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Reducing the Need for Red Cell Transfusions

Project Added:
13 December 2016
Last updated:
20 January 2017

Reducing the Need for Red Cell Transfusions


This project resulted in the implementation of a guideline in the emergency department (ED) to help staff manage patients with chronic anaemia due to iron deficiency.


To reduce the number of red cell units given to iron deficient patients in the ED of Nepean Hospital by 50%, and reduce the rate of post-operative blood transfusions in iron deficient patients who attend the preadmission clinic (PAC).


  • Reduces the number of red cell transfusions in iron deficient patients.
  • Improves the health of iron deficient patients.
  • Reduces the number of transfusion reactions, including the formation of allo-antibodies which can lead to problems in future pregnancies.
  • Reduces the costs associated with blood products, equipment, staff, and transfusion complications.


Prior to the project, haematologists and staff working in the blood bank at Nepean Hospital were aware of instances where blood transfusions were provided to iron deficient patients who presented to the ED or were admitted for elective surgery. It was generally agreed that patients could avoid blood transfusions or only receive a single unit of red cells, by having their iron deficiency treated with supplements prior to surgery or while in the ED.

In women of childbearing age, red cell transfusions for subacute or chronic anaemia can often be avoided. Patients can be treated with oral or intravenous iron. In older patients, ED staff should refer the patient for appropriate investigation of the iron deficiency, as it can reveal an underlying issue such as bowel cancer.


  • An audit of patients attending the PAC was undertaken between January and December 2015, to determine the number of patients who were iron deficient prior to surgery and who received postoperative blood transfusions.
  • An audit of all patients who received blood transfusions in the ED over a three-week period in May and June 2016 was undertaken. The number and characteristics of those who had or were likely to have iron deficiency was also recorded.
  • A guideline was developed for use in the ED, to help staff assess and manage iron deficient patients.
  • A process of sharing the guideline with general practitioners who may send patients with iron deficiency to the ED is currently underway, in consultation with Nepean Blue Mountains Primary Healthcare Network.

Project status

Implementation - the initiative is ready for implementation or is currently being implemented, piloted or tested.

Key dates

  • Preadmission clinic audit: January 2015 to December 2015
  • Emergency department audit: May to June 2016
  • Project implementation: October 2016
  • Final evaluation: January 2017

Implementation sites

Nepean Hospital, Nepean Blue Mountains Local Health District


Clincial Excellence Commission. Clinical Leadership Program


  • The presence of iron deficiency in patients attending the PAC was very small. As such, the existing processes in place were deemed sufficient in preventing unnecessary blood transfusions in ED patients.
  • Out of 22 patients who received a blood transfusion in the ED:
    • six had a likely or proven iron deficiency
    • six had a reduced mean corpuscular volume (MCV), with one of those patients diagnosed with probable haemoglobinopathy
    • one patient was iron deficient with reduced ferritin, though his MCV was in the normal range.
  • Of the six iron deficient patients in the ED, four received blood transfusions, with two of those patients identified as having menorrhagia.
  • Results will be audited three months post-implementation (January 2017), to determine whether the guideline has reduced transfusions in surgical patients.

Lessons learnt

  • Although staff suspected there were patients in the PAC with an undetected iron deficiency, this did not prove to be the case. The lesson here is that before embarking on a clinical improvement project, it’s important to determine whether a problem truly exists in the first place.
  • Once people who share values form a team, solutions can be implemented more easily. However, ongoing audits are required to determine whether the solutions are successful in achieving sustainable change.

Further reading

  • Quintana-Díaz M, Fabra-Cadenas S, Gómez-Ramírez S et al. A fast-track anaemia clinic in the Emergency Department: feasibility and efficacy of intravenous iron administration for treating sub-acute iron deficiency anaemia. Blood Transfusion 2015; 14(2): 126-133.


John Giannoutsos
Haematology Staff Specialist
Nepean Hospital
Nepean Blue Mountains Local Health District
Phone: 0428 242 922

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