Addressing Iron Deficiency Addressing Iron Deficiency AnemiaAnemia

181181stst Street Clinic Street Clinic(Washington Heights Family Health Center)(Washington Heights Family Health Center)

2006-7 PDSA Project2006-7 PDSA Project

Why Tackle Iron Deficiency?Why Tackle Iron Deficiency?

#1 Nutritional Disorder in #1 Nutritional Disorder in WorldWorld

80% Fe Deficient80% Fe Deficient

30% some form of Fe 30% some form of Fe Deficient AnemiaDeficient Anemia

Easily Administered Easily Administered TherapyTherapy

SUPPLEMENTATION WORKS!SUPPLEMENTATION WORKS!

Effect on of treatmentEffect on of treatment .78 mg/dL difference in .78 mg/dL difference in

those treatedthose treated

Positive Effects on Positive Effects on Developmental Developmental OutcomesOutcomes

Cognition?Cognition?

AIM StatementAIM StatementReduce the impact of iron Reduce the impact of iron deficiency and iron deficiency deficiency and iron deficiency anemia in children under 3 in anemia in children under 3 in our practice by:our practice by:

Increasing the Increasing the identification of children at riskidentification of children at risk

Implementing evidence-Implementing evidence-based treatment of iron based treatment of iron deficiency anemiadeficiency anemia

Establishing primary Establishing primary prevention of iron deficiency for prevention of iron deficiency for an at-risk population (Patients an at-risk population (Patients aged 1-3 years)aged 1-3 years)

PDSA for Prevention of AnemiaPDSA for Prevention of AnemiaPP: Implement primary prevention of iron deficiency: Implement primary prevention of iron deficiency

DD: Providers began prescribing prophylactic MVI with : Providers began prescribing prophylactic MVI with iron to all patients aged 1-3 yearsiron to all patients aged 1-3 years

SS: Chart Review (2 wks post intervention):: Chart Review (2 wks post intervention): Providers prescribing prophylactic MVI with Iron to 81% of Providers prescribing prophylactic MVI with Iron to 81% of

patients 1-3 years patients 1-3 years

AA: Expanded education efforts to ALL providers : Expanded education efforts to ALL providers including nurse practitionersincluding nurse practitioners

AAP Iron-deficiency Screening and AAP Iron-deficiency Screening and Treatment GuidelinesTreatment Guidelines

Universal Screening in high risk communitiesUniversal Screening in high risk communities Hgb or Hct between 9-12 months, Hgb or Hct between 9-12 months, and again 6 months laterand again 6 months later

TreatmentTreatment Treat pts 6m-1.9y with Hb <11.0mg/dL, 2-5 yrs with Hb < Treat pts 6m-1.9y with Hb <11.0mg/dL, 2-5 yrs with Hb <

11.1 with 3 - 6mg/kg/day of elemental iron11.1 with 3 - 6mg/kg/day of elemental iron Repeat CBC 1 month into treatment – if hgb increased by Repeat CBC 1 month into treatment – if hgb increased by

1g/dl then continue for 2 more months, if NOT then further 1g/dl then continue for 2 more months, if NOT then further testing recommendedtesting recommended

Repeat testing 6 months after successful treatmentRepeat testing 6 months after successful treatment

How Are We Screening?How Are We Screening?

Pre-intervention Measurement: to assess variability Pre-intervention Measurement: to assess variability in current screening practicesin current screening practices

9-12 month olds 9-12 month olds CBC AND a hemocue (68%) CBC AND a hemocue (68%) CBC (28%) CBC (28%) Hemacue alone 4%Hemacue alone 4%

Proposals brought to providers on ways to Proposals brought to providers on ways to implement uniform screening methods implement uniform screening methods Which ages to screen patientsWhich ages to screen patients Hemocue vs. venipunctureHemocue vs. venipuncture Coordinating venipunctures with state mandated Pb screeningCoordinating venipunctures with state mandated Pb screening

