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Addressing Iron Deficiency
Anemia
181st Street Clinic
(Washington Heights Family Health Center)
2006-7 PDSA Project
Why Tackle Iron Deficiency?
#1 Nutritional Disorder in
World
80% Fe Deficient
30% some form of Fe
Deficient Anemia
Easily Administered
Therapy
SUPPLEMENTATION WORKS!
Effect on of treatment
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.78 mg/dL difference in
those treated
Positive Effects on
Developmental
Outcomes
Cognition?
AIM Statement
Reduce the impact of iron
deficiency and iron deficiency
anemia in children under 3 in
our practice by:
Increasing the
identification of children at risk
Implementing evidencebased treatment of iron
deficiency anemia
Establishing primary
prevention of iron deficiency
for an at-risk population
(Patients aged 1-3 years)
PDSA for Prevention of Anemia
P: Implement primary prevention of iron deficiency
D: Providers began prescribing prophylactic MVI
with iron to all patients aged 1-3 years
S: Chart Review (2 wks post intervention):
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Providers prescribing prophylactic MVI with Iron to
81% of patients 1-3 years
A: Expanded education efforts to ALL providers
including nurse practitioners
AAP Iron-deficiency Screening and
Treatment Guidelines
Universal Screening in high risk communities
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Hgb or Hct between 9-12 months,
and again 6 months later
Treatment
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Treat pts 6m-1.9y with Hb <11.0mg/dL, 2-5 yrs with Hb <
11.1 with 3 - 6mg/kg/day of elemental iron
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Repeat CBC 1 month into treatment – if hgb increased by
1g/dl then continue for 2 more months, if NOT then further
testing recommended
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Repeat testing 6 months after successful treatment
How Are We Screening?
Pre-intervention Measurement: to assess
variability in current screening practices
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2 year olds
9-12 month olds
CBC AND a hemocue (31%)
CBC AND a hemocue (68%)
CBC (55%)
CBC (28%)
Hemacue alone 14%
Hemacue alone 4%
Proposals brought to providers on ways to
implement uniform screening methods
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Which ages to screen patients
Hemocue vs. venipuncture
Coordinating venipunctures with state mandated Pb
screening
Changes Made To Screening
At/ around 12 months:
CBC and lead
At/around 18 months:
Hemocue
At/around 24 months:
CBC and lead
Screening
P: Tentative consensus made to conduct CBC
screening at 12 venous, 18 month hemocue,
and 24 months venous
D: Providers informed via email of new plan to
screen at theses specific ages
S: Chart review of recent 12-24 month old visits
18/20 (90%) pts with CBC/Pb screen by 1 year of age
8/12 (66%) pts with f/u hemocue between 15-24
months
A: Conducted discussion via email to foster
awareness of and buy-in to the new screening
protocol
Current Protocol
Primary Prevention
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Prescribe prophylactic MVI with Iron for all pts 1-3
years to continue for duration of at least 1 year
Screening
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CBC at 12 month, Hemocue 18 months, and 24
months CBC and Hemocue
Treatment
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Treating all pts under 5 yrs with Hb < 11 with 2 4mg/kg/day of elemental iron
Repeat CBC 1 month into treatment – if hgb
increased by 1g/dl then continue for 2 more months, if
NOT then further testing recommended
Treatment
Pre-Intervention Measurement:
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4/16 (25%) patients with iron-deficiency
anemia given correct treatment doses of
Iron according to AAP
Providers educated on AAP guidelines
Discussion of how we plan to
implement/adapt the AAP guidelines,
e.g:
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Dosage
Anemia definition (i.e. cut-offs by age – vs
AAP)
Chart Review—Are we appropriately
documenting, diagnosing, & treating anemia?
patients age 1 to 3 with dx code of anemia over a 6
month period
Results:
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(1) 94% proper “anemia diagnosis
(2) 81% treated with 2-4 mg/kg/day dosing of Fer-in-sol
(3) 81% correctly instructed for follow-up as per documentation
(4) 94% followed up regardless of documentation
(5) 63% documented resolution of anemia (though some still in
Tx at time of review)
Goals: Are we reaching them? Documentation might not
lead us to believe so…
Compliance Problem
Randomly selected group of
parents of one to 3 year
olds.
Only 40% took the vitamins
nearly all the time (5 times a
week or more).
50% of the parents surveyed
admitted non-compliance
(one dose a week or
less)
Compliance Chart Review
1 to 3 year olds from each provider
59% had documentation of child taking Polyvisol
with Fe.
All charts documented appropriate screening
times for CBC
Reasons for non-compliance
Steps Towards Compliance
IRON RICH FOOD HANDOUT
English version: revised the
handout at a 4th grade reading
level using the Flesch-Kincaid
Grade Level Index.
b) Spanish version: translators
and Fernandez-Huerta scale
between 5th and 6th grade.
Future Directions
Finalize consensus screening protocol and
achieve provider buy-in
Why are parents not giving the Iron?
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Are the Handouts helping?
Chart reviews
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Treatment – Are we treating for kids who
meet criteria? For patients diagnosed with
anemia how is the follow-up – testing at 1
month? Continuing for 3 months at least?
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Primary Prevention – Are patients staying on
the MVI with Iron? Is it resulting in fewer kids
with anemia?
Previous PDSA?
Dental Health
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50% documentation of discussion
Developmental or Speech Delay
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50% documented discussion
0% used sticker’s from last year’s project
The Team
Attendings
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Steve Caddle
Adriana Matiz
Mary McCord
Melanie Gissen
Patricia Hametz
Dodi Meyer
Elise Olshen Kharbanda
Mary Zweighaft
Carol Pafundi
Harriet McGurk
Annie Armstrong
Melissa Glassman
Residents
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Monique Collier
Brenton Mar
Eliza Auerback
Sarah Schrager
Carol Senkler
Paula Ayora
Dawn Wetzel
John Babineau
Rachelle Gandica
Maja Castillo
Brenda Ritson
Matt Laurich
Patricia Tae
Ola Aganga
Mahbod Mohazzebi
Staff
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Joan Mahoney
Maralin Bautista
Candida Rodriguez
Petra Ortiz
Beatrice Frempong
Annes Silver
Annie Hertz
Bill Johnson
Leilani Vinales
Ivelisse Rodriguez
Iliana Torres
Cindy Ferrer
Evelyn Mejia
Denise ConnollyHoyt