Dr Kathryn Robinson krobinson@redcrossblood.org.auConsultant HaematologistAustralian Red Cross Blood ServiceThe Queen Elizabeth Hospital

South Australian BloodSafe Programhttp://www.health.sa.gov.au/bloodsafe/

Optimise haemoglobinMinimise blood lossTolerance of normovolaemic anaemia

ACTION: Local, practical clinical guidance:Anaemia algorithm

Who, when, how to referRational pathology ordering, adding on tests (ferritin: existing non-fasting tube)

Iron deficiencyWith & without anaemia(High ferritin levels!)

Anaemia of pre-end stage CKDManagement of anti-haemostatic

agentsUse of blood conservation strategiesTransfusion decision making AND

dosage

Pre-op anaemia rate by surgery typeArthroplasty transfusion rate 2006-11

Can t change what you can t measure! Reduce reliance on manual data collection (takes time & staff away from coal face)Central data linkage, benchmarking of multiple hospitals, patient groups (3 monthly run chartsideal for practice improvement)Helps with priority setting & planning resources (e.g. needed for anaemia management)ACTION: % transfusion rate, % single units, % pre-op anaemia (+ % with low MCH/MCV, eGFR)

% Anaemic% MCH <27% MCV <80

Champions / establish a guidance teamWorking group with fundamental knowledge of the processMap the processMeasurementDiagnostic phase: barrier analysis, multi-votingImprovement toolsPlan, Do, Study, Act (PDSA) cyclesUse run charts, seek assistance with quality improvement stats

ACTIONS: Do a CPI course, +/- funding for back fill (even 1 day per week)Join existing pathway improvement programs (e.g. elective surgery, Hip #)Involve GPs, specialist nurses/practitioners, consumers

Elective arthoplasty patients undergoing surgery with anaemiaExample: Cause & Effect Diagram

AWARENESS(Hospital and GP)

CARE PROCESSES RESULT MANAGEMENT

KNOWLEDGE (Patient)

Lack of awareness of whole pathway

Lack of awareness of the importance of pre-op anaemia

Ill defined responsibility for who is responsiblefor follow up and management of abnormal results

Difficult to interpret the cause of anaemia and therefore management

No pre-op checklist for GPor hospital pre joint replacement

Unclear about how to manage/ treat anaemia once detected

Elective patients undergoing arthroplastywith anaemia

Blood results not available at clinic

Patient access to GPs

Lack of awareness of the adverse outcomes of transfusion

Lack of knowledge about importance of pre-op anaemia

Lack of knowledge of adverse outcomes of transfusion

No pathway on how &

when to manage anaemia

ACCESSI BI LI TY

GP FORM letter (check for pre-op anaemia)PATIENT INFO: GP check-up for pre-op anaemia, taking oral iron, IV iron infusions (+ translations)Oral iron prescribing chartEasy to use IV iron protocol(s) & rapid accessTimely access to haematology assistance: interpretation of FBE and ferritin

IDA eLearning: www.bloodsafelearning.org.auIDA app for Dx, Ix & MxAcademic detailing visits: GPs and specialistsACTION: review available tools

*Intended as a guide to the relative cost NOT price to the consumer (actual cost of OTC medicines may vary). Price guide from MIMS August 2011 except **Ferro-tab (RRP from AFT). For PBS listed products, the PBS cost for concession holders is $5.60 (at time of writing). BloodSafe Oral Iron Table Version 1.7 October 2011, TP-L3-410. For updates & other resources see www.health.sa.gov.au/bloodsafe

Oral Preparations for Treatment of Iron Deficiency Anaemia (IDA) in Australia

Usual ADULT dose for IDA is around 100 200 mg elemental iron daily in divided doses# (1 2 tablets per day of above preparations, ideally 1 hr before or 2 hrs after food). GI upset may be reduced by taking tablet with food or at night & increasing dose gradually. When a rapid increase in Hb is not required, intermittent dosing (1 tablet 2 3 times a week) or lower doses of iron (e.g. 30 60 mg of elemental iron, increasing to twice daily or three times a day if tolerated: try Ferro-tabs or titrate liquid) may reduce GI upset. Multivitamin-mineral supplements should not be used to treat IDA as iron content is low & absorption may be reduced. #Australian Medicines Handbook 2011

NAME (Manufacturer)

TABLET (Actual size)

