Implementing Anaemia Pathways

In this second part of her article, Dr Anne-Marie Bougeard continues the discussion by looking at the challenges of implementing a preoperative iron pathway and service.

What are the challenges to introducing a new pathway?

If we accept that there is a case for correction of preoperative anaemia, the next question is how we set up pathways. These need to fit in with the timeframe available before surgery and allow us to make good decisions about when it is appropriate to defer surgery. Indeed in many cases, the proposed surgical procedure will be to correct the cause of anaemia (eg. colorectal cancer).

• Timescales: In the UK, an audit of blood transfusion practice [1] showed the mean time on the waiting list for surgery is 42 days, whilst the average time between preassessment clinic and surgery is 2 weeks, which makes intervention to correct anaemia particularly challenging. If if anaemia was detected at the point at which the patient is listed for surgery, in many cases there would be ample time to investigate and correct anaemia.

• Tight cancer pathway timings: The success of improved timed pathways for investigating suspected cancer means that there is often little time between decision to operate and surgery date. The decision to postpone surgery for anaemia management is therefore not to be taken lightly, with a multidisciplinary approach and case-by-case decision suggested.

• Poor response to oral iron: What do we do if a patient doesn’t respond to oral iron therapy? We need to build in enough time for a second line treatment to be given to optimise haemoglobin.

• Commissioning: In the UK there are established pathways for referral and treatment, meaning that often treatment must be instituted by the primary care team. It is crucial therefore that communication with Primary Care is efficient and clear, so that there is an understanding of preoperative anaemia treatment being a distinct and different problem than chronic anaemia managed in the community.

• Multiple appointments: Patients see a number of health professionals on their surgical journey. When designing a pathway we must be mindful of rationalising the number of visits the patient makes, particularly if coming in for intravenous iron therapy which may need to be given more than once.

What is the best available evidence for managing perioperative anaemia?

A group of expert clinicians including haematologists, surgeons, anaesthetists and transfusion experts produced guidelines on the management of perioperative iron deficiency and anaemia using best available evidence [2].

Key points from this paper include:

• Investigate anaemia in all surgical procedures where expected blood loss exceeds 500ml
• Aim for a haemoglobin of 130g/l in both males and females, on the basis that women are smaller, have a smaller body surface area and less blood volume than males, therefore the impact of a given volume of blood loss will be greater in a female than a male
• Postponement of major, non-urgent surgery to correct anaemia
• Start with oral iron in patients who have more than 6-8 weeks prior to surgery
• Intravenous iron should be used as front line therapy in patients who do not respond to or do not tolerate oral iron, or in whom surgery is less than six weeks away

The following algorithm is taken from the paper and gives an overview of management:

How to start setting up a perioperative anaemia service?

These are the main steps to making the case for the introduction of a new perioperative anaemia pathway.

Know your patient journey:

• Establish how the patient is referred into secondary care and what baseline metrics are included in the referral (eg. is a recent haemoglobin included?)
• What happens when a decision for surgery is made?
• How the waiting list operates
• When blood tests are taken
• How the results of these are communicated
• How primary care are involved in the preassessment process
• Who is responsible for giving the ‘go ahead’ to patients who have abnormal results

Know your data:

• Identify your local incidence of anaemia
• Treatment given for patients who are anaemic
• Preoperative haemoglobin
• Average haemoglobin drop
• Rate of transfusion
• Length of stay in hospital and, if applicable, in intensive care
• Identify the costs associated with transfusion in those patients who were anaemic before surgery

Evidence base:

• Review your national guidelines [3] and describe what they means for the different stakeholders in the process; service providers, commissioners, healthcare professionals and patients
• Use published evidence to support your argument for consequences of not treating perioperative anaemia, both for patient outcomes and economic impact

Multidisciplinary approach

• Work with your Haematologists, Surgeons and Primary Care colleagues to agree a reasonable pathway and thresholds for intervention.
• Identify ways to streamline the process of multiple blood draws by only processing haematinics samples on anaemic patients. Many hospitals are doing this and it reduces the number of blood tests patients require.

Write your business case:

• Consider the capital expenditure required, which in most cases should be minimal
• Consider the cost of the staff needed for the service (administration and nursing) as well as consumables and pharmacy cost.
• Identify whether there is potential for income generation; in the UK there are national tariffs for treatment of iron deficiency anaemia which can be applied
• Consider the cost savings of reduced transfusion rates and reduced length of stay – calculate these for your unit based on the data you have collected.

Measure outcomes:

• Institute a method of data collection to ensure you are measuring the success of your pathway and feed back to improve continuously. This will include data on all aspects of patient blood management.

Do you have a perioperative anaemia service in your place of work? If so which of the discussed issues or solutions did you come across when implementing it?

References

1. National comparative audit of blood transfusion 2015
2. Munoz M, Acheson AG, Auerbach M, Besser M, Habler O, Kehlet H et al. International consensus statement on the peri-operative management of anaemia and iron deficiency. Anaesthesia 2017; 72:233-47
3. Kotze A, Harris A, Baker C, Iqbal T, Lavies N, Richards T et al. British committee for standards in haematology guidelines on the identification and management of pre-operative anaemia. BJH 2015; 171: 322-31