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

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Ant

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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