Standard 12 - Management of Anemia in Hospitalized Patients Tiffany Nelson, RN BSN Eastern Maine Medical Center Bangor, Maine

Conflict of Interest I have no conflicts of interests to disclose.

Objective Describe one process for early identification and treatment options for the anemic hospitalized patient to reduce the risk of transfusion.

Standard 12 - Management of Anemia in Hospitalized Patients There is a process for early identification of patients at risk for transfusion due to anemia or at risk for developing anemia during the course of their hospitalization. Anemia is managed to reduce the likelihood of transfusion.

Guidance An important part of a patient blood management program is to evaluate a patient’s risk of transfusion and then take steps to reduce that risk.

Guidance Many patients admitted to the hospital are anemic as a result of their admission diagnosis or co-morbidity. Anemia is a common complication of common diseases Prevalence of anemia in selected conditions Rheumatoid arthritis: 30-60% Chronic heart failure: 30-50% Inflammatory bowel disease: 30-80% Diabetics without overt renal failure: 20-40% Chronic kidney disease: 40-60%

Guidance Many patients are at risk to develop anemia while in the hospital Unavoidable surgical or procedural blood loss Hemolysis Inflammation Iron deficiency Malignancy Other nutritional deficiencies A primary hematologic problem.

Guidance Recognition, diagnosis, and initial treatment of anemia as early as possible prior to and during an inpatient admission may help avoid the need for transfusion during that hospital admission as well as after discharge or during a future hospital admission. Since anemia is associated with poor outcomes in a variety of conditions, treatment of anemia without use of allogeneic red cell transfusion may improve patient outcomes independent of the outcome improvement associated with successfully avoiding transfusion.

Guidance The CBC establishes the diagnosis of anemia and provides additional information on possible etiologies based on the red blood cell indices and the presence or absence of other hematologic abnormalities. Significant additional information on the probable etiology of the patient’s anemia can be obtained from the clinical history, and additional laboratory testing easily available with minimal additional blood sampling. Guided by the clinical history and red blood cell indices, this additional testing might include creatinine, reticulocyte count, iron and iron binding capacity, ferritin, vitamin B12, folate, thyroid stimulating hormone, red cell antibody screening, and direct antiglobulin test.

Guidance In some instances, secondary testing may be indicated. Based on the clinical history and the results of initial laboratory tests, additional studies might include additional tests for hemolysis, serum protein electrophoresis, erythropoietin level, methylmalonic acid, soluble transferrin receptor, or even bone marrow exam. Based on the etiology, treatment should be considered as early as possible prior to or during the hospital admission to optimize the patient’s hemoglobin and minimize the likelihood of transfusion.

12.1 Clinical leaders of the blood management program have knowledge and experience in the recognition, diagnosis, and management of anemia. Does your program have a physician medical director who has knowledge of transfusion medicine and modalities to reduce patients’ exposure to allogeneic blood transfusions? Examples: surgeon, anesthesiologist, hematologist, intensivist, pathologist Does your program have a manager with training as a nurse, pharmacist, medical technologist or other individual with prior knowledge and experience in transfusion medicine or blood management? This person should have a working knowledge of indications and contraindications of blood and blood component use and other treatment modalities.

12.2 There is a policy requiring that anemia be documented as part of the early clinical assessment of all patients. Does your program have a policy? Where is your policy? Policy can be written into PBM departmental policies, admission process policy, patient care directives. Who evaluates the compliance with the policy? Does your hospital have problem list on admission?

12.3 Hospital protocols facilitate appropriate diagnosis, evaluation, and management of anemia. Management strategies help minimize the likelihood of transfusion. What protocols does your program utilize? Anemia management evaluation, anemia treatment algorithms, transfusion risk assessment tools, minimum blood volume protocols. Are your protocols electronic or paper?

Examples of protocol Electronic Rule can be implemented to “fire” based on criteria set by PBM for minimum blood volume protocol.

Minimal Blood Volume Rule Algorithm Patient age greater than 4 months and location of 1ICU, 1ICUA, 1CCU, or 1CSU Hgb less than 8 mg/dL or patient’s religion is Jehovah’s Witness Minimal Blood Volume Labs order added to Profile:  

Collected lab volumes are summed Nursing Action Steps Provider Action Steps Minimal Blood Volume Labs order contains these Nursing and Lab action steps: Nursing: (1) Place Blood Conservation sign over head of bed. (2) Convert nurse collections to microtainers and IStat as appropriate per Minimal Blood Volume Chart. (3) Add Safeset reservoir with blood sampling port when feasible. (4) Review the need for daily labs with medical team. (5) Consolidate labs whenever possible.   Lab: (1) Convert lab collections to microtainers. Collected lab volumes are summed Maximum allowable weight-based 24 hour blood volume is exceeded. Alert fires to Nurse, RT, and provider. Nurse and RT contacts provider: Blood Conservation Sign Minimal Blood Volume Chart prints at nursing station: available on nursing unit: Provider reviews Profile and modifies lab orders to minimize blood loss.

12.4 There are guidelines for the use of intravenous iron and erythropoietic stimulating agents. Does your hospital have guidelines in place? Who is responsible for writing your guidelines? How often do you review your guidelines?

12.5 Is this built into your hospital’s transfusion ordering process? Hospital transfusion guidelines recommend against transfusion in asymptomatic, non-bleeding patients when the hemoglobin level is greater than or equal to 6.0 -8.0 gm/dL. Is this built into your hospital’s transfusion ordering process? How do you handle situations when providers order transfusion that don’t meet the guidelines? Do you have a process to direct the provider to orders for anemia evaluation and treatment? What resources do you have for clinical staff?

12.6 Clinical strategies to optimize hemodynamics and oxygenation are followed before red cell transfusion is considered. How does your program implement these strategies? Do you have any educational sessions for staff?

12.7 Transfusion of blood and/or components is never used for volume repletion or to treat anemia that can be treated with specific hematinic medications. Is there a way to evaluate whether transfusion is ordered in stable patients with labs showing iron deficiency? Is there review of use of volume “expanders” such as albumin, crystalloids, HES solutions in Transfusion committee or elsewhere? Discussion of blood use for volume at ICU/OR/ED committees

12.8 When red cell transfusion is clinically indicated in the non-bleeding patient, only a single unit of red cells is prescribed, followed by clinical reassessment of the patient. Do you have a housewide metric for % of red cells ordered as a single unit? (Should be > 85% for non-bleeding patients) Hard stop preventing multi units in non-bleeding patient

Conclusion Anemia is BAD Anemia is to be avoided Anemia should be evaluated and treated treating the anemia may improve outcomes and shorten length of stay Transfusion for anemia, except in hemodynamically unstable bleeding patients, has never been shown to be effective.

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