Proposed Topic (Most preferred): :
Clinical Safety and Quality Service III (Projects aiming at quality service to patients and their carers)
Proposed Topic (Second preferred): :
Clinical Safety and Quality Service I (Projects aiming to improve efficiency and effectiveness of care delivery to meet international standards)
Authors (including presenting author) :
Kong SY (1), Li KH (2), Lau KN (2), Li KSJ (3), Wong CCA (2), Yip SF (2)
Affiliation :
(1) Department of Medicine and Geriatrics (M&G), Pok Oi Hospital
(2) Department of Clinical Pathology (PATH), Tuen Mun Hospital
(3) Department of Medicine and Geriatrics (M&G), Tuen Mun Hospital
Introduction :
In NTWC, a complete Fe profile requires two requests in generic clinical request system (GCRS), namely 1) Fe + total iron binding capacity (TIBC) + Fe saturation (TSAT) and 2) ferritin. The ferritin reference range differs between male (159-1441 pmol/L) and female (14-535 pmol/L). The diagnostic cutoff of ferritin for Fe deficiency (ID) is 67 pmol/L which lies within the female reference range.
Audits revealed that 53.8% of ID patients in NTWC showed apparently-normal Fe profile (TSAT ≤ 20% and ferritin within gender-specific reference range). Incomplete Fe profile requests were made in 5.7% which renders interpretation difficult. Alternate-day regimen of oral Fe replacement has been shown to be more effective. However, only 2% of ID patients were given oral Fe of alternate days.
Objectives :
- To increase the Fe replacement in ID patients with apparently-normal Fe profile
- To increase the oral Fe prescription in alternate-day regimen
- To reduce incomplete Fe profile requests
Methodology :
Multiple cluster-wide measures were promulgated through formulation and collaboration between Departments of M&G and PATH in NTWC
- Addition of footnotes in ferritin reports to highlight the guideline-recommended decision cut-off for ID and avoid reference-range-driven decision making since 15th August 2023
- Addition of template “300mg once per day on alternate day” for ferrous sulphate since 18th February 2023.
- Removal of single iron request and automatic addition of ferritin to Fe+TIBC+TSAT, since 27th April 2023
- Continuous medical education at departmental and cluster levels
Patients with ferritin < 68 pmol/L in January 2021 and November 2023 at Pok Oi Hospital (POH) were compared to evaluate the intervention outcomes.
Result & Outcome :
There were 102 and 180 patients whose ferritin < 68 pmol/L in 1/2021 and 11/2023 respectively. Patients with apparently-normal Fe profile accounted for 53.9% and 68.3% in 1/2021 and 11/2023 respectively. Overall, 63.1% of ID patients were from M&G. Our new measures successfully tackled various loopholes in ID management:
- A rising trend of Fe replacement in ID patients with apparently-normal Fe profile at POH (61.8% in 1/2021 vs. 74.8% in 11/2023, p = 0.108). In subgroup analysis, POH M&G showed significant improvement (64.4% in 1/2021 vs. 83.3% in 11/2023, p < 0.05)
- Significant increase in oral Fe prescription in alternate-day regimen (2% in 1/2021 vs. 57% in 11/2023, p < 0.05)
- Eradication of incomplete Fe profile request from 4.9% in 1/2021 to 0% in 11/2023 (p < 0.05)
