Identifying and Managing Iron Deficiency and Iron Deficiency Anaemia

Murrumbidgee Local Health District (MLHD) identified an alternative option for iron replacement therapy and developed guidelines to deliver it in the community setting where clinically indicated, in collaboration with patients and carers.

Aim

To reduce the number of patients admitted to Corowa Hospital for management of iron deficiency (ID) and iron deficiency anaemia (IDA) using slow iron replacement infusions, by 80% within 12 months.

Benefits

• Improves access to and use of the most appropriate iron replacement therapy available.
• Allows patients to receive ID and IDA therapy in the community setting.
• Improves patient satisfaction by providing treatment options that do not impact daily activity.
• Improves clinical information provided to the patient and their carer.
• Reduces the time and costs associated with accessing treatment.
• Empowers patients by involving them in the treatment planning and management of their condition.
• Reduces healthcare costs associated with acute admissions and day procedures, as well as staff attending high-frequency observations.
• Increases access to acute beds in hospitals and reduces waiting time for other patients.
• Enhances collaboration with general practitioners (GPs) and community healthcare providers.

Background

ID is a common nutritional deficiency that if left untreated can lead to IDA. Symptomatic IDA sometimes requires a blood transfusion, which exposes the patient to unnecessary risks and has been associated with negative health outcomes, increased morbidity and mortality¹. The introduction of patient blood management principles, which aim to manage the underlying cause of anaemia, has reduced unnecessary transfusions of blood and blood products.

However, the implementation of patient blood management principles has significantly increased the number of patients admitted to MLHD for slow iron replacement infusions. Iron infusions are safer than blood transfusions, but should not be the default therapy. Patients need to be assessed individually and made aware of the risks, as well as educated on alternative iron replacement therapies available.

Patients admitted to MLHD hospitals for iron infusions increased from 199 in 2014 to 494 in 2015 and 577 in 2016. With each infusion taking an average of 5-9 hours and costing approximately $551, the increasing demand for iron infusions negatively impacted bed access and the experience of the patient and their carer. It also increased healthcare costs, with iron infusions costing MLHD $294,847 in 2016.

As a result, it was determined that a review of iron replacement therapies was required, to identify the most appropriate and least invasive option that meets the needs of patients, carers and the health system.

Implementation

• Collaboration was undertaken with key stakeholders, including the Health Service Manager, clinicians and staff at the medical centre, pharmacy and community health centre.
• Rapid iron replacement infusions were identified as an appropriate alternative to slow iron replacement infusions. They can be safely delivered by GPs and other community healthcare providers, and reduce infusion time by at least four hours.
• An agreed procedure guideline for delivering rapid iron replacement infusions in the community was developed, based on product information and evidence-based best practice. It was endorsed by Corowa Health Service and the local medical centre.
• Patients were provided with consumer information on intravenous iron infusions² and iron tablets³, at the time of purchasing iron formulations.
• GPs at participating clinics involved patients and carers in the planning of their treatment to ensure they were prescribed the least invasive therapy possible.
• An informed consent process was developed, to ensure patients were aware of the risks before receiving intravenous iron replacement therapy.
• Patients and carers were asked to complete a survey after receiving rapid iron replacement infusions, to see if it improved their healthcare journey.

Project status

Implementation – The project is ready for implementation or is currently being implemented, piloted or tested.

Key dates

• Project start: July 2016
• Project Implementation: February 2017
• Project evaluation: July 2017

Implementation sites

• Corowa Health Service
• Corowa Medical Centre
• Australian Red Cross Blood Service

Partnerships

• Centre for Healthcare Redesign
• Clinical Leadership Program
• Murrumbidgee Primary Health Network

Evaluation

A full evaluation will be undertaken in February 2018 to measure the following outcomes:

• number of patients admitted to Corowa Hospital with ID or IDA who received intravenous iron replacement
• number of patients deemed appropriate for rapid iron replacement (16 years or older, not able to tolerate oral iron replacement therapy, non-haemodialysis dependant, first trimester of pregnancy,
• comorbidities contraindicating use and not requiring inpatient treatment for IDA) who received infusions in the community (target 80%)
• patient satisfaction and engagement measured by a patient survey.

Results

The project was implemented between February and July 2017. As of July 2017, the following results have been achieved:

• the total number of patients receiving intravenous iron replacement therapy (both slow and rapid formulations) reduced by 49%
• the number of patients who received intravenous iron in hospital reduced from 35 in February 2017 to 9 in July 2017, saving approximately $14,326 over a six-month period
• based on a minimum infusion time of five hours, the 74% reduction in slow iron infusions equated to a saving of 130 hours spent in treatment
• 100% of patients who required intravenous iron replacement therapy chose to receive it in the community if it was indicated and safe to do so.
• patients who purchased iron replacements and were provided with consumer information increased from 0 in February 2017 to 62 in July 2017
• 100% of patients who required iron replacement therapy were provided with consumer information from their GP
• the number of patients who indicated they would have liked more information about iron replacement therapy reduced from 90% in February 2017 to 25% in July 2017.

Lessons learnt

• Ensure the project can be adapted to the needs of the organisation, regardless of initial thoughts, aims and expectations.
• Accurate and reliable data can be difficult to obtain, as collection methods may not align with your reporting requirements. Ensure reporting methods are discussed early in the project and the right people are involved, who understand and can support your reporting needs.
• Solution design may alter throughout implementation process and adaptability may be required. It is important in this circumstances to maintain focus on the desired outcome. If the process meets the objectives than this is an indicator of success.

References

1. Leahy MF, Hofmann A, Towler S et al. Improved outcomes and reduced costs associated with a health-system-wide patient blood management program: a retrospective observational study in four major adult tertiary-care hospitals. Transfusion 2017; 57(6) 1347-1358.
2. SA Health Safety and Quality Community Advisory Group. Intravenous (IV) iron infusions: information for patients, families and carers. Adelaide: SA Health; 2016.
3. SA Health Safety and Quality Community Advisory Group. A guide to taking iron tablets: information for patients, families and carers. Adelaide: SA Health; 2016.

Further reading

• Australian Commission on Safety and Quality in Health Care (ACSQHC). Standard 7: Blood and Blood Products. Sydney: ACSQHC; 2012.
• Australian Red Cross Blood Service (ARCBS). Blood products and transfusion practice for health professionals. Sydney: ARCBS; 2017.
• Department of Health. Ferinject® Product Information AU E10. Woden, ACT: Therapeutic Goods Administration eBusiness Services; 2016.
• Government of South Australia. BloodSafe Program. Adelaide: SA Health; 2012.
• National Blood Authority Australia. Patient Blood Management Guidelines. Canberra: National Blood Authority Australia; 2017.
• Pasricha S, Flecknoe-Brown S, Allen K et al. Diagnosis and management of iron deficiency anaemia: a clinical update. Medical Journal of Australia 2010; 193(9): 525-532.

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