1. Addressing Iron Deficiency Anemia 181 st Street Clinic (Washington Heights Family Health Center) 2006-7 PDSA Project

2. Why Tackle Iron Deficiency? #1 Nutritional Disorder in World 80% Fe Deficient 30% some form of Fe Deficient Anemia Easily Administered Therapy

3. SUPPLEMENTATION WORKS! Effect on of treatment.78 mg/dL difference in those treated.78 mg/dL difference in those treated Positive Effects on Developmental Outcomes Cognition?

4. AIM Statement Reduce the impact of iron deficiency and iron deficiency anemia in children under 3 in our practice by: Increasing the identification of children at risk Implementing evidence- based treatment of iron deficiency anemia Establishing primary prevention of iron deficiency for an at-risk population (Patients aged 1-3 years)

5. PDSA for Prevention of Anemia P: Implement primary prevention of iron deficiency D: Providers began prescribing prophylactic MVI with iron to all patients aged 1-3 years S: Chart Review (2 wks post intervention): Providers prescribing prophylactic MVI with Iron to 81% of patients 1-3 years Providers prescribing prophylactic MVI with Iron to 81% of patients 1-3 years A: Expanded education efforts to ALL providers including nurse practitioners

6. AAP Iron-deficiency Screening and Treatment Guidelines Universal Screening in high risk communities Hgb or Hct between 9-12 months, Hgb or Hct between 9-12 months, and again 6 months later Treatment Treat pts 6m-1.9y with Hb <11.0mg/dL, 2-5 yrs with Hb < 11.1 with 3 - 6mg/kg/day of elemental iron Treat pts 6m-1.9y with Hb <11.0mg/dL, 2-5 yrs with Hb < 11.1 with 3 - 6mg/kg/day of elemental iron Repeat CBC 1 month into treatment – if hgb increased by 1g/dl then continue for 2 more months, if NOT then further testing recommended Repeat CBC 1 month into treatment – if hgb increased by 1g/dl then continue for 2 more months, if NOT then further testing recommended Repeat testing 6 months after successful treatment Repeat testing 6 months after successful treatment

7. How Are We Screening? Pre-intervention Measurement: to assess variability in current screening practices 9-12 month olds 9-12 month olds CBC AND a hemocue (68%) CBC (28%) Hemacue alone 4% Proposals brought to providers on ways to implement uniform screening methods Which ages to screen patients Which ages to screen patients Hemocue vs. venipuncture Hemocue vs. venipuncture Coordinating venipunctures with state mandated Pb screening Coordinating venipunctures with state mandated Pb screening 2 year olds 2 year olds CBC AND a hemocue (31%) CBC (55%) Hemacue alone 14%

8. Changes Made To Screening At/ around 12 months: CBC and lead At/around 18 months: Hemocue At/around 18 months: Hemocue At/around 24 months: CBC and lead

9. Screening P: Tentative consensus made to conduct CBC screening at 12 venous, 18 month hemocue, and 24 months venous D: Providers informed via email of new plan to screen at theses specific ages S: Chart review of recent 12-24 month old visits 18/20 (90%) pts with CBC/Pb screen by 1 year of age 8/12 (66%) pts with f/u hemocue between 15-24 months A: Conducted discussion via email to foster awareness of and buy-in to the new screening protocol

10. Current Protocol Primary Prevention Prescribe prophylactic MVI with Iron for all pts 1-3 years to continue for duration of at least 1 year Prescribe prophylactic MVI with Iron for all pts 1-3 years to continue for duration of at least 1 yearScreening CBC at 12 month, Hemocue 18 months, and 24 months CBC and Hemocue CBC at 12 month, Hemocue 18 months, and 24 months CBC and HemocueTreatment Treating all pts under 5 yrs with Hb < 11 with 2 - 4mg/kg/day of elemental iron Treating all pts under 5 yrs with Hb < 11 with 2 - 4mg/kg/day of elemental iron Repeat CBC 1 month into treatment – if hgb increased by 1g/dl then continue for 2 more months, if NOT then further testing recommended Repeat CBC 1 month into treatment – if hgb increased by 1g/dl then continue for 2 more months, if NOT then further testing recommended

11. Treatment Pre-Intervention Measurement: 4/16 (25%) patients with iron-deficiency anemia given correct treatment doses of Iron according to AAP 4/16 (25%) patients with iron-deficiency anemia given correct treatment doses of Iron according to AAP Providers educated on AAP guidelines Discussion of how we plan to implement/adapt the AAP guidelines, e.g: Dosage Dosage Anemia definition (i.e. cut-offs by age – vs AAP) Anemia definition (i.e. cut-offs by age – vs AAP)

