Prevalence of anemia and therapeutic behavior in the emergency department at a tertiary care Hospital: Are patient blood management principles applied?

doi:10.1016/j.transci.2019.07.006

Transfusion and Apheresis Science

Volume 58, Issue 5, October 2019, Pages 688-692

https://doi.org/10.1016/j.transci.2019.07.006 Get rights and content

Abstract

Background

The aim of this study was to assess the general prevalence and the treatment policy of anemic patients referring to the Emergency Department (ED) of a tertiary care Hospital during 2015.

Study design and methods

The full blood cell count data from patients admitted to the ED for any reason,excepted for those with massive hemorrhage and multiple trauma, were studied. The prevalence of anemic patients and the degree of anemia were recorded, along with the transfusion policy applied. Transfusion appropriateness was retrospectively evaluated with a specific algorithm, that also considered the administered volume of red blood cells. A particular focus was made on patients with microcytosis about the physicians' awareness of the underlying iron deficiency and the consequent iron prescription.

Results

In a group of 22,329 patients the overall prevalence of anemia was 27.5% (6144 patients). Among the anemic patients, 281 / 6144 (4.6%) were transfused. The applied transfusion policy, as evaluated with the algorithm showed an overall good level of appropriateness (74.5% of transfusion episodes) but the appropriateness of the administered red blood cell mass was low (8.8%), due to over-transfusion. In microcytic transfused patients (mean MCV 69.0 ± SD 9.1), the iron balance tests were rarely ordered (22 patients out of 98–22.2%) and intravenous iron was prescribed in only 9 patients out of the 98 eligible (9.2%).

Conclusion

The Patient Blood Management principles should be applied also in the ED setting, to promote a more appropriate and effective clinical approach to anemic patients.

Introduction

Anemia is a widespread medical condition in the general population [1], so this finding can be easy to demonstrate also in a sizable fraction of patients admitted to Emergency Departments (ED). However, reliable studies on the general prevalence of anemia at presentation to the ED and the consequent transfusion policy applied are lacking.

Allogenic red blood cell transfusion (ABT) is the most frequent therapeutic option in anemic patients admitted to the ED, also in hemodynamically stable subjects with chronic anemias and mild symptoms (i.e. moderate tachycardia, shortness of breath, fatigue) with likely or proven iron and/or hematinics deficiency. An increasing evidence is now being accumulated, demonstrating the feasibility and the efficacy of intravenous iron administration in the ED setting [2], even in patients with severe chronic anemia. This approach can be taken into account as a viable alternative to ABT also in the ED patients, according to the principles of Patient Blood Management (PBM) [3].

The primary aim of the present study was to assess the prevalence of anemia in unselected patients referring to the ED and to evaluate the consequent transfusion policy. A retrospective analysis of patients' clinical course highlighted the causes of anemia and evaluated the appropriateness of the transfusion schedule, by means of a specific algorithm. A judgement on the possible therapeutic alternatives to blood transfusion was also made, to be included in educational initiatives among the ED personnel.

The ultimate goals are the future reduction of inappropriate transfusions and a more widespread usage of intravenous iron, when indicated, also in anemic patients admitted to the ED, as included in the Patient Blood Management principles.

Section snippets

Materials and methods

The results of full blood cell counts (CBC) from 22,329 unselected patients admitted for any cause to the ED of the tertiary care Legnano General Hospital, northern Italy, during 2015 were recorded. Patients admitted with severe trauma and/or massive bleeding were excluded from the analysis.

The medical records of the patients who received transfusions were reviewed for the presence of acute bleeding, comorbidities (cardiovascular diseases, diabetes, chronic obstructive pulmonary disease),

Results

Legnano General Hospital is a 600-bed tertiary care hospital located in Northern Italy with a catchment area of more than 470,000 people. In 2015 about 66,000 patients were admitted to ED for any causes. The medical records of 22,329 patients matching our selection criteria were analyzed, whenever a CBC was ordered at admission and recorded.

