21-may-2014 iron infusions in pre op orthopaedic patients deirdre doran colleen mcfetridge
Post on 22-Dec-2015
216 Views
Preview:
TRANSCRIPT
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)
Ana
esth
esia
Lev
el 8
Clin
ic
Nur
seA
naes
thet
ic N
urse
S
peci
alis
tS
peci
alis
t/S
urge
onG
PP
atie
nt
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
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
Making the change in clinic
Process simulation/ walk throughCreating awarenessTeam brain stormingTeaching sessionsProcess aidsPatient informationReinforcement & evaluation
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
top related