Should a patient with severe anemia at a skilled nursing facility be sent out for further evaluation or treatment?

Should This Patient Be Transferred to the Hospital?

Yes, a patient with hemoglobin of 7.4 g/dL and hematocrit of 23.6% at a skilled nursing facility should be sent out for hospital evaluation and management, as this represents severe anemia requiring urgent assessment for the underlying cause, potential transfusion, and treatment that exceeds the monitoring and intervention capabilities of most SNFs.

Rationale for Transfer

Severity Assessment

• Hemoglobin of 7.4 g/dL represents severe anemia that warrants immediate evaluation for hemodynamic stability, symptoms of end-organ hypoperfusion (chest pain, dyspnea, altered mental status, syncope), and determination of acuity (acute blood loss vs chronic anemia) 1, 2, 3.
• The American Heart Association notes that SNFs have higher patient-to-staff ratios, fewer licensed nursing staff, and limited on-site healthcare provider availability, making them inappropriate for patients who are not stable or who need intensive monitoring 4.
• Patients requiring urgent diagnostic workup and potential blood transfusion are not appropriate candidates for SNF-level care 4.

Critical Diagnostic Workup Required

The following evaluation should occur in the hospital setting and cannot be adequately performed in most SNFs:

• Complete blood count with differential to assess white blood cell count, platelet count, and red cell indices (MCV, MCH, MCHC) 4, 5, 2.
• Reticulocyte count to differentiate between hemolysis/blood loss versus decreased production 1, 2.
• Peripheral blood smear to evaluate red cell morphology and identify schistocytes, spherocytes, or other diagnostic features 4, 2.
• Chemistry panel including BUN, creatinine, potassium, sodium to assess renal function and electrolyte abnormalities 4.
• Iron studies (serum ferritin, transferrin saturation, TIBC) if microcytic anemia is present 5.
• Hemolysis workup if indicated: LDH, haptoglobin, indirect bilirubin, direct antiglobulin test 4.
• Stool guaiac testing and consideration of endoscopy if gastrointestinal bleeding is suspected 5, 1.

Transfusion Considerations

• Transfusion thresholds: For stable, non-cardiac patients, transfusion is typically indicated when hemoglobin falls below 7-8 g/dL 4.
• However, symptomatic patients or those with cardiac disease may require transfusion at higher hemoglobin levels to relieve symptoms and prevent end-organ damage 4, 3.
• SNFs lack the immediate blood bank access and monitoring capabilities required for safe transfusion administration 4.

Communication Requirements for Transfer

When transferring the patient, the SNF must provide comprehensive bidirectional communication including 4:

• Essential clinical data: Complete vital signs, recent laboratory values (including trend of hemoglobin if available), current medications, and known comorbidities 4.
• Course of illness: When anemia was first detected, any associated symptoms (melena, hematochezia, hematemesis, fatigue, chest pain, dyspnea), recent procedures or medications that could contribute 4.
• Physical assessment findings: Presence of pallor, tachycardia, orthostatic hypotension, signs of bleeding, edema 4.
• Goals of care: Patient and family preferences regarding level of intervention, code status, and advance directives 4.

Common Pitfalls to Avoid

• Do not delay transfer while attempting to complete extensive workup in the SNF, as diagnostic capabilities are limited and the patient may decompensate 4.
• Do not assume chronic anemia is stable without assessing for acute-on-chronic blood loss or hemolysis 1, 2.
• Do not overlook combined deficiencies (iron, B12, folate) or multiple contributing factors (chronic disease, renal insufficiency, malignancy) 5, 1.
• Do not miss occult gastrointestinal bleeding, particularly in elderly patients on anticoagulation or antiplatelet therapy 5, 3.

Exception: Goals of Care Considerations

The only scenario where transfer might not be appropriate is if the patient has clearly documented goals of care focused on comfort measures only and avoiding hospitalization 4. In such cases:

• Goals should focus on promoting comfort and controlling distressing symptoms while avoiding emergency room visits and hospital admissions 4.
• A higher threshold for diagnostic testing should be applied 4.
• Symptomatic management of anemia-related symptoms (fatigue, dyspnea) may be provided in the SNF setting 4.
• This decision requires explicit documentation of patient/family preferences and should involve shared decision-making with the patient's healthcare proxy if the patient lacks capacity 4.