Improving compliance with iron infusion therapy in the treatment of chronic anemia in haemodialysis patients with chronic kidney disease
Authors: Nuti Amith 
Published: March 2015

This quality improvement project was conducted at the haemodialysis unit in the paediatric nephrology department at Noah’s Ark Children’s Hospital, Cardiff. Stakeholders involved were the medical and nursing staff at the haemodialysis unit, responsible for the care of children with chronic kidney disease CKD.

Anaemia is prevalent among children with CKD. Iron infusion is administered to such children with chronic anaemia. Children on haemodialysis attending the Children's Kidney Center receive iron infusion if they satisfy the criteria based on haemoglobin and serum ferritin values according to departmental guidelines. This involves measurement of c-reactive protein and serum ferritin prior to iron administration. High iron exposure is detrimental to end organ function and hence warrants regular monitoring in conjunction with CRP, another inflammatory marker. We suspect that some children may be receiving iron infusions despite being iron replete. Also, we may be over-investigating these children with anaemia.

We identified all children receiving iron infusion in the haemodialysis unit over a four week period. We retrospectively enquired blood investigations done, prior to and after iron infusion. Blood investigations lagged on pre and post infusion times.

We devised a checklist for nursing staff to follow, primarily looking at set times for measuring haemoglobin, serum ferritin, and CRP during the month (at the start of the first and third week of the month) and also tabulating the ferritin values that would trigger frequency of iron infusions. These were aimed to:

1. Prevent iron overloading in patients with chronic anemia

2. Regularise the checking of bloods in those receiving iron infusions

3. Empower the nursing staff to independently take decisions on iron infusion delivery.

The strategy for change encompassed multiple PDSA cycles.

Plan: empower decision making on iron infusion by haemodialysis nursing staff

Do: formulate a checklist for iron infusion based on the recommended set values of ferritin, CRP and haemoglobin

Study: analyse adherence to checklist in three months time

Act: make appropriate changes to workplace behaviour based on findings of the PDSA cycle

We analysed 13 patient episodes prior to the intervention and a total of 19 patient episodes after the improvement cycles. The checklist was improved based on feedback obtained after the first PDSA cycle. A second cycle showed that investigations done were optimised. The third cycle showed improved adherence and compliance with prevention of over-treatment with iron infusion. There was 100% adherence to the investigations done prior to infusion and complied well with the department guidelines. This meant that the required number of blood tests were done on a more regular basis and it did not exceed from those done previously.

Nursing behaviour with regard to initiation and maintenance of iron infusion became more independent. This empowered nursing decision making skills and consequently freed doctor-time. It also resulted in improving team morale and ultimately patient safety by mitigating human errors.

For any QI project, interventions should be carefully designed. Stakeholder buy-in and easy accessibility of the intervention improves sustainability. Multiple PDSA cycles and incorporating stakeholder feedback into the cycle are key to success.