1. QIP: Intravenous Iron Service for Renal Anaemia at SaTH
Learning To Make a Difference – Beyond CMT
Renal Department
Trainees: Lisa Crowley, Fariha Haque, Kinga Bishop
Supervisor: Sourabh Chand
QIP: Intravenous Iron Service for Renal Anaemia at SaTH
Increasing CKD specialist nursing time
Introduction
In February 2017, Dr Chand had attended the RCP Quality Improvement Training for consultants and afterwards we received QIP theory training and embarked on the QIP
There was a feeling that too many patients were receiving intravenous iron in non-dialysis CKD as a day attender on the ward (administered by CKD specialist nurses)
This team was also suffering a reduction in numbers and we wished to see if we could utilise their time better especially for pre-dialysis clinics and education
Adhere to new guidelines nationally to reduce use of EPO and replenish iron stores pre EPO use (High EPO doses = increased cost, strokes & MI risks)1,2
Intravenous iron costs £200 per use (not including administration costs) and can potentially cause skin discolourisation and severe anaphylactic reactions
Goals
AIM STATEMENT: 75% reduction in intravenous iron infused to non-dialysis CKD patients by the CKD specialist nurse team in 12 months
Key drivers:
Appropriate use of intravenous iron: create new nonHD CKD anaemia guideline for the department (utilise oral iron3, reduce EPO dose use)
Alternative site for intravenous iron delivery: utilise Diagnostics, Assessment, and Access to Rehabilitation and Treatment (DAART) service
Low clearance clinics with CKD specialist nursing education: cohort patients to use CKD specialist nursing time for review and patient education
Process Mapping
We performed 120 intravenous iron infusions from January 2016 to January 2017 with the CKD team with eGFR<30 not on haemodialysis – existing infusion service eGFR>30 iron infusions in DAART (GP)
Average time for administration of iron 60mins
D/w DAART team – they felt able to take on about an extra 50 patients per year (block contract for the hospital, no other competing effects on other specialities (gastro etc)
D/w renal consultants, happy with change in prescribing practice if evidence was available and corresponded to EPO team management
D/w haematology team re type of haematinic testing and costs implications (TSAT very costly as sent away); new analyser coming for % hypochromic cells (evidence this is best iron store test)
CKD specialist nursing team enthused with the idea
Realisation that we are currently not coding for maximum remuneration
Habits from last 12 months
Effects of Changes Implemented
At departmental MDT Forum: NICE guidance, FIND-CKD3 oral iron evidence presented and new iron CKD anaemia guideline introduced and agreed with all department
Guideline implemented March 2017
Re-discussed April 2017 with DAART who felt comfortable – change implemented with prescriptions with referral letter so no medical personnel needed (greater flexibility of infusion dates)
17 people over last 4 months (58% reduction) had iv iron with CKD team – freeing time for 1 clinic/month education time at low clearance clinics for the CKD team. This has provided support for the commencement of low clearance clinics
Monthly numbers are reducing as guideline being adopted in medical practice as reminders of guidelines are being sent. Run chart needs to be continued
More focussed education at targeted low clearance population during iron infusions
Need to observe effects on DAART and haemoglobin targets. Also, continue monitoring of prescribing habits and updating during departmental forums
Lessons Learnt from QIP
Application of QI methodology to examine service configuration and what can be changed
Appreciation of the different ways a service may be set-up and factors (including human) that affect its configuration
The many facets that are required to institute change within an organisation and awareness to avoid unbalancing the system
By implementing QIPs, how more efficient use of available resources are realised including removal of identified waste in the system
References
NICE guideline [NG8] Published date: June Chronic kidney disease: managing anaemia
Renal Association: Clinical Practice Guidelines: Anaemia of Chronic Kidney Disease. June 2017
MacDougall et al. FIND-CKD: a randomized trial of intravenous ferric carboxymaltose versus oral iron in patients with chronic kidney disease and iron deficiency anaemia. Neph Dial Transplant Apr;29(4):843-50