Limitations

Despite the very large number of analyzed cases, the data collected retrospectively served just to take a picture of the current practice, without a detailed knowledge of the type and professional experience of the ED physicians involved. Moreover, the iron balance tests were introduced only recently in the ED blood testing repertoire at our institution, and systematic educational programs on PBM and alternatives to transfusion were started in 2016 and are still ongoing.

Discussion

Anemia is considered as a worldwide public health problem [6], leading to a series of deleterious clinical consequences and with an enormous impact on social costs [7].

In our geographical area, about a half of patients had chronic anemias linked to their underlying diseases (e.g. hematological malignancies, chemotherapy for cancer, liver and renal diseases, other chronic or inflammatory diseases etc.), the other half had anemia linked to an easily detectable and curable condition, such as iron

Funding

The study was not funded.

References (33)

N.J. Kassebaum et al.
A systematic analysis of global anemia burden from 1990 to 2010
Blood
(2014)
I. Beverina et al.
Extreme Anemia (Hb 33 g/L) in a 13-year-old Girl: is the Transfusion Always Mandatory?
Transfus Apher Sci
(2018)
A. Shander et al.
Patient blood management in Europe
Br J Anaesth
(2012)
S.L. Farmer et al.
Drivers for change: western australia patient blood management program (WA PBMP), world health assembly (WHA) and advisory committee on blood safety and availability (ACBSA)
Best Pract Res Clin Anaesthesiol
(2013)
A. Odutayo et al.
Restrictive versus liberal blood transfusion for gastrointestinal bleeding: a systematic review and meta-analysis of randomised controlled trials
Lancet Gastroenterol Hepatol
(2017)
L. Lieberman et al.
A retrospective review of patient factors, transfusion practices, and outcomes in patients with transfusion-associated circulatory overload
Transfus Med Rev
(2013)
Australian patient blood management guidelines: module 3 – medical. Canberra
(2012)
World Health Organization
Haemoglobin concentrations for the diagnosis of anaemia and assessment of severity
(2011)
World Health Organization and United Nations Children’s Fund. Focusing on anaemia. Towards an integrated approach for effective anaemia control
(2004)
R.E. Smith
The clinical and economic burden of anemia
Am J Manag Care
(2010)

World Health Organization

Iron deficiency anaemia: assessment, prevention and control

(2001)

R. Zimmerman et al.

Posttransfusion increase of hematocrit per se does not improve circulatory oxygen delivery due to increased blood viscosity

Anesth Analg

(2017)

J.L. Carson et al.

Indications for and adverse effects of red-cell transfusion

N Engl J Med

(2017)

H.G. Klein et al.

Crisis in the sustainability of the U.S. Blood system

N Engl J Med

(2017)

A. Shander et al.

Activity-based costs of blood transfusions in surgical patients at four hospitals

Transfusion

(2010)

K.M. Trentino et al.

Increased hospital costs associated with red blood cell transfusion

Transfusion

(2015)

Cited by (14)

