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Hospital Harm: Anemia – Hemorrhage (Health Care / Medication Associated Condition)

Anemia is a decrease in the number of red blood cells (RBCs), hematocrit (Hct), or hemoglobin (Hb) content. Anemia is not a diagnosis; it is a manifestation of an underlying disorder. Anemia can occur as the result of one or more of three basic mechanisms; blood loss, deficient erythropoiesis, and excessive hemolysis (Lichtin, 2017). The focus of this resource is on anemia related to acute blood loss (acute posthemorrhagic anemia) and hemorrhagic disorders due to circulating anticoagulants.

Topics
  • Patient safety
  • Hospital harm
Audience

  • Point of care provider

  • Quality or safety improvement lead

  • Policy advisor or analyst

Goal

Reduce the incidence of hemorrhagic anemia or hemorrhagic disorders identified during a hospital stay, related to the health care delivered or therapeutic use of anticoagulants.

Overview and Implications

Healthcare Excellence Canada has developed this Hospital Harm Improvement Resource – a compilation of resources to support patient safety and improvement efforts.

Acute post-hemorrhagic anemia secondary to Gastrointestinal (GI) Bleeding

Patients may have acute blood loss from GI bleeding. Nosocomial GI bleeding is source of preventable hospital morbidity and mortality (Herzig et al. 2013). Causes of upper GI bleeding include peptic ulcers, gastritis and inflammation of the GI lining from ingested materials. Ulcers are localized erosions of the mucosal lining of the digestive tract and they usually occur in the stomach or duodenum. Breakdown of the mucosal lining results in damage to blood vessels, which causes bleeding. Gastritis and inflammation of the GI lining may be caused by non-steroidal anti-inflammatory drugs (NSAIDs) and steroids (Lanza et al. 2009; Narum et al. 2014). In the ICU, stress-induced mucosal lesions are a risk factor for bleeding (McEvoy & Shander, 2013).

Acute GI bleeding will appear as vomiting of blood, bloody bowel movements or black, tarry stools. Vomited blood may look like coffee grounds. Other symptoms include fatigue, weakness, shortness of breath, abdominal pain, and pale appearance.

Risk Factors for nosocomial GI bleeding in ICU patients (Guillamondegui et al. 2008; Weinhouse, 2019):

  • Universally accepted risk factors stress ulceration:

  • Mechanical Ventilation for more than 48 hours

  • Coagulopathy

    Other risk factors identified:

  • shock

  • sepsis

  • spinal cord injury

  • multiple trauma

  • head trauma

  • burns over 35 per cent of the total body surface area

  • acute renal failure

  • hepatic failure

  • history of peptic ulcer disease

  • history of upper GI bleed

  • Organ transplantation

  • Glucocorticoid therapy (when combined with other risk factors)

  • Hemorrhagic disorder due to circulating anticoagulants

Anticoagulation is the mainstay of medical treatment, prevention and reduction of recurrent venous thromboembolism, acute ischemic limbs, acute stroke, stroke prevention in patients with non-valvular atrial fibrillation, and it reduces the incidence of recurrent ischemic events and death in patients with acute coronary syndrome (Christos & Naples, 2016). Unfortunately, however the use of these medications carries significant risk of bleeding or hemorrhage.

Bleeding, or hemorrhagic disorder, is a possible side effect of anticoagulation therapy. (Carnovale et al. 2015). Anticoagulation therapy includes the use of warfarin (Coumadin), a Vitamin K antagonist, as well as the newer direct oral anticoagulants (DOACs) (Fernandez, 2015). Hemorrhage secondary to the use of vitamin K antagonists varies from one to 12 per cent per year, and is related to other risk factors. The risk of bleeding is highest in the initial few weeks of anticoagulation therapy (Cairns, 2011). As a drug category, anticoagulants are one of the top five drug types associated with patient safety incidents (Cousins, 2006).

Antithrombotic agents* are included on the Institute for Safe Medication Practice's (ISMP, 2018) high alert medication list due to the significant risk of causing life-threatening bleeding or thrombosis if the appropriate safe practices are not in place. This high risk is due to the complexity of administering this therapy:

  • Selecting the appropriate agent and determining the appropriate dose

  • Individual patient variability in response to therapy

  • Timing of and use of the appropriate laboratory measures to monitor response

  • Proper adjustment of dose based upon the laboratory parameters and/or clinical response

  • The transition of patients from Heparin therapy to Warfarin

  • Ensuring patient education and compliance

  • Use of these agents in a variety of settings, by various practitioners, and within differing patient populations

  • Interdisciplinary coordination needed between lab, pharmacy, nursing, medical staff, and dietary (Purdue University PharmaTAP, 2008)

*Antithrombotic agents, include:

  • anticoagulants (e.g., warfarin, low molecular weight heparin, IV unfractionated heparin)

  • Factor Xa inhibitors (e.g., fondaparinux, apixaban, rivaroxaban) direct thrombin inhibitors (e.g., argatroban, bivalirudin, dabigatran etexilate)

  • thrombolytics (e.g., alteplase, reteplase, tenecteplase)

  • glycoprotein IIb/IIIa inhibitors (e.g., eptifibatide)

Adverse drug events associated with anticoagulants can be reduced by implementing recognized safe practices in high risk areas such as: Use Programmable Pumps and Independent Double-Checks for IV Anticoagulants, Prepare All Heparin Doses and Solutions in the Hospital Pharmacy, and Provide Coagulation Test Results Within Two Hours or at Bedside (IHI, 2020b).

Patients who are receiving anticoagulant therapy have increased risk of hemorrhage when undergoing medical and surgical procedures (Guidelines and Protocols Advisory Committee 2015). Bleeding that occurs in hospital is associated with increased morbidity, mortality, increased length of stay, increased health care costs and increased hospital readmission (Purdue University PharmaTAP, 2008; Herzig et al. 2013; McEvoy & Shander, 2013).

For additional information regarding anemia – hemorrhage associated with a medical or surgical procedure, please refer to the Hospital Harm Improvement Resource Procedure Associated Conditions: Anemia – Hemorrhage.

Importance to Patients and Families

Hemorrhage is understandably alarming to patients and families. Not only may it be life-threatening, it complicates care and prolongs hospitalization. Anticoagulants such as warfarin and heparin are powerful medications that save lives and prevent further harm. This group of medications also has the potential to cause serious harm if not taken carefully. Patients who are knowledgeable about their medication therapy can help to reduce the risk of adverse drug events (IHI, 2020a).

Clinical and System Reviews, Incident Analyses

Given the broad range of potential causes of Anemia – Hemorrhage (Health Care / Medication Associated Condition), in addition to recommendations listed above, we recommend conducting clinical and system reviews to identify latent causes and determine appropriate recommendations.

Occurrences of harm are often complex with many contributing factors. Organizations need to:

  1. Measure and monitor the types and frequency of these occurrences.

  2. Use appropriate analytical methods to understand the contributing factors.

  3. Identify and implement solutions or interventions that are designed to prevent recurrence and reduce risk of harm.

  4. Have mechanisms in place to mitigate consequences of harm when it occurs.

Measures

Vital to quality improvement is measurement, and this applies specifically to implementation of interventions. The chosen measures will help to determine whether an impact is being made (primary outcome), whether the intervention is actually being carried out (process measures), and whether any unintended consequences ensue (balancing measures). In selecting your measures, consider the following:

You may use different measures or modify the measures described below to make them more appropriate and/or useful to your particular setting. However, be aware that modifying measures may limit the comparability of your results to others.

Evaluate your choice of measures in terms of the usefulness of the final results and the resources required to obtain them; try to maximize the former while minimizing the latter.

Whenever possible, use measures you are already collecting for other programs.

Try to include both process and outcome measures in your measurement scheme.

Discharge Abstract Database

Discharge Abstract Database (DAD) Codes included in this clinical category: A01: Anemia – Hemorrhage (Health Care/Medication Associated Condition)

Concept: Hemorrhagic anemia or hemorrhagic disorders that require(s) blood transfusion, identified during a hospital stay, related to the health care delivered or therapeutic use of anticoagulants

Notes:

  1. This clinical group excludes obstetric hemorrhage (refer to A02: Obstetric Hemorrhage and D02: Obstetric Hemorrhage) and hemorrhage or hemorrhagic anemia associated with a medical or surgical procedure (refer to D01: Anemia — Hemorrhage).

  2. The blood transfusion indicator is optional to code in British Columbia.

Success Stories

​We are looking for an improvement success story related to Anemia - Hemorrhage. If you have one you would like to share, please contact Healthcare Excellence Canada at info@hec-esc.ca.

References

Cairns JA, Connolly S, McMurtry S, Stephenson M, Talajic M, CCS Atrial Fibrillation Guidelines Committee. Canadian Cardiovascular Society atrial fibrillation guidelines 2010: prevention of stroke and systemic thromboembolism in atrial fibrillation and flutter. Cn J Cardiol. 2011; 27 (1), 74-90. doi: 10.1016/j.cjca.2010.11.007. https://www.onlinecjc.ca/article/S0828-282X%2810%2900008-5/fulltext

Carnovale C, Brusadelli T, Casini ML. Drug-induced anaemia: a decade review of reporting to the Italian Pharmacovigilance data-base. Int Clin J Pharm. 2015, 37 (1), 23-26. doi: 10.1007/s11096-014-0054-3

Christos S, Naples R. Anticoagulation reversal and treatment strategies in major bleeding: Update 2016. West J Emerg Med. 2016; 17 (3): 264-70. doi: 10.5811/westjem.2016.3.29294. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4899056/

Cousins D, Harris, Safe Medication Practice Team. Risk assessment of anticoagulation therapy. National Patient Safety Agency; 2006. https://www.sps.nhs.uk/wp-content/uploads/2018/02/NRLS-0233-Anticoagulant-tssessment-2006-01-v1.pdf

Fernández CS, Formiga F, Camafort M, et al. Antithrombotic treatment in elderly patients with atrial fibrillation: a practical approach. BMC Cardiovasc Disord. 2015; 15: 143. doi: 10.1186/s12872-015-0137-7. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4632329/

Erratum: Fernández CS, Formiga F, Camafort M, et al. Erratum: Antithrombotic treatment in elderly patients with atrial fibrillation: a practical approach. BMC Cardiovasc Disord. 2015; 15: 157. doi: 10.1186/s12872-015-0150-x. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4653852/

Guillamondegui OD, Gunter OL Jr, EAST Practice Management Guidelines Committee. Practice management guidelines for stress ulcer prophylaxis. Chicago, IL: Eastern Association for the Surgery of Trauma; 2008. https://www.east.org/education/practice-management-guidelines/stress-ulcer-prophylaxis

Herzig SJ, Rothberg MB, Feinbloom DB, et al. Risk factors for nosocomial gastrointestinal bleeding and use of acid-suppressive medication in non-critically ill patients. J Gen Intern Med. 2013; 28 (5): 683-690. doi: 10.1007/s11606-012-2296-x. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3631055/

Institute for Healthcare Improvement (IHI). How-to Guide: Prevent Harm from High-Alert Medications. Cambridge, MA: IHI; 2012. http://www.ihi.org/resources/Pages/Tools/HowtoGuidePreventHarmfromHighAlertMedications.aspx

Institute for Healthcare Improvement (IHI). Educate Patients to Manage Warfarin Therapy at Home. Cambridge, MA: IHI; 2020a. http://www.ihi.org/resources/Pages/Changes/EducatePatientstoManageWarfarinTherapyatHome.aspx

Institute for Healthcare Improvement (IHI). Changes: Reduce adverse drug events involving anticoagulants. Cambridge, MA: IHI; 2020b. http://www.ihi.org/resources/Pages/Changes/ReduceAdverseDrugEventsInvolvingAnticoagulants.aspx

Institute for Safe Medication Practices (ISMP). ISMP list of high-alert medications in acute care settings. Horsham, PA; ISMP: 2018. https://www.ismp.org/sites/default/files/attachments/2018-08/highAlert2018-Acute-Final.pdf

Lanza FL, Chan FK, Quigley EM. Guidelines for prevention of NSAID-related ulcer complications. Am J Gastroenterol. 2009; 104 (3), 728-738. doi: 10.1038/ajg.2009.115.

Lichtin AE. Etiology of anemia. Merck Manual. 2017. www.msdmanuals.com/professional/hematology-and-oncology/approach-to-the-patient-with-anemia/etiology-of-anemia

McEvoy MT, Shander A. Anemia, bleeding, and blood transfusion in the intensive care unit: causes, risks, costs, and new strategies. Am J Crit Care. 2013; 22 (6 Suppl): eS1-13. doi: 10.4037/ajcc2013729. http://ajcc.aacnjournals.org/content/22/6/eS1.long

Narum S, Westergren T, Klemp M. Corticosteroids and risk of gastrointestinal bleeding: a systematic review and meta-analysis. BMJ Open. 2014, 4 (5): e004587. doi: 10.1136/bmjopen-2013-004587. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4025450/

Purdue University PharmaTAP. Anticoagulant tool kit: Reducing adverse drug events & potential adverse drug events with unfractionated heparin, low molecular weight heparins and warfarin. Indianapolis, IN: Purdue University PharmaTAP: 2008. http://www.ihi.org/resources/pages/tools/anticoagulanttoolkitreducingades.aspx

Weinhouse GL. Stress ulcer prophylaxis in the intensive care unit. UpToDate. 2018. https://www.uptodate.com/contents/stress-ulcer-prophylaxis-in-the-intensive-care-unit

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