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Transcript of Anaemia Management Breakthrough Collaborative. Best scientific knowledge? Kidney senses tissue...
Anaemia Management
Breakthrough Collaborative
Best scientific knowledge?
Kidney senses tissue oxygen tension
EPO
Bone marrowstimulated
Increased red cells
Reduce costs and increase quality
• In simple terms– More of our patients meet renal association or
NICE guidelines– Ideally we reduce our costs as well
• Eg Norwich cut esa bill by £140k after introduction of TSAT
Sentinel organisations?
UK Renal Registry 8th Annual Report, 2006. Chapter 8
% patients with Hb 10.5-12.5Percentage of HD patients with Hb 10.5-12.5g/dl
20
25
30
35
40
45
50
55
60
65
70
75
80
3 S
then
d 1
Tru
ro 8
Ant
rim 0
Ipsw
i 0
Uls
ter
1 R
edng
6 C
lwyd
4 N
ewry
1 E
xete
r 0
Not
tm 4
Inve
rns
1 B
asld
n17
Ste
vng
2 H
ull
2 E
dinb
0 A
irdrie
2 A
brdn
5 D
unde
e 2
Che
lms
7 L
Rfre
e 1
Dor
set
1 D
unfn
2 C
ovnt
0 S
hrew
2 L
eic
8 P
lym
th 0
Nor
wch
6 B
ango
r 3
Pre
stn
2 G
lasR
I 1
Oxf
ord
0 D
&Gal
l 1
L H
&Cx
7 C
arlis
7 T
yron
e12
Car
sh 1
Mid
dlbr
0 L
Kin
gs 6
B H
eart
3 S
wan
se 1
She
ff 2
Gla
sWI
0 B
risto
l11
L G
uys
0 N
ewc
0 L
eeds
3 B
QEH
18 W
rexm
19 M
anW
st 1
Klm
arnk
0 W
olve
1 G
louc
7 B
elfa
st 1
Por
ts 2
Car
dff
0 D
erby
0 Y
ork
31 C
amb
2 L
ivrp
l31
Brig
htn
16 D
udle
y 2
Sun
d 0
Bra
dfd
10 E
ng 6
NI
2 S
ct 5
Wls
8 U
K
Centre
Perc
enta
ge o
f pat
ient
s
Upper 95% Cl% with Hb 10.5 - 12.5Lower 95% Cl
Guidelines and standards
• Renal Association 2003– Hb > 10
• European Best Practice 2004– Targeted Hb level >11g/dl for all CKD patients– In HD, pre-dialysis Hb >14 is not desirable– Diabetes/CV disease Hb>12 is not
recommended
CREATE, CHOIR and NICE
Phrommintikul Lancet 2007
NICE
• UK Guideline for the management of anaemia in CKD 2007
• 10.5-12.5
• Consider dose adjustment if outside 11-12
Can Bradford change course?
0
2
4
6
8
10
12
14
16
9.5-10 10-10.5 10.5-11 11-11.5 11.5-12 12-12.5 12.5-13 13-13.5 13.5-14 14-14.5 15-15.5 15.5-16 16-16.5
Series1
Can Bradford change course?
%>10 % >12.5 %>13 %NICE
2005 91 43 42 48
2007 85 38 29 47
St lukes only (no 90 day rule)
Antrim Course
%>10 % >12.5 %>13 %NICE
2005 100 35 19 56
2007 95 16 7 69
Norwich Course
%>10 % >12.5 %>13 %NICE
2005 77 24 11 57
2007 98 18 8 65
It can be done
Let’s do it!