Extreme anemia (hemoglobin < 5 G/DL) at the emergency department
2023, European Journal of Internal Medicine
Bloodless Management of the Anemic Patient in the Emergency Department
2022, Annals of Emergency Medicine
Citation Excerpt :
This threshold is based on the disequilibrium of oxygen delivery and extraction as well as the clinical symptoms that occur at higher frequency below this hemoglobin concentration.7 While blood transfusion is the most commonly utilized therapeutic intervention in anemic ED patients, some patients may be unable to receive transfusion of blood products due to medical or religious concerns.2 Autoimmune hemolysis and ABO incompatibility are medical issues that may preclude patients from receiving blood transfusions in the ED setting; however, the majority of patients who are unable to receive blood transfusions are members of the Jehovah’s Witness faith.8
Anemia is a commonly encountered condition in emergency medicine; transfusion of packed red blood cells is commonly performed for anemic patients in the emergency department (ED), but some patients are unable to accept transfusion of blood products due to medical or religious concerns. The unique, acute, and time-sensitive nature of emergency medicine practice requires that physicians maintain an enhanced awareness of bloodless medicine treatment modalities. Identification of bloodless medicine patient preferences in the ED can help guide physicians in the recommendation of acceptable methods of treating anemia in this patient population. A focus on early hemostasis and resuscitation, instead of attempts to convince the patient to accept blood transfusion, can be lifesaving in patients with acute bleeding. Treatment strategies including the use of methods to reduce unnecessary blood loss, enhance red blood cell production, and increase the oxygen-carrying capacity of blood should also be considered early in patient presentation. Timely involvement of the Hospital Liaison Committee can help facilitate successful interpersonal communication and shared decisionmaking between emergency physicians and bloodless medicine patients. By embracing an understanding of bloodless medicine patient needs as well as available treatment strategies, ED physicians can contribute to optimal overall outcomes for anemic bloodless medicine patients.
Attitude changes in prescribing intravenous iron supplementation in different settings at a hospital consortium in Italy
2021, Transfusion and Apheresis Science
Citation Excerpt :
Iron deficiency anaemia (IDA) is the most widespread form of anaemia in the world, affecting about a sixth of the earth’s population [1]. The prevalence of IDA is high in medical [2–4], surgical [5,6] and emergency settings [7] through all ages and genders, with a huge impact on global health [8], transfusion rate [5], length of hospital stay and costs [9]. In haemodynamically stable patients, intravenous iron (IV) preparations instead of blood transfusion should be the treatment of choice when oral iron supplementation is ineffective, poorly tolerated or contraindicated, in case of malabsorption and whenever a rapid increase in haemoglobin is advisable [10–12], such as extreme anaemia [13,14] or upcoming surgery.
Iron deficiency anaemia is a public health problem. In case oral iron treatment is ineffective, poorly tolerated or contraindicated, the intravenous route becomes the first choice.
The aim of the study was to evaluate the shift between ferrous gluconate (FG) and ferric carboxymaltose (FCM) usage at our hospitals over the years. We also performed a cost comparison between pre and post-FCM availability periods, taking into account the acquisition costs of both intravenous iron and red blood cell units (PRBC).
The amount and costs of FG and FCM released by hospital Pharmacy Services from 2010 to 2019 were analysed, along with the number of transfused PRBC units in the same timeframe.
Overall, the proportion of FCM usage rose from 8.6 % in 2014 to 71.9 % in 2019, as percentage of total intravenous iron released. After exclusion of haemodialysis, where FG is still widely used, the FCM use in the last four years raised from 12.9% to 92.5%. Despite the higher FCM cost, the mean yearly expenditure for intravenous iron plus PRBC units did not differ between pre- and post-FCM eras (2010–2013, € 2,396,876 € versus 2014–2019, € 2,307,875 - p = 0.234), as a result of a net decrease of PRBC usage, namely from 15,083 to 12,654 (−16.1 %), respectively.
Intravenous iron has a major role in treating iron deficiency anaemia in several settings. Third generation compounds are paving the way to more updated and safer treatments.
Response to Letter to the Editor “Therapeutic Alternative to Transfusion in Nonpregnant Women With Iron Deficiency Anemia Caused by Uterine Blood Loss”
2021, Journal of Emergency Medicine
Is the Italian consent to transfusion really informed? A medico-legal analysis between old ghosts and new evidence
2020, Transfusion and Apheresis Science
Citation Excerpt :