12. Chart Review—Are we appropriately documenting, diagnosing, & treating anemia? patients age 1 to 3 with dx code of anemia over a 6 month period Results: (1) 94% proper “anemia diagnosis (1) 94% proper “anemia diagnosis (2) 81% treated with 2-4 mg/kg/day dosing of Fer-in-sol (2) 81% treated with 2-4 mg/kg/day dosing of Fer-in-sol (3) 81% correctly instructed for follow-up as per documentation (3) 81% correctly instructed for follow-up as per documentation (4) 94% followed up regardless of documentation (4) 94% followed up regardless of documentation (5) 63% documented resolution of anemia (though some still in Tx at time of review) (5) 63% documented resolution of anemia (though some still in Tx at time of review) Goals: Are we reaching them? Documentation might not lead us to believe so…

13. Compliance Problem Randomly selected group of parents of one to 3 year olds. Only 40% took the vitamins nearly all the time (5 times a week or more). Only 40% took the vitamins nearly all the time (5 times a week or more). 50% of the parents surveyed admitted non-compliance (one dose a week or less)

14. Compliance Chart Review 1 to 3 year olds from each provider 59% had documentation of child taking Polyvisol with Fe. All charts documented appropriate screening times for CBC Reasons for non-compliance

15. Steps Towards Compliance IRON RICH FOOD HANDOUT English version: revised the handout at a 4th grade reading level using the Flesch-Kincaid Grade Level Index. English version: revised the handout at a 4th grade reading level using the Flesch-Kincaid Grade Level Index. b) Spanish version: translators and Fernandez-Huerta scale between 5th and 6th grade.

16. Future Directions Finalize consensus screening protocol and achieve provider buy-in Why are parents not giving the Iron? Are the Handouts helping? Are the Handouts helping? Chart reviews Treatment – Are we treating for kids who meet criteria? For patients diagnosed with anemia how is the follow-up – testing at 1 month? Continuing for 3 months at least? Treatment – Are we treating for kids who meet criteria? For patients diagnosed with anemia how is the follow-up – testing at 1 month? Continuing for 3 months at least? Primary Prevention – Are patients staying on the MVI with Iron? Is it resulting in fewer kids with anemia? Primary Prevention – Are patients staying on the MVI with Iron? Is it resulting in fewer kids with anemia?

17. Previous PDSA? Dental Health 50% documentation of discussion 50% documentation of discussion Developmental or Speech Delay 50% documented discussion 50% documented discussion 0% used sticker’s from last year’s project 0% used sticker’s from last year’s project

18. The Team Attendings Steve Caddle Steve Caddle Adriana Matiz Adriana Matiz Mary McCord Mary McCord Melanie Gissen Melanie Gissen Patricia Hametz Patricia Hametz Dodi Meyer Dodi Meyer Elise Olshen Kharbanda Elise Olshen Kharbanda Mary Zweighaft Mary Zweighaft Carol Pafundi Carol Pafundi Harriet McGurk Harriet McGurk Annie Armstrong Annie Armstrong Melissa Glassman Melissa Glassman Residents Monique Collier Monique Collier Brenton Mar Brenton Mar Eliza Auerback Eliza Auerback Sarah Schrager Sarah Schrager Carol Senkler Carol Senkler Paula Ayora Paula Ayora Dawn Wetzel Dawn Wetzel John Babineau John Babineau Rachelle Gandica Rachelle Gandica Maja Castillo Maja Castillo Brenda Ritson Brenda Ritson Matt Laurich Matt Laurich Patricia Tae Patricia Tae Ola Aganga Ola Aganga Mahbod Mohazzebi Mahbod MohazzebiStaff Joan Mahoney Joan Mahoney Maralin Bautista Maralin Bautista Candida Rodriguez Candida Rodriguez Petra Ortiz Petra Ortiz Beatrice Frempong Beatrice Frempong Annes Silver Annes Silver Annie Hertz Annie Hertz Bill Johnson Bill Johnson Leilani Vinales Leilani Vinales Ivelisse Rodriguez Ivelisse Rodriguez Iliana Torres Iliana Torres Cindy Ferrer Cindy Ferrer Evelyn Mejia Evelyn Mejia Denise Connolly- Hoyt Denise Connolly- Hoyt