• What we do
• 5 areas for you to focus on
What have we learnt about each other so far?
antrim brad norwich truro
Written policy epo
yes No PGD yes
Written policy iron
yes No PGD yes
Who prescribes
Pharm/Cons Cons/AS Anaemia nurse adjusts
Computer (override poss)
Who gives epo
Nurse on HD Nurse on HD
Nurse on HD Nurse on HD
Hb tests Monthly Monthly 6/52 monthly
Iron tests monthly monthly 6/52 3-monthly
Antrim brad norwich truro
What iron tests
Ferr/TSAT Ferr/%hypo Ferr/TSAT Ferr/%hypo
Speed of response
2 days approx 1 week
2-3 days approx 1 week
Esa Darbo/recor darbo epprex Darbo
Iron target 200-800/>20%
200-800 200-800
Tsats>20%
(aim30-40)
200-600/ <5%hyp
Hb target (pre-2006)
11-13 > 11 > 11 11-12
continuity 1 year Cons 6/12 rotation 4/12 rotation Cons/nurse lead (no jnr docs)
Medical r/v Monthly cons WR
Monthly cons WR
6/12 clinic + daily visit
Monthly MDT/QA
5 change areas
• Give esa on the unit (HD)
• Understand your esa mechanism
• Audit regularly
• Know your patients • The 15%
• Diversion into vascular access
• Pre-dialysis
Change No. 1
• Give the esa on the unit
• It’s the only factor common to all 4 units
Change 2: The epo mechanism
Blood tests
targets
Test results
prescription
decisionpatient
AUDIT
Blood tests to dose adjustments
• Antrim– Renal pharmacist adjusts within 2 days
• Norwich– Anaemia nurse
• Truro– Computer
• Bradford– Senior doctor
But we do have in common….
• The same pharmacist/nurse/computer/doctor makes the decisions on the same patients for a prolonged period
• Continuity of care
1 2 3 4
week
‘monthly’bloods
Pharmacistreview
Consultant +PharmacistWard rounds
Antrim
1 2 3 4
week
‘monthly’bloods
Computer/algorithmsuggests dose
MDT/QAMeeting-agree or disagree with dose
Truro
NICE algorithm
Hb <11 Hb 11-12 Hb 12-15 Hb >15
Increase esaunless rising >1g/month
No changeunless rising >
1g/month
?stop ironReduce esa
unless falling>1g/month
Stop iron?stop or
halve esa. recheck 2/52
Consider poor responsealgorithm
Esa changes according to NICE schedule
Algorithm example (NICE)Current dose(Microg/week)
Increased dose (consider
frequency)
Reduced dose
10 15 Suspend
15 20 10
20 30 15
30 40 20
40 50 30
50 60 40
60 80 50
80 Seek advice 60
>80 Seek advice Seek advice
Truro algorithm
Darbepoietin Alfa Erythropoietin Beta
Weight <60 kg 60->90kg >90kg <60 kg 60->90kg >90kg
HB Range
<10.1 (NOT 2 x week
15 micg 1 x week
30 micg 40 micg 1000 iu 2000 iu 3000 iu
1 x week 1 x week 3 x week 3 x week 3 x week
<10.1 (2 x week) 20 micg 1 x week
2000 iu 3000 iu 4000 iu
2 x week 2 x week 2 x week
10.1->11 10 micg 1 x week
20 micg 30 micg 1000 iu 2000 iu 3000 iu
1 x week 1 x week 2 x week 2 x week 2 x week
11.1->12 10 micg fortnightly
10 micg 15 micg 1000 iu 1000 iu 3000 iu
1 x week 1 x week 1 x week 1 x week 1 x week
12.1->13 10micg 10 micg 10 micg 500 iu 1000 iu 2000 iu
monthly fortnightly 1 x week 1 x week 1 x week 1 x week
>13 NIL NIL NIL NIL NIL NIL
Some other top tips
• If you stop esa check a mid-month Hb
• Don’t adjust darbopoetin dose in 2 consecutive months
• Don’t be too hasty to adjust if a ‘short-term’ infection
Change 3: Audit
• You can’t just wait for the registry report
Monthly audit report Median 11.7 1.9
st dev
