Rangel QI Ironing out the kinks: Improving Screening and Treatment of Iron Deficiency Anemia

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Rangel QI Ironing out the kinks Improving
Screening and Treatment of Iron Deficiency Anemia
Betty Reyes, Taina Sanchez, PFA Staff Michelle
Coleman, Clara Paris, RN Staff Wendy Acosta,
Jessie Soriano, MA Staff Evelyn Berger, Hetty
Cunningham, Christine Krause Elshadey Bekele,
Sandhya Brachio, Alicia Chang, Laura Perreta,
Wee Chua, Kenny McKinley, Jen Cohen, Andrew
Wehrman, Ashish Ankola, Nisha Broodie, Ashley
Blanchard, Pooja Desai
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Iron Deficiency

• Iron is the worlds most common single nutrient
  deficiency.
• Many studies have shown an association between
  iron deficiency and later cognitive deficits.

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Iron Deficiency Anemia (IDA)
Bothwell TH et al. Oxford Blackwell Scientific
1979 44-81
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AIM Statement

• To standardize screening by sending CRP/ferritin
  and CBC levels in 9-month to 2.5 year olds (6?
  80)
• To improve treatment of iron deficiency (without
  anemia) in 9-month to 2.5-year olds. (0? 80)
• Improve follow up by expediting prescriptions
  within one week (73 ? 90) and follow up labs
  within in one month (43 ? 75)
• Involve Rangel MAs and RNs in education of
  patients on high iron diets, iron deficiency
• and anemia

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AAP 2010 Guidelines

• Universal screening at 1 year
• Selective screening at any age if risk factors
  present
• Screening
• Serum Ferritin (SF) and C-Reactive Protein
  increase the sensitivity and specificity of the
  diagnosis
• Reticulocyte Hb (CHr) preferable biomarker
• Establish a means of carefully tracking infants
  identified as iron deficient.

Baker et al. Clinical Report- Diagnosis and
Prevention of Iron Deficiency and
Iron-Deficiency Anemia in Infants and Young
Children (0-3 years of age). Pediatrics. 126(5)
1-11.
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Rangel Baseline Data

• Chart review 50 patients(ages 9mo - 2y6mo)
• Screening rates
• 37/37 (100) patients gt1y1mo with 1y screening
  CBC sent
• 9/10 (90) patients gt2y1mo with 2y screening CBC
  sent
• 3/48 (6) patients had ferritin/CRP sent with
  screening labs
• Incidence
• 7/37 (15) 1 year olds anemic most recent CBC
• 3/10 (30) 2 year olds anemic on most recent CBC
• Treatment Follow Up
• 73 of patients received treatment within 1 week
  of lab result
• Follow up appointments not standardized
• 3/7 (43) of patients followed up within 1 month

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Intervention Algorithm
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Screening goal 80
Iron Deficient without anemia

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Intervention Posted Algorithm, Reminder Emails
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Interventions Dietary screen
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Dietary Screening Results

• Results
• Screens were given to PFAs to distribute in
  patient charts however, very few patients were
  receiving them.
• 0/13 patients received the screening form in
  their charts
• Screening forms were given to MAs so that they
  could preferentially give the forms after vitals
  were taken to children coming in for WCC.
• 1/16 patients received the screen

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InterventionPatient Survey (n10)

• Most common symptom of Fe deficiency Tiredness
  (90)
• Take iron supplements with orange juice (80),
  milk (60)
• Nuts and meats are good sources of iron (50)
• While only 10 identified having a child with
  anemia, 40 answered that they had been
  prescribed iron and 50 answered they gave the
  supplement daily

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InterventionFollow Up Binder

• Providers responsible for
• Following up own labs
• If labs not cleared within
• 2 weeks or unable to contact
• Patient/family, placed patients
• Name in follow up binder
• RN Clara helps with
• Follow up education
• of patients

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February 2014 (n15)Treatment Follow up
TREATMENT TREATMENT FOLLOW UP FOLLOW UP
Treated Average days until treatment Who followed up Average days until follow up
IDA 100 (3/3) 4.7 66 (2/3) 78
ID without anemia 100 (5/5) 2.7 40 (2/5) 64
Anemia without ID 25 (1/4) 9 0 0
Anemia with normal ferritin/high CRP 33 (1/3) 7 33 (1/3) 163
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Results

• Successfully utilized Ferritin and CRP as
  screening labs for Fe deficiency in our high-risk
  population
• Increased rate of Ferritin/CRP screening from 6
  ? 92 (target 80)
• Increased rate of treating ID without IDA from 0?
  100 (target 80)
• Increased appropriate prescription within 1 week
  from 73 ? 100 (target 90)
• Decreased anemia follow up within in one month
  from 43 ? 6 (target 75)

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Lessons We Learned.

• Barriers to Change
• Screening tools hard to incorporate into work
  flow, Follow up hurdles, time (PDSA cycles)
• Applicable to Other ACN Clinics?
• YES!
• Next Steps
• Patient Survey and Education, System changes to
  improve follow up, Other possible tests

Thank You!!!