Even when patients are subjected to the administration of drugs to optimise erythropoiesis, such as intravenous infusions of iron, which inevitably involve some risks, it is reasonable to conclude that these risks are well-known and can be adequately controlled by means of prevention strategies [20] and that “the benefits of all medicines containing iron for intravenous administration continue to outweigh the risks” [21–22]. Therefore, there should be no medicolegal obstacles to the complete implementation of each aspect of Patient Blood Management programs [23–26]. The discipline of informed consent serves as a fundamental clinical activity which guarantees the patient’s exercise of rights.
In healthcare systems of developed countries, obtaining informed consent is a necessary and fundamental requirement for the administration of any medical treatment. In Italy, for the administration of the recipient's informed consent for a blood transfusion, a pre-printed form is used in line with the Decree of the Ministry of Health dated 2 November 2015. This paper aims to analyse this form in light of the European legal provisions and following the enactment of Italian Law No. 219 of 2017 on informed consent and advance treatment directives.
Our review shows that the structure of the form can be improved in light of the new direction provided by Italian law, the scientific advancement on transfusion risks, and the potential to reduce the use of blood components. Revising this form could be the opportune time to include written information on Patient Blood Management strategies. Though not exhaustive, this proposal may stimulate debate on the point and produce further contributions.
Management of Nonpregnant Women Presenting to the Emergency Department With Iron Deficiency Anemia Caused by Uterine Blood Loss: A Retrospective Cohort Study
2020, Journal of Emergency Medicine
Citation Excerpt :
A large retrospective cohort of >22,000 patients in an Italian tertiary care ED identified a high overall prevalence of anemia (27.5%) with a transfusion rate of 4.6% of anemic subjects. Of the patients receiving transfusion, only 22% were assessed for iron deficiency (6). In a chart review of 49 patients with IDA at a tertiary care Canadian ED, Spradbrow et al. found that emergency physicians documented iron deficiency in 61% of cases, while only 55% of discharged patients not already taking iron supplementation received a prescription at discharge (7).
Women with abnormal uterine bleeding are commonly encountered in the emergency department (ED). Contemporary management of severe iron deficiency anemia (IDA) in this setting may be inadequate and expose patients to unnecessary blood transfusions.
We sought to describe the characteristics and management of women presenting to the ED with moderate to severe anemia caused by uterine bleeding. We hypothesized that blood transfusions were frequently administered to stable patients without severe symptoms or active bleeding.
This is a retrospective cohort study of women presenting to the ED from October 31, 2018 to March 31, 2019 with IDA from uterine bleeding. Eligible subjects were adult females with IDA caused by uterine blood loss, hemoglobin ≤10 g/dL, and who were discharged from the ED.
One hundred twenty-seven encounters (117 unique patients, mean 40 years of age) met the eligibility criteria. No patients were hemodynamically unstable and clinically significant active bleeding was rare (6%). Blood transfusion was administered during 70 (55%) encounters, with ≥2 units given to more than half (53%) of those transfused. Subsequent ED visits (14%) and transfusions (16%) during the follow-up period were common.
In this cohort of adult females with moderate to severe IDA caused by uterine bleeding, blood transfusion was often administered in the absence of hemodynamic instability or active hemorrhage, iron deficiency was inadequately treated, and a high rate of subsequent transfusions occurred. Future studies should investigate optimal indications for transfusion and emphasize adequate iron supplementation.

View all citing articles on Scopus

View full text

Prevalence of anemia and therapeutic behavior in the emergency department at a tertiary care Hospital: Are patient blood management principles applied?

Abstract

Background

Study design and methods

Results

Conclusion

Introduction

Section snippets

Materials and methods

Results

Limitations

Discussion

Funding

Blood

Transfus Apher Sci

Br J Anaesth

Best Pract Res Clin Anaesthesiol

Lancet Gastroenterol Hepatol

Transfus Med Rev

Australian patient blood management guidelines: module 3 – medical. Canberra

Haemoglobin concentrations for the diagnosis of anaemia and assessment of severity

World Health Organization and United Nations Children’s Fund. Focusing on anaemia. Towards an integrated approach for effective anaemia control

The clinical and economic burden of anemia

Am J Manag Care

Iron deficiency anaemia: assessment, prevention and control

Posttransfusion increase of hematocrit per se does not improve circulatory oxygen delivery due to increased blood viscosity

Anesth Analg

Indications for and adverse effects of red-cell transfusion

N Engl J Med

Crisis in the sustainability of the U.S. Blood system

N Engl J Med

Activity-based costs of blood transfusions in surgical patients at four hospitals

Transfusion

Increased hospital costs associated with red blood cell transfusion

Transfusion