FORMULATION ELEMENTAL IRON CONTENT

OTHER ACTIVE INGREDIENTS

RELATIVE COST* 2011 MIMS / (PBS)

FERRO-GRADUMET

(Abbott)

325 mg

Ferrous Sulphate Controlled release tablet

105 mg nil $6.56

30 tablets

FERRO-GRAD C (Abbott)

325 mg

Ferrous Sulphate Controlled release tablet

105 mg Ascorbic acid 500 mg

$8.16 30 tablets

Ferro-f-tab (AFT pharmaceuticals)

310 mg Ferrous Fumarate

Non-controlled release tablet 100 mg Folic acid

350 mcg

$9.47 60 tablets

PBS listed ($12.79)

FEFOL Iron & Folate Supplement

(Pharm-a-care)

270 mg Ferrous Sulphate

Controlled release capsule 87.4 mg Folic acid

300 mcg $9.95

30 tablets

FGF (Abbott)

250 mg Ferrous Sulphate

Controlled release tablet 80 mg Folic acid

300 mcg $3.92

30 tablets

Ferro-tab (AFT pharmaceuticals)

200mg Ferrous Fumarate

Non-controlled release tablet 65.7 mg nil

$8.95** 60 tablets

PBS listed ($11.62)

FERRO-LIQUID (AFT pharmaceuticals)

Ferrous Sulphate Oral liquid 30 mg/5 mL nil

$16.00 250ml bottle

PBS listed ($19.35)

Intravenous (IV) iron infusions Why iron given by a drip into a vein is sometimThis leaflet answers some common questions about Inot contain all available information and does not takeyour doctor about why IV iron has been recommende

What is an IV iron infusion? Intravenous or IV means giving

something directly into the blood stream of the body through a vein. A needle placed into a vein (usually in the back of the hand or arm) is attached to a drip that contains iron mixed with saline (a sterile salt water solution). This fluid is slowly dripped

(infused) into the vein and mixes with the blood in your body.

Why is iron important? Iron is essential for the body to make haemoglobin (Hb), a pigment that makes red blood cells red. When the amount of iron in the body gets too low, the haemoglobin level falls below normal. This is known as iron deficiency anaemia .

Haemoglobin is very important as it carries oxygen from

the lungs

to the rest

of

the

Risks & bYour doctor wavailable alterparticular casIV iron is a sallergic reactbe life threatiron deficiencnot tolerated,quickly enoughoutweigh thethere is a chainform your davoided in th

Alternative

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rapid

Are you starting your joint replacement journey in the best possible condition? The importance of a check-up with your GP and blood tests for anaemia and low vitamin levels in the months leading up to surgery.

This fact sheet is for people who may be having hip or knee replacement surgery.

Why is a check up with my

GP

important?

What is anaemia? Anaemia

is

a

low

red

blood

cell

count.

Make an appointment for a check-up with your GP If you are already on the waiting list for joint replacement surgery or are likely to go onto the waiting list in the near future, then make an appointment with your GP for a check-up to review:

existing medical problems

new or undiagnosed conditions

general health such as weight, blood pressure and smoking

the need for blood tests to check for anaemia or other problems such as low vitamin levels

If you have a number of problems then a double appointment (ask the doctor s surgery when booking) or a second appointment at a later time may be needed. Try to wear clothes that are easy to get on and off.

e.g. Pre-op Anaemia Management

FBE at referral for surgeryGP & patient letter when on waiting listPre-habilitation workshopsReview of results prior to pre-admission clinic (PAC)Bloods done before PAC clinicReview of results with haematology supportDocument plan on discharge, patient info

ACTION: look at opportunities in current system

Care pathwaysInvolve primary careHospital anaemia clinicHigh risk anaesthetic clinicNurse coordinatorNurse practitionersNurse initiated oral iron Support for anaethetic staff to manage anaemia when short time to surgeryEnsure iron repletion in patients having scopes

1. Choose a patient group (need champions & experts) e.g. arthroplasty, colorectal, gastro/endoscopy

2. Use CPI methodology, find some protected time for a coordinator & meet weekly

3. Involve primary care & integrate pathway into other aspects of care for that patient group

Once a pathway is established: easier to extend to other patient groups, other hospitals

Continue efforts on appropriate transfusion decision making /dosage

www.bloodsafelearning.org.au

Iron Deficiency Anaemia eLearning Program