2 year olds 2 year olds CBC AND a hemocue (31%) CBC AND a hemocue (31%) CBC (55%) CBC (55%) Hemacue alone 14% Hemacue alone 14%

Changes Made To ScreeningChanges Made To Screening

At/ around 12 months: At/ around 12 months: CBC and leadCBC and lead

At/around 18 months: At/around 18 months: HemocueHemocue

At/around 24 months: At/around 24 months: CBC and leadCBC and lead

ScreeningScreening

PP: Tentative consensus made to conduct CBC : Tentative consensus made to conduct CBC screening at 12 venous, 18 month hemocue, screening at 12 venous, 18 month hemocue, and 24 months venous and 24 months venous

DD: Providers informed via email of new plan to : Providers informed via email of new plan to screen at theses specific ages screen at theses specific ages

SS: Chart review of recent 12-24 month old visits: Chart review of recent 12-24 month old visits18/20 (90%) pts with CBC/Pb screen by 1 year of age18/20 (90%) pts with CBC/Pb screen by 1 year of age8/12 (66%) pts with f/u hemocue between 15-24 8/12 (66%) pts with f/u hemocue between 15-24

monthsmonths

AA: Conducted discussion via email to foster : Conducted discussion via email to foster awareness of and buy-in to the new screening awareness of and buy-in to the new screening protocolprotocol

Current ProtocolCurrent Protocol

Primary PreventionPrimary Prevention Prescribe prophylactic MVI with Iron for all pts 1-3 Prescribe prophylactic MVI with Iron for all pts 1-3

years to continue for duration of at least 1 yearyears to continue for duration of at least 1 year

ScreeningScreening CBC at 12 month, Hemocue 18 months, and 24 CBC at 12 month, Hemocue 18 months, and 24

months CBC and Hemocuemonths CBC and Hemocue

TreatmentTreatment Treating all pts under 5 yrs with Hb < 11 with 2 - Treating all pts under 5 yrs with Hb < 11 with 2 -

4mg/kg/day of elemental iron4mg/kg/day of elemental iron Repeat CBC 1 month into treatment – if hgb Repeat CBC 1 month into treatment – if hgb

increased by 1g/dl then continue for 2 more months, if increased by 1g/dl then continue for 2 more months, if NOT then further testing recommendedNOT then further testing recommended

TreatmentTreatment

Pre-Intervention Measurement:Pre-Intervention Measurement: 4/16 (25%) patients with iron-deficiency 4/16 (25%) patients with iron-deficiency

anemia given correct treatment doses of anemia given correct treatment doses of Iron according to AAPIron according to AAP

Providers educated on AAP guidelines Providers educated on AAP guidelines

Discussion of how we plan to Discussion of how we plan to implement/adapt the AAP guidelines, implement/adapt the AAP guidelines, e.g:e.g:

DosageDosage Anemia definition (i.e. cut-offs by age – vs Anemia definition (i.e. cut-offs by age – vs

AAP)AAP)

Chart Review—Are we appropriately Chart Review—Are we appropriately documenting, diagnosing, & treating anemia?documenting, diagnosing, & treating anemia?

patients age 1 to 3 with dx code of anemia over a 6 patients age 1 to 3 with dx code of anemia over a 6 month periodmonth period

Results: Results: (1) 94% proper “anemia diagnosis (1) 94% proper “anemia diagnosis (2) 81% treated with 2-4 mg/kg/day dosing of Fer-in-sol (2) 81% treated with 2-4 mg/kg/day dosing of Fer-in-sol (3) 81% correctly instructed for follow-up as per documentation(3) 81% correctly instructed for follow-up as per documentation (4) 94% followed up regardless of documentation (4) 94% followed up regardless of documentation (5) 63% documented resolution of anemia (though some still in (5) 63% documented resolution of anemia (though some still in

Tx at time of review)Tx at time of review)

Goals: Are we reaching them? Documentation might not Goals: Are we reaching them? Documentation might not lead us to believe so…lead us to believe so…

Compliance ProblemCompliance Problem

Randomly selected group of Randomly selected group of parents of one to 3 yearparents of one to 3 yearolds.olds.