No of Patients >10 % > 10 > 12.5 % > 12.5115 93 80.87% 38 33.04%
No Of Patients
No of Patients on EPO
Percentage of Patients
ON EPO115 96 83.48%
No Of Patients
No of Patients on Iron
Percentage of Patients
ON Iron115 96 83.48%
No of Patients >1.2 % > 1.2115 73 63.48%
Haemoglobin
% of Patients Haemoglobin Greater Than 10
Percentage of Patients on EPO
Percentage of Patients on Iron
% of Patients KT/V Greater Than 1.2
eg Bradford, Antrim
% HD patients with Hb (g/dl) above required level
40% 50% 60% 70% 80% 90% 100%
Region (HD- 1098- 1014- 980)
WSH(HD- 49- 45- 41)
N&N J PU (HD- 159- 143- 137)
J ames Paget (HD- 79- 77- 74)
Addenbrooke's (HD- 173- 154- 154)
Kings Lynn (HD70- 70- 69)
I pswich (HD- 96- 91- 86)
Basildon (HD- 134- 119- 113)
Broomfield (HD- 104- 95- 93)
Southend (HD- 130- 120- 113)
Lister (HD- 104- 100- 100)
% Hb>10 % Hb>11
Eastern Regional audit
Iron
UK Renal Registry 8th Annual Report, 2006. Chapter 8
Value of audit
• Norwich– Addition of TSAT to iron profile led to a
reduction in esa doses and increase in iv iron– Huge cost saving– But with higher overall ferritins– Picked up by audit
• Do not rely on ferritin alone
Change 4: the 15%
• With a good system in place for esa administration and adjustment and with regular audit most of your patients take care of themselves
• 10-15% may have problems• Sepsis• Blood loss• PTH• Etc
• The better you are at 1-3, the more time you have for these
Eastern Region HD Scatter-Plot June 2005
6.0
7.0
8.0
9.0
10.0
11.0
12.0
13.0
14.0
15.0
16.0
0 50 100 150 200 250 300 350 400 450
Dose / Wt (IU/Kg/Wk)
Hb (g
/dl)
Fe (0-200) Fe (201-500) Fe (>500)
50% 20%
15% 15%
Change 4: the 15%
• Know your patients– Monthly ward rounds (Bradford, Antrim)– Prescriber should know what is going on– Well attended and focused MDT meetings with
continuity of care
Diversion into vascular access
• Bradford Early Vascular Access project
• Process management
• Faxed vascular access referral proforma
• One stop clinic
• Link to CKD work in primary care
UK Renal Registry 8th Annual Report, 2006. Chapter 8
Pre-dialysisantrim brad norwich truro
clinic Weekly +r/v meeting
Weekly +r/v meeting
Weekly clinics, pt’s seen3-6mthly
team Cons, nurse,
Pharm, diet
AS, nurse, diet, Psych
Cons, diet, anaemia nurse,
Cons, anaemia nurse +
Esa prescribe Pharm/Cons AS/GP Cons, in house
Anaemia nurse
Esa given by 10% self, community
Self/community/pre-D nurse
Self/DN/PN Self usually (D Nurse)
iron Oral first, iv if not >100
Oral, iv if not target
IV in house clinic, some oral
iv in various local hosp
Pre-dialysis set up
• Process manage this in the same way
• Antrim– Hospital dispenses the esa (supplementary
prescriber)– 3/12ly audit– Epo-education clinic (patient information
meetings in Norwich)
Finally a word to the big units
• The system is even more important
• Divide and compete– eg Eastern regional audit
Summary
• Systematically review the whole process involved in managing your patients’ Hb– Continuity of care
• Audit regularly• 2 measurements for iron• Systematic approach to non-responders
– MDT meeting, ward rounds
• Pre-dialysis/CKD
The team
• Camille Harron, Marie McManus– Antrim
• Janet Guyton– Norwich
• Jon Stratton– Truro
• Russell Roberts– Bradford