Evaluating the management of severe anemia in the emergency department: A single-center analysis

Abstract Introduction: Severe anemia is commonly encountered in emergency departments (EDs), often prompting red blood cell (RBC) transfusions. However, transfusions may be given without adequate investigation of underlying etiologies, potentially resulting in unnecessary exposure, delayed definitive care, and increased healthcare costs. Deficiencies in iron, vitamin B12, and folate are frequently treatable and may not require transfusion if promptly addressed. This study aimed to evaluate diagnostic and management practices surrounding severe anemia in the ED, with particular attention to transfusion appropriateness and diagnostic workup completeness. Methods: With institutional review board (IRB) approval, a retrospective chart review was conducted using data from the University of Florida's Integrated Data Repository (IDR). Adult patients (≥18 years) who received at least one unit of packed RBCs in the ED between January 1, 2021, and December 31, 2022, were eligible for inclusion. Patients were included if they had a documented hemoglobin level ≤9 g/dL and had at least one anemia-related diagnostic test (iron studies, vitamin B12, or folate) ordered during the ED encounter or subsequent hospitalization. Charts were reviewed to determine whether patients exhibited signs of hemodynamic instability, defined as a mean arterial pressure (MAP) <65 mmHg or heart rate >110 bpm. Symptomatic anemia was also assessed, characterized by shortness of breath, fatigue, dizziness, or palpitations. Historical laboratory data from the preceding six months were also reviewed to identify previously established deficiencies. Laboratory markers included hemoglobin, mean corpuscular volume (MCV), ferritin, vitamin B12, and folate. Transfusion volume, diagnoses, and treatment interventions such as intravenous (IV) iron or vitamin supplementation were recorded. Data were analyzed using Microsoft Excel and SAS® for Windows version 9.4. Results: Among 270 patients screened, 45 met inclusion criteria. The mean age was 51.3 years. The majority were female (89%, n=40), with males accounting for 11% (n=5). Only four patients (9%) met criteria for hemodynamic instability, while 23 patients (51%) met criteria for symptomatic anemia at presentation. The average hemoglobin was 5.9 g/dL (range: 2.7–7.2 g/dL). Contributing conditions included peptic ulcer disease, gastrointestinal bleeding, dysfunctional uterine bleeding, and Crohn's disease. Other identified etiologies included anemia of chronic disease (n=4, 9%), sickle cell anemia (n=3, 7%), myelodysplastic syndrome (n=2, 4%), and megaloblastic anemia (n=1, 2%). Thirty-five patients (78%) had microcytic anemia, 7 (15%) were normocytic, and 3 (7%) were macrocytic. Ferritin levels ≤40 ng/mL, consistent with iron deficiency, were found in 82% of patients; however, only 16% received IV iron during that hospitalization. Although vitamin B12 was assessed in most patients, 36% lacked B12 testing entirely. Six patients (13%) had B12 levels ≤300 pg/mL, and only half of those received supplementation. Folate was not assessed in 40% of patients; no patients met the deficiency threshold (≤3 ng/mL). In terms of transfusion volume, 40% received one unit of PRBCs, 33% received two units, 20% received three units, and 7% received four units. Notably, transfusions were frequently administered despite the absence of hemodynamic instability or confirmed symptomatic anemia, and were often the primary intervention rather than part of a broader diagnostic workup. Conclusion: This study identified a pattern of reflexive RBC transfusion in the ED without comprehensive evaluation for treatable causes of anemia. Despite a high prevalence of iron deficiency, IV iron was rarely administered. Diagnostic workups for vitamin B12 and folate were frequently incomplete or omitted. The underutilization of targeted therapies such as IV iron and reliance on transfusion alone may reflect knowledge gaps, limited access to prior records, or systemic workflow barriers in the ED setting. Hematologists are well-positioned to support the development of ED protocols that prioritize evidence-based anemia evaluation and limit unnecessary transfusions. Incorporating point-of-care diagnostic algorithms and increasing provider awareness could enhance care, reduce transfusion-related risks, and optimize resource utilization. Future multicenter studies are warranted to confirm these findings and inform standardized guidelines for acute anemia management in the ED.