Towards Better Control in CKD: Improving Anemia Management

ANNA CE Satellite Symposium - New Orleans, Louisiana, October 17, 2004

Managing Anemia Management



Michelle Turgeon, MSW
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This satellite symposium is sponsored by an unrestricted educational grant from American Regent Laboratories, Inc. This activity has been planned and produced in accordance with CE guidelines and policies. From a CE symposium held on October 17, 2004 at the American Nephrology Nurses' Association (ANNA) Fall Meeting in New Orleans, LA. This symposium was approved by ANNA. It was not part of the official ANNA Annual Meeting.
This activity has been awarded 1.5 contact hours by the American Nephrology Nurses Association (ANNA) which is accredited as a provider and approver of continuing education in nursing by the American Nurses Credentialing Center-Commission on Accreditation (ANCC-COA).
Posting Date: January, 2005
CE Credit Eligible Through: May, 2006
CE Credit Hours/Completion Time: 1.5
Target Audiences: Nurses, nurse practitioners, and other healthcare professionals who treat and manage patients with CKD.
Method of participation: Listen to the talk, read the PubMed abstracts linked to data slides and talk references, take the post-test, read the linked abstracts in the post-test answer feedback material.
LEARNING OBJECTIVES:
After participating in this program, the participant should be able to:
  1. Describe the benefits of anemia management in chronic kidney disease (CKD).
  2. Outline the results of a U.S. clinical trial of iron sucrose and erythropoietin in the treatment of anemia in CKD.
  3. Appraise the characteristics of available parenteral iron products.
  4. Explain the critical role of the nephrology nurse in anemia management.
SPEAKER DISCLOSURE STATEMENT:
Speaker is a member of the Speakers Bureau for American Regent Laboratories Inc.

ANNA and HDCN CE POLICY STATEMENTS:
The CE policy and disclosure statements of the American Nephrology Nurses' Association are given in detail on the Symposium Home Page. The CE policy statements of HDCN are listed on this page.

Dr. Van Wyck:
We have come to the portion of the talk where Ms. Michelle Turgeon is going to talk about managing anemia management a topic which I have never heard discussed, but when we talk about outcomes and we talk about people working together, that is really where the rubber meets the road.

Michelle is from Gambro. She is a Regional Director at Gambro. She graduated from Widener University in Pennsylvania, took a job as a social worker at Gambro, and within a year was promoted to Regional Director. She has her hands full in that job.

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Managing anemia management
She is going to give you her perspective on anemia management as a manager.

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My background
Michelle Turgeon:
Thank you Dr. Van Wyck. I appreciate that. Hello everyone. I am very excited to be here. This is a great opportunity for me to be here. I want to assure everybody, I know I am a social worker, and a lot of people think - what are you actually going to talk to us about? I am not a nurse, did not go to medical school, did not go to nursing school, but I hope that in this presentation, you will find some information useful on what worked for us to be successful in anemia management. As Dr. Van Wyck said, I have a Master's Degree in Social Work. I have been with Gambro Healthcare for 3 years. I started as a Social Worker. I have been the regional director for 2 years. My interest in taking a management position was to really focus on being a part of a team and to building a solid team. Also, to be able to make decisions, to problem solve, and be a part of the team to make sound decisions for our patients. We are also driven by our outcomes. We want to be successful to help our patients, and just meet our goals and our targets.

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My job
I cover 7 hemo clinics. I have 6 acute programs I cover. I also have 2 PD programs that are under my supervision. My territory is in Western South Carolina, and I have 2 clinics in Augusta, Georgia. My responsibilities, my main job duties, are patient outcomes, business outcomes, and really running an efficient organization to meet State and Federal regulations. I am sure which most you can attest to, our goal, as per Gambro, is to get the percent of patients with sub-11 Hb values to below 18%. We do not have an actual target goal for ferritins, but our goal is to keep them below 800. That way, we can keep them from having infections or certain other processes.

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My region
This slide is just a little example of the region in my area where I cover.

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My world
This just zooms in on my geographic area.

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My people and my world
It is a rural area. We have predominantly African American patients. My clinics are mostly smaller-sized clinics. I do have one larger clinic with over 120 hemo patients, and we have about 20 PD patients. I know it varies from what company you work for and what area you are in, but for my area, my center directors are the anemia managers. There may be a charge nurse who is a backup or another nurse, but predominantly my center directors are in charge of the anemia management. That works out well for us because our physicians pretty much stay out of it, which is beneficial to us. I know a lot of times you can have physicians that can really be more conservative in the way they dose. They do not look at trends, and so I am happy to say that our physicians pretty much leave it up to us. We may have care plans to discuss problems, patients, or concerns about we are not sure what to do, but pretty much the nurses and center directors do the anemia management. This year, Gambro Healthcare did create positions called Outcome Director, and they have been a huge plus to us. They are another set of eyes that help us put focus and attention to the anemia management. There are also RNs in that field.

