Implementation Projects: Iron

Publications & presentations

Implementing iron management clinical practice guidelines in patients with chronic kidney disease having dialysis
Irving MJ, Craig JC, Gallagher M, McDonald S, et al. MJA 2006:185(6):310-314
[PubMed abstract]

43rd Australian & New Zealand Society of Nephrology {ANZSN); 2007 Sept; Gold Coast, Qld
Effectiveness of multifaceted intervention strategy for the Caring for Australasians with Renal Impairment (CARI) Guidelines [abstract no: 0041]
Irving M, Gallagher M, Frommer M, Polkinghorne K, McDonald S, Roger S, Walker R, Craig JC Nephrology 2007; 12 Suppl 2: A11

4th Annual Guidelines International Network (G-I-N) Conference: Collaboration in Clinical Practice Guidelines; 2007 Aug 22-25; Toronto, Canada
Implementation of clinical practice guidelines: overcoming barriers to implementation of iron management guidelines in chronic kidney disease patients [abstract no: B65] Michelle Irving, Martin Gallagher, Rowan Walker, Michael Frommer, Jonathan Craig

Summary: Stage 1

In 2004, the first stage of an Iron implementation project was commenced. This involved performing a clinical audit of 6 renal centres for their practices and procedures regarding iron levels for their patients and comparison of these results against the KHA-CARI Guidelines on iron and haemoglobin targets in use at that time.

We found that there was considerable variability in achievement of iron and haemoglobin targets, with 30-68% falling within ferritin targets of 300-800 µg/L; 65-73% within transferrin saturation (TSAT) targets of 20-50 % and 25-32% of patients in the haemoglobin targets of 110-120g/L, across the units.

Barriers to implementation include:

  • lack of knowledge
  • lack of awareness or trust in the CARI Guideline
  • inability to implement the guideline
  • as well as inability to reach agreement within a unit to a uniform protocol

Factors that were associated with achievement of targets set by the CARI Guidelines included:

  • having a nurse-driven iron management protocol
  • use of an iron management decision aid
  • presence of fewer nephrologists per dialysis unit
  • and whether the unit’s protocol aimed at actively keeping iron levels within target range (proactive) or only reacting if out of range (reactive)

Summary: Stage 2

In 2005, the second stage of this project was begun. Six renal units were monitored for their iron management and ferritin, haemoglobin, TSAT and epoetin use. Three of the 6 units actively made changes in their iron management practices to reflect the guidelines. Strategies to implement the CARI iron guideline differed in each unit. Each unit focussed on their management of in-centre haemodialysis patients. Wide variation of iron indices was observed across the units. Statistically significant improvements in median ferritin levels were seen across the study.

Based on our observations, the variation in results between the 3 units are due to differences in the upper management support for the project, workplace culture and selection of opinion leaders to oversee the practice change. This study shows that with a senior, motivated, opinion leader implementation of a guideline can indeed be successful. Support from an external body such as CARI may assist units to change.

A paper outlining further results of this study is currently being written.