Published: 27/05/2004, Volume II4, No. 5907 Page 28 29
The renal national service framework will further increase the demand for anaemia management.To cope with this, George Peebles helped to create a Sunday service
An increase in non-haemodialysis renal patients in need of intravenous iron was contributing to longer waiting lists and sub-optimal patient care at City Hospitals Sunderland trust. The requirement of the renal national service framework for earlier referral and intervention for patients approaching established renal failure will further increase demand for anaemia management in pre-dialysis patients.
Erythropoietin treatment for patients with anaemia caused by chronic renal disease is now commonplace.
This naturally occurring hormone promotes the formation of red blood cells and restores haemoglobin levels, producing a dramatic effect on patients'wellbeing and quality of life.
However, efficient use of erythropoietin demands adequate levels of iron, required in the production of haemoglobin. Careful management of iron status therefore improves clinical outcomes and can often result in a substantial reduction in erythropoietin consumption, with subsequent cost savings.
Iron management for the trust's haemodialysis patients presents few difficulties, as patients attend the haemodialysis unit three times a week. But the renal ambulatory care department had difficulty coping with increasing numbers of general nephrology, transplant and pre-dialysis and chronic ambulatory peritoneal dialysis patients. These people often require four to six hospital visits per course of intravenous iron sucrose, each of which requires them to stay in the department for up to two hours. In addition, they may need two courses of treatment each year.
Like many other UK renal units, ours covers a large area, with patients having to travel up to 30 miles to the hospital, usually by hospital transport. So for these patients, many of whom are elderly and frail, frequent visits cause considerable inconvenience and disruption.
We analysed our waiting lists, and in January 2002 reviewed our approach to iron management for nonhaemodialysis patients.We found that a new, low molecular weight iron dextran complex, CosmoFer, gave us an opportunity to administer patients' iron requirements in a single visit through 'total dose infusion'.While administration takes three to four hours, depending on individual requirements, it has the major advantage that patients only need to attend the unit once.
There are a number of potential gains. Repeated venopuncture can be avoided, thereby preserving access to veins for future arteriovenous fistulae. Cost savings follow from patients' reduced travel needs, the use of only one administration set and from the lower cost of CosmoFer compared to iron sucrose.
The only drawback was that the renal ambulatory care department was already working to capacity and could not cope with the additional workload caused by patients requiring longer infusions.Most patients attended the unit during normal working hours.
To increase capacity, we decided to open our haemodialysis unit, consisting of 20 stations, for regular Sunday sessions, enabling iron to be administered by total dose infusion to up to 10 non-haemodialysis patients per session.We envisaged that this could be done by two trained nurses.
Patient group directions were prepared to facilitate nurse administration of the intravenous iron supplement. Protocols in case of hypersensitive reaction were already in place and covered the administration of all intravenous iron preparations.
In the first year, we held 14 Sunday clinics and administered iron to 125 patients. This was normally in groups of nine, with three scheduled to arrive at midday, three at 12.30pm and three at 1.30pm.We have not only cleared our backlog of patients, but are now able to sustain a 'waiting-list free' service.
Patients seem happy to come in on a Sunday. Even though hospital transport is unavailable, there is plenty of parking space.
The cost savings per patient are£110 for those living locally and£479 for those located outside Sunderland.
The cost of additional sessions is nominal as the facility is normally standing idle on a Sunday, and nurse costs are minimised by rescheduling contracted sessions. In addition, because of the improved iron management, some patients have reduced their erythropoietin dose requirements, saving a further£12,500 a year. As more patients have their anaemia actively managed at the earliest stage of disease progression, the savings will be even greater.
Most UK renal units are experiencing similar pressures caused by non-haemodialysis patients requiring intravenous iron therapy.We have shown that reconfiguring service delivery, based on a relatively new form of intravenous iron and single-visit administration to patients, makes it possible to achieve dramatic reductions in patient visits to the department.
By using our haemodialysis facility when it is usually standing idle, and adopting new initiatives for nurse supply and administration of medication, we have been able to improve quality of life for patients and reduce waiting lists.
Sunday service: checklist for success
A haemodialysis unit may be an appropriate facility for Sunday or out-of-hours sessions, but it needs to be appropriately staffed for nonhaemodialysis patient sessions.
Patient group directions, or a similar formalised mechanism allowing administration of intravenous iron by total dose infusion, must be established, which may require additional staff training.
A protocol covering reactions to all forms of intravenous iron administration should be in place, with appropriate clinical back-up within the hospital for all sessions.
Where haemodialysis units are satellites, separated geographically from the hospital, or where the unit is remote from the main facilities, there may need to be specific arrangements for medical cover during each session.
Non-haemodialysis renal patients requiring intravenous iron therapy are increasing the pressure on renal units.
A new form of iron therapy can dramatically reduce patient visits, but takes longer to administer.
Sunday provision of nurse-led clinics has enabled a switch to this new therapy.
Cost savings have more than offset the additional nurse-led sessions and eliminated waiting lists for this group.