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My challenges in anemia management
When doing anemia management, we always say there are always so many factors on why we cannot get the results we want. Because I know everybody works hard to get at least 18% sub-11 - and that is our goal. But, you hear always excuses, these are the list, - I am sure there is a myriad of others that you can think of - but for us we found time. Who has time when my CDs are working the floor, filling in staffing, trying to work with state regulations, round with physicians, so time was an issue for us. Also, making sure that you adjust dosing in a timely manner. When you get your labs back, are you making doses in a day or two when you get the results or because of time are you waiting a week, 2 weeks, or more, and that is important.

Also protocols - do you have any in place? If you do, are they aggressive, are they efficient? For us, with Gambro, we have had throughout the 2 years I have been there, several revisions of our iron dosing protocol. We have gotten a new one this year for anemia, and it is also just about being revised right now. Also, with staff turnover, how efficient are your anemia managers? Do you have high turnover? What training do you have? Also, with our physicians, there are a few physicians we still have who have a few patients who will override a decision, be a little bit more conservative, and not really let the CD and the anemia manger make those decisions.

Also documentation - a lot of times, we have patients whose hemoglobins are above 13 or are really low, and who need a large dose (of EPO). We found that sometimes we might be missing the proper documentation to get reimbursed - so that was an issue.

Also, managing patients who are hospitalized. I think that is probably a major concern for us - sending a patient to the hospital with a hemoglobin of 11 or 12, and they come back with a hemoglobin of 9 or 10, and having that be an issue.

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My philosophy
Hearing those concerns from my CDs, it is okay. We are going to do this. We are going to try to get good results. A member once said, I am really not big on some of the excuses I just mentioned. I think there are reasons that you could have some difficulty with anemia, but if you have continuously poor results month after month, I just was not going to buy that. I think that there might be other issues on why the timely manner, dosing appropriately, things like that - let us just cut off the excuses and get at what the problem is.

My philosophy is - I am not a nurse, I do not make the changes. Let me instill and empower my center directors and my anemia managers, so they can believe in themselves, that they have the knowledge, and they can do it. Because a lot of times, we do not give enough praise and credit, saying you are doing a great job, keep it up! I see you thinking outside the box, this is fantastic. Things like that that motivate them. I wanted to hold that as part of my philosophy; I am here today to represent my area, but I praise my center to say - it is because of all of you guys that I am here. I am just one piece of that puzzle.

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Exemplary Clinic: Low Hb. Rural, small (42 patients), low staff turnover
I am going to give some clinic examples here. This is one of my clinics that has 42 patients in rural South Carolina. This is a steady clinic, not much turnover with staff - I am happy to say. This just shows pretty much a steady sub-11. In March of last year, we came up with a new protocol. It was going more to a maintenance dose of iron, a little bit change in how we dosed the epogen, and so we did spike up in 2003. For a year and a half, except for one 2-month period, the percent of sub-11s has been below 20%; this shows excellent focus and attention.

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Exemplary Clinic: High ferritins. Rural, small (42 patients), low staff turnover
Another great clinic, same thing, rural, low staff turnover. For a year and a half, she has had less than 20% of her patients with serum ferritin values greater than 800 ng/mL. How can this clinic be successful knowing they have those challenges? They "do not have enough time, they have hospitalizations" - so is an example that it can be done with proper focus and attention.

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Early 2003
With that, we said - For 2003 we will continue to make changes to be successful; and we said - Let us just continue to focus. Make the time, focus, schedule, delegate other tasks if you have to. Again, implement the latest protocols from Gambro Healthcare and adapt them if we need to. One thing that we did differently that few people had done before was, we actually got a pharmaceutical company and pharmaceutical reps involved. I scheduled monthly clinic visits for them to come in to educate myself being a non-RN, to educate my staff, the PCPs, RNs, to in-service them, and to also provide education to the patients. Sometimes the patients hear it from us, it tends to go one way or the other, but we wanted the drug reps to put on luncheons, and come into the waiting room and really talk with the patients - do they understand anemia management, do they understand how it affects them?

Also, we had an issue with our IV iron dosing. We had heard that if you use too much iron sucrose or certain irons, you can get a high ferritin. What we did was, we switched to a lower maintenance iron dose - one that varies depending on what you need, 25 mg, 50 mg/week. You will see that we actually did not notice a spike in ferritin when we did that. If anything, serum ferritin levels started to decrease, showing the importance of proper iron dosing.

