Anemia Management Quality Team (AMQT) Meeting

Anemia Management Quality Team (AMQT) Meeting Minutes Wednesday July 26, 2017 : 10:30-11:30 am Room 5132 - 5th Floor Dickson AGENDA

PRESENT: Jo-Anne Wilson (Chair), Angela Shorter, Carolyn Bartol, Cindy Kelly, Sandy Lee Canston, Susan Betts, Emily Bennett, Jaclyn Tran, Annette Veith

REGRETS: Krista Chaulk, Dr. Neil Finkle, Carrie Ann Boyd, Tabassum Quraishi

ABSENT: Sohani Welcher, Dr. David Clarke, Shondal Bryne, Gina Harding

1. Minutes and action items of of April 26, 2017 reviewed. i. Anemia management check-ins for all program areas (Dickson/NHI/ DGH,Satellites, Home HD/PD, Renal Clinic) identified that checking blood work every 3 weeks for Dickson, NHI, DGH dialysis and checking blood work every 2 weeks for Renal Clinic, HHD/PD (when ever there is a dose change for ESA therapy) often results in ESA dose escalation and then at the next blood work target Hb levels are high. In addition it was raised that often HHD/PD and renal clinic patients find it challenging to have blood work done in 2 weeks. ACTION ITEM: Jo-Anne and Carolyn will initiate discussions with prescribers around possibly changing anemia management ESA protocol for all program areas. An audit may be necessary to assess.

2. Quarterly Anemia Reports i. Hgb ,TSATs ,and hyporesponsive reports and reports of patients with TSATs < 20% on ESA therapy were reviewed by one representative from each program area for Q4 2016/17, except Dickson and HI Hemodialysis Centers ii. Note: Desired Hgb targets for patients on ESA therapy are to achieve Hgb targets 70% of the time and desired targets for TSATs are for patients to be within target 85% of the time. iii. All the reports can be viewed at

https://sharepoint.nshealth.ca/RenalSite/SitePages/Home.aspx

The following table outlines anemia metrics per program area. Most of the indices are in target or have exhibited improvements Cindy Kelly reported for DGH; Jo- Anne reported for HHD, PD Dickson/NHI; Sandy Lee reported for Satellites; and Susan Betts reported for Renal Clinic. Thanks everyone.

Q Hgb (95-115 TSAT (20- Hyporesponders TSAT < 20% 42016/17 g/L) 50%) (hgb < 95 g/L, on on ESA (Reassess Target: 70% Target: 85% high dose ESA) (N= need for Iron) (N= patients) patients) Q1 Q4 Q1 Q4 Q1 Q4 Q1 Q4 2017 2016 2017 2016 2017 2016 2017 2016 HHD 78 84 78 76.5 0 1 4 2 PD 73 77 76 83 2 1 9 4 Satellites 65 75 85 84 2 2 5 6 Dickson 72 69 84 87 7 5 14 5 NHI 81 82 100 89 0 2 2 DGH 71 69 67 83 3 2 7 4 Renal 70 76 72 81 3 34 8 Clinic

ACTION ITEMS: 1) Jo-Anne will follow-up with Sohani regarding the 7 hyporesponders for Dickson dialysis. Emily reported that many are currently requiring transfusions. 2) Jo-Anne will follow-up with Heidi, who is charge for Home Unit regarding follow-up and review of the anemia reports as no representative from the Home unit was available today to attend the meeting. It was noted that there were 4 and 9 patients from the HHD and PD programs who had TSAT < 20% on ESA. These will be reviewed to ensure IV iron is not required.

