Context The QI 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 caring for children with chronic kidney disease CKD.
Problem Anaemia is prevalent amongst children with CKD. Iron infusion is administered to such children with chronic anaemia. Children on haemodialysis attending the Children Kidney Centre receive iron infusion if they satisfy the criteria based on haemoglobin and serum ferritin values in accordance with departmental guidelines. This involves measurement of C-reactive protein CRP 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.
Assessment of problem and analysis of its causes We identified all children receiving iron infusion in the haemodialysis unit over an 8 week period. We retrospectively enquired blood investigations done, prior to and after iron infusion. Blood investigations were noted to lag, during pre and post infusion times.
Intervention and Study design We devised a checklist for nursing staff to follow, which looked 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
prevent iron overloading in patients with chronic anaemia
regularise the checking of bloods in those receiving iron infusions
empower the nursing staff to independently take decisions on iron infusion delivery
Strategy for change The following PDSA cycle was employed.
Plan - empower independent decision making on iron infusions by haemodialysis nursing staff
Do - setting up of iron infusion checklist to be followed for every patient who warrants iron infusion for chronic anaemia, with recommendations based on set values of ferritin, CRP and haemoglobin.
Study -analyse adherence to checklist in 3 months time
Act - make appropriate changes to workplace behaviour based on findings of PDSA cycle.
Measurement of improvement The measurement encapsulated all three domains of the Donabedian framework: Structure (investigating chronic anaemia of CKD) + Process (decision to administer iron infusion) = Outcome (blood investigations validity). We analysed 13 patient episodes at the commencement of the project and a total of 19 patient episodes at the end of the improvement cycles.
Effects of changes Blood investigations done were more regularised and not excessive in comparison from those done previously. Nursing behaviour with regard to initiation and maintenance of iron infusion became more independent. Consequently, it freed up doctor-time and empowered nursing decision making skills. This also resulted in improved team morale and ultimately patient safety by mitigating human errors.
Lessons learnt The checklist was improved based on feedback obtained after the first PDSA cycle. A second cycle showed that investigations done were now optimised. The third cycle showed improved adherence and compliance with prevention of over treatment with iron infusion.
Message for others For any QI project, interventions should be carefully designed. Stakeholder buy-in and easy accessibility of the intervention improves sustainability. Performing multiple PDSA cycles and incorporating the feedback is vital to any QI project.
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