Background: The most common cause of Iron Deficiency (ID) in men and post-menopausal women is gastrointestinal (GI) bleeding. Despite the high prevalence of ID in patients with GI bleeding, patients admitted to the hospital with GI bleeding are under recognized and undertreated for ID. Patients with severe GI bleeding requiring blood transfusions are at risk of profound ID and benefit from iron replacement prior to discharge. Randomized trials of iron repletion following hospital discharge for patients with GI bleeding have shown improvement in anemia at follow up. Moreover, intravenous (IV) iron may be better tolerated in this population and more reliably absorbed compared to oral iron, ensuring adequate iron repletion. Although modern IV iron formulations are generally safe, only iron dextran can provide an adequate dose of 1000 mg in a single infusion and is relatively inexpensive compared to other IV iron formulations.

Objective: A quality improvement project to improve delivery rate of IV iron to patients with severe GI bleeding from a baseline of 19% to 40% by and to promote the use of IV iron dextran as the preferred IV iron formulation from a baseline of 11% to 50% by April 2025.

Methods: We identified patients with ICD10 diagnosis codes for GI bleeding and/or Iron Deficiency Anemia and a blood transfusion within the same hospital encounter. Our primary outcome measure was the proportion of these patients who received an IV iron infusion. Our primary process measure was the proportion of patients who received an IV iron infusion with iron dextran or ferric gluconate for any indication other than heart failure or ESRD on dialysis. The primary balancing measure was the increased cost per patient receiving IV iron dextran. We used the quality improvement methods of process mapping, cause-and-effect (Ishikawa fishbone) diagram, and Pareto chart to identify key opportunities for change. There were 3 Plan-Do-Study-Act (PDSA cycles) within the follow up time-period. 1) PDSA 1 in June 2024 consisted of a hospital-wide transition to EPIC as the electronic medical record, 2) PDSA 2 in September 2024 consisted of a lecture to internal medicine house staff and the creation of an educational reference “one-pager” to providers, and 3) PDSA3 in January 2025 consisted of an update to the IV iron dextran order to include a linked order with guidance to recognize and manage non-severe iron infusion reactions. We used statistical process control (SPC) p-charts to determine the impact of each process change. The project was supported via the American Society of Hematology Quality Improvement Training Institute.

Results: Between May 2023 – April 2024, the baseline proportion of patients with severe GI bleeding who received a blood transfusion and IV iron was 19% and the baseline proportion of IV iron infusions that were iron dextran was 11%. The cost of 1000 mg of IV iron dextran was $337.20, leading to a weighted cost of $37.09 per patient. By April 2025, the primary outcome measure was seen in 24% of patients and the primary process measure was seen in 65% of patients. The weighted increase in cost per patient by increasing the proportion of IV iron dextran administrations was $182.09.

Conclusions: An increase in the proportion of IV iron dextran utilization was seen over the course of this quality improvement project; however, the proportion of patients being treated with IV iron was relatively stable. Subsequent PDSA cycles should focus on clinical care pathways and electronic medical record alerts to more reliably identify patients at risk of ID who could benefit from IV iron therapy prior to discharge.

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2025
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