3. Iron Therapy i) Jo-Anne reported that overall wait-times have improved from 60 days (2015) to 20 days (2017) for IV iron administration. In addition, over the past 9 months in particular, no nephrology patients have experienced any complications while waiting for IV iron administration. However, a few patients who were triaged a category 1 a, necessitating IV iron administration in 1 week (using the Nephrology Triage Facilitator Sheet) did not meet target wait times. It was also identified upon review of the doses ordered of Venofer, that Venofer 100 mg IV times 10 doses is the most commonly prescribed regimen. Jo-Anne and Dr. Poyah sent out a memo to prescribers and renal clinic nurses to consider the following two points when ordering Venofer: 1) Where appropriate and there are no signals of harm (ie., multiple drug allergies, severe asthma) Venofer 200 mg IV times 5 doses is also a labeled dosage recommendation for non-dialysis dependent chronic kidney disease patients. Fewer visits to the MDU have many patient benefits including: reduced venipunctures thereby preserving vascular access and minimizing patient discomfort, improved resource management due to reduced MDU chair time and lastly less patient travel costs. 2) Reminder to complete the Nephrology Triage Facilitator Sheet which are part of the MDU referral package for IV iron administration. The MDU are committed to triaging nephrology patients using this triage facilitator sheet. ACTION ITEM: Susan Betts will share the IV Iron referral package to the MDU with Carolyn and the Home units so that the Nephrology Triage Faclitator Sheet is included in Home unit referrals to the MDU. ii) There was also a meeting with the renal clinic on June 19, 2017 (minutes on share drive) to discuss the anemia management protocol. The renal clinic is nearly to full RN complement. One area that was identified that requires clarification is the eligibility criteria for the RN-led anemia management protocol as there appears to be two streams identified and includes: 1) the RNs managing anemia based on the RN-led anemia management protocol whereby patients are on Aranesp and fit the established hemoglobin target;

2) the RNs co-managing with a prescriber the anemia management of a patients who fall outside the RN-led anemia management protocol (for example: patients not on Aranesp but require IV iron; Patients on Aranesp but receiving it weekly or every 4 weeks or another frequency outside RN-led anemia management protocol; Patients with cancer or recent stroke who are on Aranesp but target hemoglobin is lower than specified in the RN-led anemia management protocol; or Patients who are receiving transfusion or who are being investigated for hemorrhagic event. It was identified that their needs to be clear criteria around RN/Prescriber co-managing model of anemia management. ACTION ITEM: Susan, Emily and Jo-Anne will meet to discuss criteria and collect data on patients who fall outside the RN-led anemia management protocol for patients not on Aranesp but require IV iron and patients on Aranesp but do not fit the RN-led anemia management protocol. iii) It was identified that Home HD patients who self administer their own IV iron at home may not recently have received the consent letter. ACTION ITEMS: 1) Carolyn will update letter with NSHA letterhead and educate staff. 2) Angela will send an email to Home unit charge to ensure all patients have received the standardized consent letter and that consent has been documented in the chart. 3) Susan Betts will share the renal clinic resource binder with Carolyn which contains all materials (letters, ppos, educational materials) related to anemia management.

4. IV Iron Ambulatory Drug Policy Update was provided by Annette Veith. She shared that the new reorder system is in place and working well. Presently, 85% of HI and VG patients have their own supply of IV Iron and 97% of satellite patients have their own supply of IV Iron. A planning meeting took place with the home unit for HHD patients this week and the 19 HHD patients on Venofer will be enrolled in the program pharmacy (if applicable). The renal clinic is now helping in obtaining drug insurance information for patients getting close to RRT.

5. CORR report and review of renal program ferritins and cumulative dose of Venofer will be a quality initiative. A pharmacy student has been organized for 5-6 days and will work with Tabassum in August to collect necessary data. ACTION ITEM: Jo-Anne/Jaclyn will meet with student to review anemia protocols and Tabassum will guide student to collect necessary data. 6. Anemia Data Process Audits – Tabled to October after accreditation

7. Other Business  AMQT annual report was submitted by Jo-Anne and is available in the annual report. This committee has accomplished a lot over the course of the year. Well done everyone.  Education pamphlets were discussed. ACTION ITEM: Carolyn will review if the pamphlets need to be updated. The IV iron and CKD pamphlet was updated in 2015 and will not need to be updated until 2018. Carolyn will follow-up on Oral Iron and ESA & CKD pamphlets.  Jo-Anne reminded everyone to check refrigerator thermometer expiry in program areas ACTION ITEM: Krista will follow-up with David Landry regarding a medication refrigerator for main unit.

8. Next Meeting on October 25, 2017

Respectively submitted by Dr. Jo-Anne Wilson, Chair AMQT on July 26, 2017