Island Health delivers health care for Vancouver Island, neighbouring islands and a section of mainland adjacent to Queen Charlotte Sound. Renal Services within Island Health coordinates and delivers the nephrology care for dialysis, renal transplant and advanced renal failure patients. This project focused on improving anemia in Renal Service’s patients.
Anemia of chronic renal disease is an almost universal condition in severe (stage 5) renal failure. Treatment consists of correcting iron deficiencies and providing replacement erythropoeitic hormone. Historically, treatment was not standardized or coordinated. Individual physicians prescribed therapy often resulting in undesirable swings in laboratory parameters. Additionally, overcorrecting haemoglobin poses stroke and cardiac risks to the patient.
We thought a standardized algorithmic approach would be best to tackle this issue. To devise an evidence-based algorithm and standardize care to best practice, primary literature was collected and key elements of the protocol were created, such as target haemoglobin, TSAT and ferritin. The renal pharmacist used guideline dose adjustments to create pre-specified dosing tables to standardize care. Clinicians were engaged locally to comment, assist and champion the remaining development. The “current state” at the time was also reviewed to demonstrate variations from best practice – specifically with respect to meeting target values and using higher than provincial average doses of erythropoeitic. This information was shared with the renal program and support for this work was approved by the Island Health leadership team. Once the algorithm was designed and dosing schedules created, the algorithm was implemented in an Island Health community dialysis unit that was both in close proximity to the champions and enthusiastic to engage in change.
With each area that the team implemented the algorithm came new challenges and new perspectives. As we were consistent in our messaging and paid prompt attention to any concern raised we demonstrated both our commitment to the algorithm and availability to help resolve any problems arising. We ensured that we were present and available until the staff in the unit was comfortable and confident they could manage on their own and all issues had been addressed. Our willingness to stay with the team until they were comfortable along with our prompt response to queries was key to overcoming barriers. What started as an innovation to create an algorithm became more transformational as nurses expanded their professional role to make clinical decisions to change therapy within the framework of a prescribed algorithm.
Over the intervening years, the protocol has been implemented provincially and has evolved to reflect changes in guidelines and evidence, and to capture refinements in efficiency and feedback from stakeholders. As a result, anemia across the province in renal patients is treated in a standardized fashion reflecting best evidence.
Based on PDSA cycles, we implemented the algorithm across Island Health providing education and support. Subsequently, the protocol has been adopted and implemented in all BC health authority renal programs and results have indicated anemia target laboratory values being met sooner and staying within desired ranges for longer. This has demonstrated a savings of approximately three million dollars provincially thus far. Moreover, the Canadian Society of Nephrology has recently adopted our anemia protocol to use nationally. This work better utilizes clinicians’ time and helped finance new patient care initiatives.