Introduction | Anemia Prevention and Management Program Implementation Toolkit

Download the Anemia Toolkit

It is estimated that nearly one-third of the world’s population suffers from anemia. The prevalence in North America is even higher, approaching 40 percent. The dominant etiologies vary from region to region. Infectious diseases are most common in sub-Saharan Africa, hematologic disorders lead the list in Europe and nutrition deficits are also common. Across the globe, iron deficiency is the most common cause.1

The prevalence of anemia in hospitalized patients ranges from what is normally seen in the general population to much higher numbers, depending on the reason for admission, comorbidities and patient factors such as age and gender. The reported prevalence is at least 25-50 percent and may be substantially higher, with elderly patients and those with chronic conditions (e.g., chronic kidney or heart failure) at increased risk.2-4

Anemia in hospitalized patients has been accepted as an “innocent bystander.”5 However, anemia is an independent risk factor for a handful of unfavorable outcomes, including increased risk of hospitalization or readmission, prolonged hospital length of stay (LOS), loss of function, diminished quality of life and increased risk of morbidity and mortality.3,6,7 Additionally, while anemia can be caused or exacerbated by a number of chronic conditions, it can also exacerbate the underlying chronic condition in a positive feedback loop that further increases patients’ negative outcomes.8 Finally, anemia is a leading (yet modifiable) risk factor for allogeneic blood transfusion 9,10 and the evidence of the harmful effects of unwarranted allogeneic blood is indisputable.6

Anemia in hospitalized patients is a dynamic condition that evolves in both character and severity. As LOS increases, more initially non-anemic patients develop hospital-acquired anemia (HAA), while anemia in those who had it at admission continues to worsen.11 In a study of more than 180,000 non-anemic patients admitted to 10 U.S. hospitals, three-fourths developed HAA, which is associated with an increased risk of death, LOS and resource utilization.12 HAA may even be more harmful than pre-existing anemia. An analysis of data from more than 3,700 patients hospitalized with heart failure indicated that anemia at discharge, not at admission, was independently associated with increased all-cause mortality.13 Moreover, the prevalence of anemia and iron deficiency may continue to rise in the months following discharge from the hospital,1,2,14 and iron deficiency anemia can easily be overlooked or ignored in follow-up visits.15 Unfortunately, ignoring anemia does little to treat it or prevent it from harming patients and often results in transfusion with added risks and cost.

As stated above, anemia is often ignored or inappropriately treated with transfusion but it can be treated effectively; it is a modifiable and preventable risk factor.3 Early detection and treatment can reduce or eliminate anemia-related risks.16 Strategies span a wide array of approaches, including various hematinics, management of underlying causes and preventive measures, such as minimization of blood loss,17 which could be something as conspicuous as surgical hemorrhage, or something as seemingly mundane as unnecessary phlebotomy.18 While some evidence suggests the potential impact of broad anemia management strategies in the inpatient setting, more is known about the advantages of restrictive transfusion practices, which have been successfully implemented in real-world settings.

This toolkit is intended to improve patient outcomes by providing a framework for hospital-based anemia management quality improvement projects. It will review each step of the process from forming a multidisciplinary team, obtaining institutional support, assessing baseline performance and defining key metrics, to implementing changes and monitoring their effects, with a focus on blood transfusion best practices. Such projects can be expected to improve patient outcomes, improve the utilization of scarce resources (such as allogeneic blood), and decrease transfusion-related adverse events, enabling hospitals to provide a better quality of care at a lower cost. In today’s competitive healthcare environment, these are quality gains and cost savings that hospitals cannot afford to miss.


