical practice guidelines that specifically address the management of patients with iron deficiency anemia (IDA) in the emergency department (ED). The goal of this study was to describe the characteristics of IDA patients who present to the ED, documentation of IDA by emergency physicians, utilization of iron supplementation, and the appropriateness of red blood cell (RBC) transfusions ordered in the ED.

Methods

A retrospective medical chart review was performed of IDA patients who visited the ED of a large tertiary center over a three-month period. Appropriateness of RBC transfusion was determined using a novel algorithm developed by our institution.

Results

Over the study period, there was a 0.3% (49/14,394) prevalence of IDA in the ED. In thirty (30/49; 61%) patients, IDA was documented by an emergency physician. RBC transfusions were administered to 19 patients; 10 transfusions (53%) were appropriate, 3 (16%) were appropriate for indication, but more than the required number of units were ordered, and 6 (32%) were inappropriate. Of the patients discharged, one (1/25; 4%) patient received intravenous iron in the ED and 6 of the 11 patients (55%) that were not already taking oral iron received a prescription at discharge from the ED.

Conclusions

This assessment demonstrated that management of IDA patients presenting to the ED may represent an important knowledge-to-practice gap. It revealed that RBC transfusion may be over-utilized and could be replaced by safer, lower-cost alternatives such as intravenous and oral iron. Guidelines for management of IDA in the ED may be necessary to achieve consistent IDA management and avoid inappropriate use of RBC transfusion.

Identifying existing Choosing Wisely recommendations of high relevance and importance to hematology

Choosing Wisely (CW) is a medical stewardship initiative led by the American Board of Internal Medicine Foundation in collaboration with professional medical societies in the United States. In an effort to learn from and leverage the work of others, the American Society of Hematology CW Task Force developed a method to identify and prioritize CW recommendations from other medical societies of high relevance and importance to patients with blood disorders and their physicians. All 380 CW recommendations were reviewed and assessed for relevance and importance. Relevance was assessed using the MORE(TM) relevance scale. Importance was assessed with regard to six guiding principles: harm avoidance, evidence, aggregate cost, relevance, frequency and impact. Harm avoidance was considered the most important principle. Ten highly relevant and important recommendations were identified from a variety of professional societies. Recommendations focused on decreasing unnecessary imaging, blood work, treatments and transfusions, as well as on increasing collaboration across disciplines and considering value when recommending treatments. Many CW recommendations have relevance beyond the society of origin. The methods developed by the ASH CW Task Force could be easily adapted by other Societies to identify additional CW recommendations of relevance and importance to their fields. Am. J. Hematol. 91:787-792, 2016. © 2016 Wiley Periodicals, Inc.

Possible neurocognitive benefits of exercise in persons with heart failure

More than 6 million Americans have heart failure (HF) and more than 500,000 are diagnosed each year. In addition to its many adverse medical consequences, HF is also a significant risk factor for neurological disorders like Alzheimer's disease and associated with cognitive impairment long prior to the onset of these conditions. Converging bodies of literature suggest cognitive dysfunction in HF may be at least partially modifiable. One key mechanism for cognitive improvement is improved cerebral blood flow, which may be possible with exercise in patients with HF. This brief review provides a model for the likely neurocognitive benefits of exercise in HF and encourages further work in this area.

Co-morbidities in heart failure

Heart failure is a clinical syndrome characterized by poor quality of life and high morbidity and mortality. Co-morbidities frequently accompany heart failure and further decrease in both quality of life and clinical outcome. We describe that the prevalence of co-morbidities in patients with heart failure is much higher compared to age-matched controls. We will specifically address the most studied organ-related co-morbidities, that is, renal dysfunction, cerebral dysfunction, anaemia, liver dysfunction, chronic obstructive pulmonary disease, diabetes mellitus and sleep apnoea. The pathophysiologic processes underlying the interaction between heart failure and co-morbid conditions are complex and remain largely unresolved. Although common risk factors are likely to contribute, it is reasonable to believe that factors associated with heart failure might cause other co-morbid conditions. Inflammation, neurohumoral pathway activation and hemodynamic changes are potential factors. We try to provide explanations for the observed association between co-morbidities and heart failure, as well as its impact on survival.

The role of blood transfusion in the management of upper and lower intestinal tract bleeding

Patients with gastrointestinal (GI) haemorrhage use 13.8% of all red blood cell transfusions in England. This review addresses the evidence for red blood cell, fresh frozen plasma and platelet transfusions in acute and chronic blood loss, from both the upper and lower intestinal tract. It reviews the indications for transfusion in GI bleeding, the haematological consequences of massive blood loss and massive transfusion, and the importance of managing coagulopathy in bleeding patients. It also looks at the safety and risks of blood transfusion, and provides clinicians with evidence to reduce unnecessary transfusion. Large controlled clinical trials of blood transfusion specifically in GI bleeding are required, along with further research into the use of adjuvant therapies such as recombinant activated factor VIIa. Changing clinician behaviour to reduce inappropriate blood transfusion remains a key target for future transfusion research.

The transfusion audit as a tool to improve transfusion practice: a critical appraisal

Transfusion audits have a long history and they are required by many regulatory agencies. These audits have been touted as effective in reducing unnecessary transfusions as evidenced by many published articles on the subject. Most of these studies, however, have one or more flaws in their design including the use of historical controls, disregard of the Hawthorne effect, use of multiple interventions, and publication bias. Studies differ in the baseline rate of inappropriate transfusions and have different methods of measuring these rates. There is also little data on how long the effect of implementing a transfusion audit system may last. Transfusion audits appear most successful when there is a high baseline rate of inappropriate transfusions and interventions other than the audit itself are performed. Individual institutions should critically evaluate whether or not their current system of transfusion audits is useful.