Background: Early formulations of intravenous (IV) iron were associated with anaphylaxis and have since been removed from the market. Despite this, healthcare workers remain anxious about potential for reactions. Premedication with acetaminophen and diphenhydramine are often ordered for IV iron infusions, but these do not prevent reactions, can worsen reactions, and lead to longer appointment times. Expert guidelines from the American Journal of Hematology recommend premedication consideration only for those having substantial risk factors of reactions (i.e. multiple drug allergies or prior reactions to IV iron formulas). More commonly seen is a complement mediated, pseudo-allergy that is dependent on infusion rate and improves after stopping the infusion. Between 2024-2025 amongst all ordering providers, 12,367 IV iron infusions were administered at Thomas Jefferson University Hospital outpatient infusion centers and 3071infusions (24.8%) were administered with premedication. Amongst hematology providers, November 2024-March 2025, the rate of premedication use was 5.4% of 902 total infusions. Our AIM is to decrease the percentage of premedications ordered for classical hematologypatients, with all formulations of IV Iron from 5.4% to 4.1%, an overall 25% reduction, between April 1st, 2025, to July 31st, 2025. Participants include physicians and advanced practice clinicians (APC) of the classical hematology department, infusion center nursing staff, and pharmacists. This project was completed as a part of the American Society of Hematology's Quality Improvement Training Institute.

Methods: The Plan Do Study Act (PDSA) method of quality improvement was implemented for this project. Baseline assessment included evaluation of the number of IV iron doses ordered, frequency of premedications, ordering providers, location of infusion, rate of medications used for hypersensitivity reactions, and rate of emergency room visit attributed to infusion related reactions of IV iron. A survey was sent to outpatient providers and APC who order IV iron to assess ordering practices of IV iron premedications; this survey allowed us to further assess reasoning of providers who order premedication and potential areas for intervention. A literature review was performed to establish the safety of IV iron and create an infographic.

Intervention: The focus of this project was the classical hematology group, given the volume of infusions ordered within the practice; the team included 4 physicians and 3 APC. PDSA 1 (April 22nd, 2025-May 29th, 2025) included education to this group on the safety of IV iron, coupled with the request to no longer order premedication for IV iron treatment plans and remove premedication for existing plans. Methods of communication included email, and in person discussions. PDSA 2 (July 1st, 2025-July 31st, 2025) provided education to the infusion center staff and patients with an educational infographic, physically placed in infusion centers- visible to patients and staff. This was accompanied by direct discussion to infusion center nurses.

Results: After PDSA 1's educational intervention, premedication orders with IV iron decreased from 5.4% to 3.1% (chi square, p=0.049). Reuslts of PDSA 2 showed further decrease from 3.1% to 0.8% (chi square, p=0.172). There was no change in the use of hypersensitivity medications. There were 2 Emergency Room (ER) encounters attributed to potential side effects from IV iron, as well as 1 ER enounter post intervention. All 3 patients were pregnant, presented due to increase in post infusion blood pressure (BP), and were admitted to the hospital for BP monitoring.

Conclusions: Educational interventions for the hematology department and infusion center staff on the safety of IV iron formulas, reduced the rate of premedication ordered for IV iron treatment plans from 5.4% to 0.8%, an overall reduction in 85.1%, with no increase in the use of hypersensitivity reaction medications. Total saved time post intervention was 480 minutes over 3 months between PDSA 1 and 2. Continued focus on specific populations, i.e. pregnant women, receiving IV iron formulations is necessary given hospital admissions noted post infusion for BP monitoring. We hope to showcase these encouraging results regarding the safety of IV iron to other departments and across the enterprise. Future directions include removing premedication orders from standardized electronic medical record ordering plans.

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2025
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