  1. Kassebaum NJ, Jasrasaria R, Naghavi M, Wulf SK, Johns N, Lozano R, et al. A systematic analysis of global anemia burden from 1990 to 2010. Blood. 2014 Jan 30;123(5):615-624.
  2. Migone De Amicis M, Poggiali E, Motta I, Minonzio F, Fabio G, Hu C, et al. Anemia in elderly hospitalized patients: prevalence and clinical impact. Intern Emerg Med. 2015 Aug;10(5):581-586.
  3. Shander A, Goodnough LT, Javidroozi M, Auerbach M, Carson J, Ershler WB, et al. Iron deficiency anemia--bridging the knowledge and practice gap. Transfus Med Rev. 2014 Jul;28(3):156-166.
  4. Caughey MC, Avery CL, Ni H, Solomon SD, Matsushita K, Wruck LM, et al. Outcomes of patients with anemia and acute decompensated heart failure with preserved versus reduced ejection fraction (from the ARIC study community surveillance). Am J Cardiol. 2014 Dec 15;114(12):1850-1854.
  5. Nissenson AR, Goodnough LT, Dubois RW. Anemia: not just an innocent bystander? Arch Intern Med. 2003 Jun 23;163(12):1400-1404.
  6. Shander A, Javidroozi M, Ozawa S, Hare GM. What is really dangerous: anaemia or transfusion? Br J Anaesth. 2011 Dec;107 Suppl 1:i41-59.
  7. Zilinski J, Zillmann R, Becker I, Benzing T, Schulz RJ, Roehrig G. Prevalence of anemia among elderly inpatients and its association with multidimensional loss of function. Ann Hematol. 2014 Oct;93(10):1645-1654.
  8. Klip IT, Jankowska EA, Enjuanes C, Voors AA, Banasiak W, Bruguera J, et al. The additive burden of iron deficiency in the cardiorenal-anaemia axis: scope of a problem and its consequences. Eur J Heart Fail. 2014 Jun; 16(6):655-662.
  9. Gombotz H, Rehak PH, Shander A, Hofmann A. The second Austrian benchmark study for blood use in elective surgery: results and practice change. Transfusion. 2014 Oct; 54(10 Pt 2):2646-2657.
  10. Yoshihara H, Yoneoka D. Predictors of allogeneic blood transfusion in total hip and knee arthroplasty in the United States, 2000-2009. J Arthroplasty. 2014 Sep; 29(9):1736-1740.
  11. Koch CG, Li L, Sun Z, Hixson ED, Tang AS, Phillips SC, et al. From Bad to Worse: Anemia on Admission and Hospital-Acquired Anemia. J Patient Saf. 2014 Oct 6.
  12. Koch CG, Li L, Sun Z, Hixson ED, Tang A, Phillips SC, et al. Hospital-acquired anemia: prevalence, outcomes, and healthcare implications. J Hosp Med. 2013 Sep; 8(9):506-512.
  13. Mentz RJ, Greene SJ, Ambrosy AP, Vaduganathan M, Subacius HP, Swedberg K, et al. Clinical profile and prognostic value of anemia at the time of admission and discharge among patients hospitalized for heart failure with reduced ejection fraction: findings from the EVEREST trial. Circ Heart Fail. 2014 May; 7(3):401-408.
  14. Lasocki S, Chudeau N, Papet T, Tartiere D, Roquilly A, Carlier L, et al. Prevalence of iron deficiency on ICU discharge and its relation with fatigue: a multicenter prospective study. Crit Care. 2014 Sep 30; 18(5):542-014-0542-9.
  15. Bager P, Dahlerup JF. Lack of follow-up of anaemia after discharge from an upper gastrointestinal bleeding centre. Dan Med J. 2013 Mar; 60(3):A4583.
  16. Goodnough LT, Maniatis A, Earnshaw P, Benoni G, Beris P, Bisbe E, et al. Detection, evaluation, and management of preoperative anaemia in the elective orthopaedic surgical patient: NATA guidelines. Br J Anaesth. 2011 Jan; 106(1):13-22.
  17. Shander A, Javidroozi M. Blood conservation strategies and the management of perioperative anaemia. Curr Opin Anaesthesiol. 2015 Jun; 28(3):356-363.
  18. Salisbury AC, Reid KJ, Alexander KP, Masoudi FA, Lai SM, Chan PS, et al. Diagnostic blood loss from phlebotomy and hospital-acquired anemia during acute myocardial infarction. Arch Intern Med. 2011 Oct 10; 171(18):1646-1653.


This Implementation Guide is supported by a grant from American Regent.

Disclaimer: The authors had full responsibility in designing and compiling the Toolkit. American Regent had no involvement in, or influence over, the development of the content included in this Toolkit