Only 40% took the vitamins Only 40% took the vitamins nearly all the time (5 times a nearly all the time (5 times a week or more).  week or more).  

50% of the parents surveyed 50% of the parents surveyed admitted non-compliance admitted non-compliance (one dose a week or(one dose a week orless)less)

Compliance Chart ReviewCompliance Chart Review

1 to 3 year olds from each provider1 to 3 year olds from each provider

59% had documentation of child taking Polyvisol 59% had documentation of child taking Polyvisol with Fe.with Fe.

All charts documented appropriate screening All charts documented appropriate screening times for CBCtimes for CBC

Reasons for non-complianceReasons for non-compliance

Steps Towards ComplianceSteps Towards Compliance

IRON RICH FOOD HANDOUTIRON RICH FOOD HANDOUT

English version: revised the English version: revised the handout at a 4th grade reading handout at a 4th grade reading level using the Flesch-Kincaid level using the Flesch-Kincaid Grade Level Index.  Grade Level Index.  

b) Spanish version: translators b) Spanish version: translators and Fernandez-Huerta scale and Fernandez-Huerta scale between 5th and 6th grade.between 5th and 6th grade.

Future DirectionsFuture Directions

Finalize consensus screening protocol and Finalize consensus screening protocol and achieve provider buy-inachieve provider buy-in

Why are parents not giving the Iron?Why are parents not giving the Iron? Are the Handouts helping?Are the Handouts helping?

Chart reviewsChart reviews Treatment – Are we treating for kids who Treatment – Are we treating for kids who

meet criteria? For patients diagnosed with meet criteria? For patients diagnosed with anemia how is the follow-up – testing at 1 anemia how is the follow-up – testing at 1 month? Continuing for 3 months at least? month? Continuing for 3 months at least?

Primary Prevention – Are patients staying on Primary Prevention – Are patients staying on the MVI with Iron? Is it resulting in fewer the MVI with Iron? Is it resulting in fewer kids with anemia?kids with anemia?

Previous PDSA?Previous PDSA?

Dental HealthDental Health 50% documentation of discussion50% documentation of discussion

Developmental or Speech Delay Developmental or Speech Delay 50% documented discussion50% documented discussion 0% used sticker’s from last year’s project0% used sticker’s from last year’s project

The TeamThe TeamAttendingsAttendings

Steve CaddleSteve Caddle Adriana MatizAdriana Matiz Mary McCordMary McCord Melanie GissenMelanie Gissen Patricia HametzPatricia Hametz Dodi MeyerDodi Meyer Elise Olshen KharbandaElise Olshen Kharbanda Mary ZweighaftMary Zweighaft Carol PafundiCarol Pafundi Harriet McGurkHarriet McGurk Annie ArmstrongAnnie Armstrong Melissa GlassmanMelissa Glassman

ResidentsResidents Monique CollierMonique Collier Brenton MarBrenton Mar Eliza AuerbackEliza Auerback Sarah SchragerSarah Schrager Carol SenklerCarol Senkler Paula AyoraPaula Ayora Dawn WetzelDawn Wetzel John BabineauJohn Babineau Rachelle GandicaRachelle Gandica Maja CastilloMaja Castillo Brenda RitsonBrenda Ritson Matt LaurichMatt Laurich Patricia TaePatricia Tae Ola AgangaOla Aganga Mahbod MohazzebiMahbod Mohazzebi

StaffStaff Joan MahoneyJoan Mahoney Maralin BautistaMaralin Bautista Candida RodriguezCandida Rodriguez Petra OrtizPetra Ortiz Beatrice FrempongBeatrice Frempong Annes SilverAnnes Silver Annie HertzAnnie Hertz Bill JohnsonBill Johnson Leilani VinalesLeilani Vinales Ivelisse RodriguezIvelisse Rodriguez Iliana TorresIliana Torres Cindy FerrerCindy Ferrer Evelyn MejiaEvelyn Mejia Denise Connolly-HoytDenise Connolly-Hoyt