PreOPerative Iron deficiency identification and Management ...community Health, Blood Bank Staff,...
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Case for change In 2009 new research drastically changed blood transfusion practice as we knew it. Whilst Australia holds one of the world’s safest blood supplies, an increasing amount of data now implicates adverse events following blood transfusions to the below: In 2012 the National Blood Authority identified preoperative iron deficiency anaemia as a significant contributor to blood transfusion. If appropriately managed clinicians could substantially decrease blood use intraoperatively and decrease the aforementioned risks. In SLHD the preoperative pathway is complex and inconsistent. As can be seen from our current patient journey, many opportunities to identify and manage iron deficiency are missed. Thus exposing patients to an increase chance of the above adverse outcomes. Mr Mickael Gieules, Mr Nathaniel Alexander Sydney Local Health District Acknowledgements Patients and carers, members of the preoperative patient optimisation steering committee, member of the SLHD Patient Blood Management and Transfusion committee, Surgeons, Anaesthetists, General Practitioners, Hospital & District Executives, Nursing community Health, Blood Bank Staff, Medical Records staff, SLHD performance unit managers, UGI & Colorectal CNC’s, and the project team. Special Mention: Dr Katherine Moore, Ms Ivanka Komusanac, Ms Dimitra Kaldelis, Ms Hannah Blyth, Dr Liane Khoo, Professor John Gibson & our Project Sponsor: Professor Douglas Joshua PreOPerative Iron deficiency identification and Management (POPI) Contact Mr Mickael Gieules, A/SLHD Haemovigilance CNC & SLHD Patient Blood Management Project Lead. Sydney Local Health District [email protected] (02) 9515 4195 32.26% 32.26% 35.48% Patients screened for Anaemia and Iron deficiency (N=31) Anaemia and No Iron Deficiency Iron Derangement +/- Anaemia Neither Aneamic or Iron Deficient 10% 90% Identified Iron Deficient patient Preoperatively (N=10) Managed Unmanaged Clinical Pathway – RPAH Management Pathway once a patient has been identified as iron deficient and requires a Intravenous Iron infusion Outcomes Following the implementation of solutions, the below ideal patient journey was piloted in the RPAH Upper Gastrointestinal department for 2 months resulting in the below highlighted successful outcomes Sustaining change The project team is committed to sustaining the change; various strategies have been put in place these include: 1. Commitment to funding the Patient Blood Management Project lead permanently. 2. Commitment to spreading the project solution to other surgical specialties 3. Department will be benchmarked altogether to engage departmental competition 4. Ongoing reporting to district and facility patient blood management committees Conclusion Strong clinician and management engagement in the redesign process is pivotal to a successful implementation model. Key lessons learnt are: • Sponsorship support and surgeon buy-in is crucial to the success and progression of any surgical projects. • Communicate early and repeat, repeat, repeat • Presentations at committee meetings and ongoing discussions will yield surprising change agents. • Progress can be very slow, when relying on senior clinicians to engage their team. However, persevere and continue the conversation. • Avoid an accreditation year In all, this project can be implemented across NSW and I would encourage other districts to implement similar preoperative models of care. Patient Blood Management is no longer a new paradigm; it’s a standard of care. Every prevented blood transfusion is a testament to the success of this pathway. We are here 12 patient interviews 154 Retrospective file audits 3 consultations sessions 6 process maps 20 General Practitioner surveys Goal All patients undergoing elective colorectal or upper gastrointestinal surgical procedures within SLHD are to be identified, evaluated, and managed for preoperative iron deficiency anaemia. Objectives Primary Objective (1): To achieve 100% compliance with preoperative iron deficiency screening for preoperative patients receiving high risk surgeries or surgeries where substantial blood loss is anticipated, by October 2018. Secondary Objective (2): To reduce instances of Red Blood Cell (RBC) transfusions throughout the perioperative period by 20% (baseline 3,300 transfusions per year) by October 2018. Method This project is being developed in line with the Clinical Healthcare Redesign methodology supported by the NSW Agency for Clinical Innovation. This 6 step methodology aims to support project team through the redesign process with a strong emphasis on behavioural change management in order to ensure change sustainability. Three key themes were identified by the project team via the Root Cause Analysis: 1) Lack of a clinical pathway/process to prompt and guide clinicians through the preoperative optimisation process 2) Breakdown in communication between General Practitioners, Anaesthetists, Surgeons and Pathology results 3) Lack of management strategies in place to rapidly optimise patients Diagnostics Retrospective patient file audit (UGI & Colorectal services, RPAH/CRGH) 39% 19% 43% Combined Iron deficiency testing (N=54) CRGH Iron Studies RPAH Iron Studies No Iron Studies Completed Now 75% of patients are being appropriately managed (up from 10%) Throughout the pilot phase, iron deficiency has increased from 30% to 90% Visual cues were developed to prompt surgeons to notify the CNC & complete testing Following the pilot, a new pathology process is being considered by surgeons, which would see patients’ complete iron deficiency testing the same day as the surgical appointment within the Pre- Admission clinic. This would be a substantial improvement to the current patient journey Solutions The project team developed 4 key solutions: 1) Development of a list identifying high risk surgery or where substantial blood loss is anticipated 2) Development of a clinical pathway inclusive of Iron deficiency identification and management. 3) Development of online support tools for General Practitioners via Healthpathways 4) Enable external pathology results to be uploaded into the eMR Mortality Morbidity Length of stay by an average of 2.5 days Post surgical complication/recovery time = Possible missed iron study opportunity
Transcript of PreOPerative Iron deficiency identification and Management ...community Health, Blood Bank Staff,...