Then, also, we did share results with each other. We are part of a team effort. We strive to learn from each other's successes. During meetings, I share results with who has good sub-11s and different criteria, and they really took pride in that. If they did not meet goals, then they worked harder to meet them next month.

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Problem clinic: Low Hb. Staff turnover contributes to inconsistent results
Now I am going to go over some problem areas, some areas where we have struggled. We are not immune to staff turnover - having some inconsistencies in our sub-11s, but what I wanted to stress is that at least if not consistently - I guess I see some clinics who have 4 sub-11s just month after month with not much improvement, and so that is where we needed to do something different. With this clinic, you could see with the new protocol, the percent of sub-11s came down in early 2003. Then the percentages started to increase; we had a new anemia manager, we lost a CD, and we hired a new one, and then we had to take time to train and to educate. The percent of sub-11s came down; then staff turnover, had a new center director. The percent sub-11s were back up above 20%, and now they have come down from March of this year. This is a good example of how not having a solid anemia manager and having turnover can affect your rate of sub-11s.

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Same clinic: High ferritins. Results are less affected by turnover
With the high ferritin; this is the same clinic, so you would expect to see a spike, like you just saw with this spike here of having sub-11 and with the ferritin we do not see that. What does that mean? What we equated that to is, that hemoglobin is very difficult to manage. We have so many factors of blood loss, hospitalizations that really affect the hemoglobin. If we do not check on them on a regular basis - we draw them weekly now, all hemoglobins. You could have high results or high sub-11s. Here with the ferritin, we do not have that. We equate that to, if you have a good protocol in place and you dose your iron appropriately, that you will not have a spike in ferritin. This is a good example in terms of the same clinic. Only once have there been more than 20% of patients with ferritins greater than 800, and that was in March of last year.

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Good getting better: Low Hb. Large clinic, very stable staffing, protocol improved
This is another example of a clinic in terms of hemoglobin values. This clinic has a pretty stable staff and it is my largest clinic. They have had above 20% patients with sub-11 Hbs. Early last year, we came up with a new anemia management protocol, and patients stayed pretty constant, but you see that when Gambro came out with their new protocol this year, the percentage of patients with sub-11 Hbs has dramatically dropped. This is an example that even though you are doing all you should, sometimes your results are based on your protocol, how aggressively you use it, and how well you use it. This is just an example of that.

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Same clinic: High ferritins. Dropping the iron dose corrects high ferritins
This is the same clinic. This clinic has great staff, have RNs there with 10-plus years for Gambro, and they had just this conception that the more iron you give, the better it is for them, and they were giving an iron maintenance of 100 mg a week, and they did this before I got there. As you can see, when we started with them in early last year, they had about 45 percent of patients who had a ferritin greater than 800 and it spiked up in June of last year to about 75%, and that is a lot of people. Then when we switched that and said that is just too much iron, came up with a new protocol, and we started to give 25 to 50 mg of iron sucrose a week, you can see from June of last year just slowly the ferritins decreasing. The point is, that a proper maintenance dose will lower the percent of patients with inappropriately high serum ferritin values.

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More evidence that high ferritins result from too much iron: Two good clinics getting better
These are two clinics that illustrate the same point. Initialy, patients were given 100 mg a week of IV iron, and then we changed to give 25 mg a week - thinking that the previous dose was just too much iron - and since then, slowly, the serum ferritins have come down. So initially, we did not have the right dosing protocol. I think we compared it to iron dextran, where you could give 100 mg a week as a maintenance dose; and you cannot do that with some of these other IV iron drugs.

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Exemplary anemia outcomes are compatible with good business.
For me, as manager I ask: What is this going to do for my budget? - because that is ultimately one of my focuses, but I did not want to make that the only focus. I said if we can have good patient outcomes, good patient care, then the finances will be there. You can see here an example of one clinic. In December, they were barely meeting the iron, but they were not even meeting their iron budget, then it just spiked up, and they have been meeting their budget ever since. Financially, from a financial management standpoint, excellent anemia management equals good business results as well.

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Keys to success
Now that we have kind of painted this picture, you say now what - how do you continue to do it? I have just continued to support my CDs. I have stressed to them that you need to make the time, and that sounds easier said than done, but I think as manager sometimes we feel the only way to get something done is for me to do it myself and that is not always the case. I think that certain tasks need to be delegated. I know usually my staff, the anemia managers, will make the dosing recommendations and then give it to an RN to put in the computer, and that takes the longest amount of time, just sit at the computer and put in orders. You need to maximize the staff you have and the time you have to get things done. Also, we are trying to create a team approach and to minimize staff turnover. I know that seems impossible especially with the RN shortage I am sure we all feel, but that is just extremely important, and is shown in some of the slides I showed earlier, that staff turnover can give you bad results. