A call to the “iron police” helps prevent iron overload

Is the patient in danger of iron overload following transfusions of packed red blood cells (RBCs)? If so, we call in the “iron police.” This dedicated team, comprised of a nurse practitioner, a registered nurse, and a social worker, will help ensure each patient requiring a transfusion is appropriately monitored, said Angela Lambing, MSN, NP-C, Henry Ford Health System, Detroit, Michigan, during the Oncology Nursing Society 36th Annual Congress.

In many hematologic conditions, bone marrow suppression or malfunction may necessitate packed RBC transfusions. The body lacks the ability to eliminate excess iron effectively; therefore, extended exposure to transfusions may result in iron overload. Many institutions, however, lack a monitoring process to identify transfusion-dependent patients at risk for iron overload, Lambing and colleagues explained.

At their institution, an algorithm was created that would identify patients at risk of iron overload (Table). A nurse-driven protocol was instituted that required a baseline ferritin level be ascertained for patients requiring transfusion if no record for one existed with the previous 6 months. A repeat ferritin level was triggered for every 10 units of packed RBCs.

When the ferritin level increased to higher than 1,000 µg/mL, the registered nurse initiates contact with the “iron police.” The nurse practitioner reviews the case and presents findings to the physician, who then determines if iron chelation should be initiated. Once iron chelation is indicated, the “iron police” contacts the patient, provides education, orders the medication, evaluates insurance issues, initiates iron chelation, and provides contact and ongoing monitoring.

Prior to program initiation, of 75 patients who were receiving packed RBC transfusions, more than 50% had either a ferritin level higher than 1,000 µg/mL without treatment or had no documented ferritin level within 6 months of transfusion outset and 1% were receiving iron chelation therapy.

Program “successes” included a 98% adherence to protocol with ferritin levels drawn at the time of transfusion; in addition, 30% of patients were on iron chelation therapy and 30% had an elevated ferritin level but treatment was on hold for medical reasons with ongoing monitoring for potential initiation of iron chelation therapy when appropriate. Currently, 50 patients are being monitored on the iron chelation protocol. Lambing noted the program engages the expertise of the infusion nurse, who provides ongoing contact to the patient, while the registered nurse supports the activities of the “iron police” team when iron chelation therapy is in progress. Education of infusion center nurses, physicians, hematology/oncology fellows, and patients is also increased, and standardized care can be provided to all patients who become transfusion dependent.

Table. Diagnoses Identified at Risk for Transfusional Iron Overload

Myelodysplastic syndrome (MDS) Sickle cell Hepatitis C Aplastic anemia Multiple myeloma Pre-post bone marrow transplantation CLL AML

Anemia of chronic disease Liver transplant Thalassemia Amyloidosis Cancer: lymphoma, ovarian, melanoma, prostate