Case for change In 2009 new research drastically changed blood transfusion practice as we knew it. Whilst Australia holds one of the world’s safest blood supplies, an increasing amount of data now implicates adverse events following blood transfusions to the below:
In 2012 the National Blood Authority identified preoperative iron deficiency anaemia as a significant contributor to blood transfusion. If appropriately managed clinicians could substantially decrease blood use intraoperatively and decrease the aforementioned risks.
In SLHD the preoperative pathway is complex and inconsistent. As can be seen from our current patient journey, many opportunities to identify and manage iron deficiency are missed. Thus exposing patients to an increase chance of the above adverse outcomes.
Mr Mickael Gieules, Mr Nathaniel AlexanderSydney Local Health District
Acknowledgements Patients and carers, members of the preoperative patient optimisation steering committee, member of the SLHD Patient Blood Management and Transfusion committee, Surgeons, Anaesthetists, General Practitioners, Hospital & District Executives, Nursing community Health, Blood Bank Staff, Medical Records staff, SLHD performance unit managers, UGI & Colorectal CNC’s, and the project team. Special Mention: Dr Katherine Moore, Ms Ivanka Komusanac, Ms Dimitra Kaldelis, Ms Hannah Blyth, Dr Liane Khoo, Professor John Gibson & our Project Sponsor: Professor Douglas Joshua
PreOPerative Iron deficiency identification and Management (POPI)
ContactMr Mickael Gieules, A/SLHD Haemovigilance CNC & SLHD Patient Blood Management Project Lead.
Sydney Local Health District
(02) 9515 4195
32.26%32.26%
35.48%
Patients screened for Anaemia and Iron deficiency (N=31)
Anaemia and No Iron DeficiencyIron Derangement +/- AnaemiaNeither Aneamic or Iron Deficient
10%
90%
Identified Iron Deficient patient Preoperatively (N=10)
Managed Unmanaged
Clinical Pathway – RPAH Management Pathway once a patient has been identified as iron deficient and requires a Intravenous Iron infusion
Outcomes Following the implementation of solutions, the below ideal patient journey was piloted in the RPAH Upper Gastrointestinal department for 2 months resulting in the below highlighted successful outcomes
Sustaining change The project team is committed to sustaining the change; various strategies have been put in place these include:
1. Commitment to funding the Patient Blood Management Project lead permanently.
2. Commitment to spreading the project solution to other surgical specialties
3. Department will be benchmarked altogether to engage departmental competition
4. Ongoing reporting to district and facility patient blood management committees
Conclusion Strong clinician and management engagement in the redesign process is pivotal to a successful implementation model. Key lessons learnt are: • Sponsorship support and surgeon buy-in is crucial to the success
and progression of any surgical projects.• Communicate early and repeat, repeat, repeat• Presentations at committee meetings and ongoing discussions
will yield surprising change agents.• Progress can be very slow, when relying on senior clinicians to
engage their team. However, persevere and continue the conversation.
• Avoid an accreditation year
In all, this project can be implemented across NSW and I would encourage other districts to implement similar preoperative models of care. Patient Blood Management is no longer a new paradigm; it’s a standard of care. Every prevented blood transfusion is a testament to the success of this pathway.
We are here
12 patient interviews
154 Retrospective file
audits
3 consultationssessions
6 process maps
20 General Practitioner
surveys
Goal All patients undergoing elective colorectal or upper gastrointestinal surgical procedures within SLHD are to be identified, evaluated, and managed for preoperative iron deficiency anaemia.
ObjectivesPrimary Objective (1): To achieve 100% compliance with preoperative iron deficiency screening for preoperative patients receiving high risk surgeries or surgeries where substantial blood loss is anticipated, by October 2018.Secondary Objective (2): To reduce instances of Red Blood Cell (RBC) transfusions throughout the perioperative period by 20% (baseline 3,300 transfusions per year) by October 2018.
Method This project is being developed in line with the Clinical Healthcare Redesign methodology supported by the NSW Agency for Clinical Innovation. This 6 step methodology aims to support project team through the redesign process with a strong emphasis on behavioural change management in order to ensure change sustainability.
Three key themes were identified by the project team via the Root Cause Analysis:
1) Lack of a clinical pathway/process to prompt and guide clinicians through the preoperative optimisation process
2) Breakdown in communication between General Practitioners, Anaesthetists, Surgeons and Pathology results
3) Lack of management strategies in place to rapidly optimise patients
Diagnostics Retrospective patient file audit (UGI & Colorectal services, RPAH/CRGH)
39%
19%
43%
Combined Iron deficiency testing (N=54)
CRGH Iron StudiesRPAH Iron StudiesNo Iron Studies Completed
Now 75% of patients are being appropriately managed (up from 10%)
Throughout the pilot phase, iron deficiency has increased from 30% to 90%
Visual cues were developed to prompt surgeons to notify the CNC & complete testing
Following the pilot, a new pathology process is being considered by surgeons, which would see patients’ complete iron deficiency testing the same day as the surgical appointment within the Pre-Admission clinic. This would be a substantial improvement to the current patient journey
Solutions The project team developed 4 key solutions:
1) Development of a list identifying high risk surgery or where substantial blood loss is anticipated
2) Development of a clinical pathway inclusive of Iron deficiency identification and management.
3) Development of online support tools for General Practitioners via Healthpathways
4) Enable external pathology results to be uploaded into the eMR
Mortality Morbidity
Length of stay by an average of 2.5 days
Post surgical complication/recovery time
= Possible missed iron study opportunity
