21-May-2014

Iron Infusions in pre op orthopaedic patients

Deirdre DoranColleen McFetridge

Auckland District Health Board

Background

Approx 33% ID/IDA in ADHB population Anaemia increases probability of transfusion

during or post surgery ID/IDA requires treatment with iron not RBC!! Secondary impact of enhanced recovery for

patients post surgery

Auckland District Health Board

Original State

Wanted iron deficient patients undergoing high blood loss orthopaedic procedures referred for IV iron, however× No recent bloods× No process in place× Ad hoc referral system× Referral outcomes not documented

Auckland District Health Board

Multi-disciplinary Project Team

Deirdre Doran – Anaesthetic Assessment Amanda Rae – Orthopaedic Outpatients Colleen McFetridge – Orthopaedic Outpatients Lizzie Sithole – Orthopaedic Outpatients Kerry Gunn – Anaesthesia Karen Patching – Anaesthesia Tammy Bryan – Performance Improvement Deba Biswas – Performance Improvement

Auckland District Health Board

Objectives

Early identification of iron deficient patients

Timely referral

Clear communication

No substantial increase in current workload

Auckland District Health Board

How it was done

Workshops held to• Map patient journey• Decide eligibility criteria• Simplify the algorithm• Set up documentation• Clear roles and

responsibilities• Clarify data requirements

Engaged nursing staff from orthopaedics outpatients • Lead taken by Sr.

nurses from the orthopaedic clinic

• Ownership of the process

• Teaching sessions

Auckland District Health Board

Process and Algorithm

Hb< 130g/L male

< 120g/L female

ADHB Indications for IV Iron to Treat Pre-operative Anaemia

Refer for IV Iron

Yes

Evaluate Ferritin & CRP results

YesIs Ferritin 40-100mg/L

and CRP >5 ?

Is Ferritin <40mg/L ?

No

No action needed

No

Hb< 130g/L male

< 120g/L female

Is MCV <80 ?

Is Ferritin <45mg/L ?

ADHB Indications for IV Iron to Treat Pre-operative Anaemia

? Renal failure Consult NephrologyGive IV Iron

Is MCV 80 - 100 ? Is MCV >100 ?

Yes

Yes

Is Ferritin 40-100mg/L and CRP >5 ?

Yes

Is eGFR <60 ?

Yes

Reticulocyte countFolate /

B12 levels /Iron Studies

Yes

Low

Give B12, Folate & Iron

Normal

? Alcoholism, Liver Dysfunction, Hypothyroidism or

Myelodysplasia

Iron Therapy

Give oral iron if surgery is > 2 months away.

Give IV iron if < 2 months to surgery or unable to tolerate oral iron .

Note: 150mg of IV iron / 10g/L of Hb drop may be given post-op to compensate for iron loss. (1ml of whole blood contains approx. 0.5mg of elemental iron.)

Yes

? Haemolysis, consult Haematology

Increased

Normal

Yes

Is Ferritin <100 and blood loss >600ml?

No

Yes

No

Ferritin

If in operating room

Soluble transferrin receptor > 1.6 mg/L

Yes

No

Karen Patching - ADHB indications for IV Iron to Treat Pre-operative Anaemia (6).vsd

Iron Infusion Referral Process (Orthopaedics – Knee and Hip Joint Replacement, Spinal & Open Pelvis Surgery)

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Yes

No

Yes

Start

1.1 Patient goes to the

GP with joint/spinal/pelvis

issues

1.2Patient referred to specialist/surgeon for assessment or possible surgery

1.10Results show Iron

deficiency anaemia?

1.5Follow alternate

care plan for patient’s ailment

1.4Is surgery

necessary?

1.3At FSA

Appointment assess patient to

see if surgery required

End

1.8Get Blood Tests

done

Kerry will advise Anaesthesia coordinators of decision?

1.9Check Hb, Ferritin and CRP Levels

for the patient against protocol

1.11 Triage as normal

except where case to be deferred for

further investigation

1.12Refer for IV Iron Infusion (Email

form to Iron Infusion Generic

Mailbox)

End

1.16Book patient into

ORDA for Iron Infusion on PHS

1.15Advise patient

about infusion and available time

slots

For the moment, will go to Kerry Gunn (back up person to be confirmed), Triage to continue as per normal

Nurse will include a blood form in the assessment folder

No

1.14Advise Nurse

Specialist patient doesn’t require

infusion

No No

1.6Patient completes

questionnaire

1.7Patient’s obs completed &

Nurse orders FBC, Ferritin & CRP

Yes

1.19Advise GP of a follow up plan to

maintain iron levels where reqd.

1.13Patient to

be given Iron Infusion?

Yes

Letter sent to state deferment of surgery where necessary till investigation completed – Kerry to compile std template

Forms to be given by person completing the infusion for follow up bloods

1.14 Communicate to the Anaesthetic nurse specialist the decision via

email

1.17Complete infusion

Anaesthetic Nurse Specialist to monitor those cases that need further investigation

1.20Send copy of referral to GP, Surgeon and

Anaesthetic Clinic

1.21Raise referral for

appropriate service for the patient

1.18Does patient need further investigation

End

Surgical Waitlist form filled out

Decision Algorithm

Cross Functional Process Flow

Auckland District Health Board

Referral Form

Auckland District Health Board

Making the change in clinic

Process simulation/ walk throughCreating awarenessTeam brain stormingTeaching sessionsProcess aidsPatient informationReinforcement & evaluation

Auckland District Health Board

Supporting Documentation

Patient Hand-out

Reference Aids

Auckland District Health Board

Results so far

Testing has gone up from a random 10 % to 87% of eligible patients A further 9% of these patients have been referred for iron infusions

Auckland District Health Board

Spin offs

Increased engagement from staff Improvement of pre admit area Confidence in implementing changes Improved relationships between

orthopaedics & anaesthetics Other services now implementing the

process Patient satisfaction

Auckland District Health Board

Next Steps

Rationalizing blood tests

Referral for high ferritin results

Evaluating impact on transfusion

Patient satisfaction survey

Thanks