Background: Albumin, the predominant plasma protein, maintains oncotic pressure and transports hormones, drugs, and endogenous molecules. Intravenous albumin leverages these functions to mobilize interstitial fluid and stabilize intravascular volume in specific scenarios such as large-volume paracentesis (LVP), spontaneous bacterial peritonitis (SBP), hepatorenal syndrome (HRS), and therapeutic plasma exchange. Medication-use evaluation at our community hospital revealed frequent albumin use for indications without strong evidence (e.g., IV diuresis, hypoalbuminemia in malnutrition, hypotension), prompting a need to standardize practice and minimize low-value care.
Purpose: To develop and implement evidence-based guidelines for intravenous albumin use with pharmacist review and escalation of inappropriate orders, and to measure the impact on albumin utilization and cost.
Description: Multidisciplinary stakeholders (hospital medicine, critical care, pharmacy, nephrology, hepatology, gastroenterology, surgery) co-created guidelines specifying:- Approved indications for albumin use (LVP in cirrhosis, SBP, HRS, plasmapheresis, and select severe hypoalbuminemia with severe renal insufficiency requiring diuresis under nephrology guidance).- Exclusions (traumatic brain injury, major trauma, pancreatitis, acute respiratory distress syndrome, malnutrition-related hypoalbuminemia).- Operational requirements: definitive end dates on orders, dose verification, and pharmacist review with escalation to Medicine Leadership for orders that did not follow guidelines. Scope included ED, Medicine, Surgery, and ICU; excluded intraoperative use and pediatrics.Education was provided to frontline providers, and the policy was disseminated to all departments and divisions prior to launch in April 2025. Pharmacy reviewed all albumin orders for appropriate indications thereafter.Utilization (units of albumin administered) and cost were tracked quarterly:- 2024 Q1: 340 units; $20,202- 2024 Q2: 321 units; $16,226- 2024 Q3: 305 units; $15,186- 2024 Q4: 217 units; $16,888- 2025 Q1: 333 units; $19,245- 2025 Q2 (intervention): 119 units; $6,729- 2025 Q3 (post-intervention): 131 units; $8,119
Conclusions: Implementation of evidence-based albumin guidelines with pharmacist review produced rapid and sustained reductions in albumin use and cost. Units decreased by 64% immediately post-launch (333 to 119 units, Q1 to Q2 2025) and remained 61% lower in the subsequent quarter (131 units, Q3 2025). Corresponding costs fell by 65% in the implementation quarter ($19,245 to $6,729) and remained 58% lower the following quarter ($8,119). Importantly, all patient safety and quality metrics were maintained, including length of stay, mortality, morbidity, and readmissions. Based on these results, this initiative is now being scaled across our health system. This multidisciplinary approach—combining evidence-based guidelines, clear clinical criteria, and pharmacist oversight—demonstrates that low-value albumin use can be meaningfully reduced while standardizing care and generating substantial cost savings without compromising patient outcomes. The framework is adaptable to other overused resources and includes ongoing monitoring, reinforcement of appropriate indications, and evaluation of clinical outcomes to ensure sustained guideline adherence.