Feasibility of a Preoperative Anemia Protocol in a Large Integrated Health Care System

Optimizing preoperative anemia is a required component of the Joint Commission Patient Blood Management Certification and an important component of Enhanced Recovery After Surgery.

To describe a preoperative anemia protocol developed and implemented at the Kaiser Permanente San Jose Medical Center in California to facilitate preoperative identification and treatment of anemia.

The protocol included all operations at risk of causing substantial blood loss. It excluded emergent operations and those for which the patient had a normal last hemoglobin value within the prior 12 months unless newly developed anemia was suspected. Eligible patients were screened for laboratory evaluation, and those with anemia were treated for reversible causes. Consistency was ensured by physician, staff, and patient education, and by use of electronic health records. Administration of intravenous iron and erythropoietin and consultation with specialists were expedited as part of a management algorithm.

Among 510 patients enrolled during 1 year, 442 (87%) received anemia screening laboratory tests. Half of those with laboratory results were eligible for further optimization: 207 had anemia and 21 had iron deficiency without anemia. Among the 228 patients eligible for optimization, 189 (83%) had anemia addressed preoperatively. Of 129 patients with iron deficiency anemia, 102 (79%) received intravenous iron preoperatively, with a mean preoperative increase in hemoglobin level by 0.98 g/dL (n = 79).

Integration of specialty services, optimization of technology, and consistency across practitioners were crucial for successful implementation and sustainability of a preoperative anemia protocol developed to expedite and enhance best practices.