Anaemia Management Breakthrough Collaborative

Best scientific knowledge? Kidney senses tissue oxygen tension EPO Bone marrow stimulated Increased red cells

Reduce costs and increase quality In simple terms –More of our patients meet renal association or NICE guidelines –Ideally we reduce our costs as well Eg Norwich cut esa bill by £140k after introduction of TSAT

Sentinel organisations? UK Renal Registry 8th Annual Report, Chapter 8

% patients with Hb

Guidelines and standards Renal Association 2003 –Hb > 10 European Best Practice 2004 –Targeted Hb level >11g/dl for all CKD patients –In HD, pre-dialysis Hb >14 is not desirable –Diabetes/CV disease Hb>12 is not recommended

CREATE, CHOIR and NICE Phrommintikul Lancet 2007

NICE UK Guideline for the management of anaemia in CKD Consider dose adjustment if outside 11-12

Can Bradford change course?

%>10% >12.5%>13%NICE St lukes only (no 90 day rule)

Antrim Course %>10% >12.5%>13%NICE

Norwich Course %>10% >12.5%>13%NICE

It can be done Let’s do it!

What we do 5 areas for you to focus on

What have we learnt about each other so far? antrimbradnorwichtruro Written policy epo yesNoPGDyes Written policy iron yesNoPGDyes Who prescribes Pharm/ConsCons/ASAnaemia nurse adjusts Computer (override poss) Who gives epo Nurse on HD Hb tests Monthly 6/52monthly Iron tests monthly 6/523-monthly

Antrimbradnorwichtruro What iron tests Ferr/TSATFerr/%hypoFerr/TSATFerr/%hypo Speed of response 2 daysapprox 1 week 2-3 daysapprox 1 week Esa Darbo/recordarboepprexDarbo Iron target />20% Tsats>20% (aim30-40) / <5%hyp Hb target (pre-2006) 11-13> continuity 1 year Cons6/12 rotation4/12 rotationCons/nurse lead (no jnr docs) Medical r/v Monthly cons WR 6/12 clinic + daily visit Monthly MDT/QA

5 change areas Give esa on the unit (HD) Understand your esa mechanism Audit regularly Know your patients The 15% Diversion into vascular access Pre-dialysis

Change No. 1 Give the esa on the unit It’s the only factor common to all 4 units

Change 2: The epo mechanism Blood tests targets Test results prescription decision patient AUDIT

Blood tests to dose adjustments Antrim –Renal pharmacist adjusts within 2 days Norwich –Anaemia nurse Truro –Computer Bradford –Senior doctor

But we do have in common…. The same pharmacist/nurse/computer/doctor makes the decisions on the same patients for a prolonged period Continuity of care

1234 week ‘monthly’ bloods Pharmacist review Consultant + Pharmacist Ward rounds Antrim

1234 week ‘monthly’ bloods Computer/algorithm suggests dose MDT/QA Meeting-agree or disagree with dose Truro

NICE algorithm Hb <11Hb 11-12Hb 12-15Hb >15 Increase esa unless rising >1g/month No change unless rising > 1g/month ?stop iron Reduce esa unless falling >1g/month Stop iron ?stop or halve esa. recheck 2/52 Consider poor response algorithm Esa changes according to NICE schedule

Algorithm example (NICE) Current dose (Microg/week) Increased dose (consider frequency ) Reduced dose 1015Suspend Seek advice 60 >80 Seek advice

Truro algorithm Darbepoietin AlfaErythropoietin Beta Weight<60 kg60->90kg>90kg<60 kg60->90kg>90kg HB Range <10.1 (NOT 2 x week 15 micg 1 x week 30 micg40 micg1000 iu2000 iu3000 iu 1 x week 3 x week <10.1 (2 x week)20 micg 1 x week 2000 iu3000 iu4000 iu 2 x week 10.1->1110 micg 1 x week 20 micg30 micg1000 iu2000 iu3000 iu 1 x week 2 x week 11.1->1210 micg fortnightl y 10 micg15 micg1000 iu 3000 iu 1 x week 12.1->1310micg 500 iu1000 iu2000 iu monthlyfortnightly1 x week >13NIL

Some other top tips If you stop esa check a mid-month Hb Don’t adjust darbopoetin dose in 2 consecutive months Don’t be too hasty to adjust if a ‘short-term’ infection

Change 3: Audit You can’t just wait for the registry report

Monthly audit report eg Bradford, Antrim

% HD patients with Hb (g/dl) above required level Eastern Regional audit

Iron UK Renal Registry 8th Annual Report, Chapter 8

Value of audit Norwich –Addition of TSAT to iron profile led to a reduction in esa doses and increase in iv iron –Huge cost saving –But with higher overall ferritins –Picked up by audit Do not rely on ferritin alone

Change 4: the 15% With a good system in place for esa administration and adjustment and with regular audit most of your patients take care of themselves 10-15% may have problems Sepsis Blood loss PTH Etc The better you are at 1-3, the more time you have for these

Eastern Region HD Scatter-Plot June %20% 15%

Change 4: the 15% Know your patients –Monthly ward rounds (Bradford, Antrim) –Prescriber should know what is going on –Well attended and focused MDT meetings with continuity of care

Diversion into vascular access Bradford Early Vascular Access project Process management Faxed vascular access referral proforma One stop clinic Link to CKD work in primary care

UK Renal Registry 8th Annual Report, Chapter 8

Pre-dialysis antrimbradnorwichtruro clinic Weekly +r/v meeting Weekly clinics, pt’s seen3-6mthly team Cons, nurse, Pharm, diet AS, nurse, diet, Psych Cons, diet, anaemia nurse, Cons, anaemia nurse + Esa prescribe Pharm/ConsAS/GPCons, in house Anaemia nurse Esa given by 10% self, community Self/commun ity/pre-D nurse Self/DN/PNSelf usually (D Nurse) iron Oral first, iv if not >100 Oral, iv if not target IV in house clinic, some oral iv in various local hosp

Pre-dialysis set up Process manage this in the same way Antrim –Hospital dispenses the esa (supplementary prescriber) –3/12ly audit –Epo-education clinic (patient information meetings in Norwich)

Finally a word to the big units The system is even more important Divide and compete –eg Eastern regional audit

Summary Systematically review the whole process involved in managing your patients’ Hb –Continuity of care Audit regularly 2 measurements for iron Systematic approach to non-responders –MDT meeting, ward rounds Pre-dialysis/CKD

The team Camille Harron, Marie McManus –Antrim Janet Guyton –Norwich Jon Stratton –Truro Russell Roberts –Bradford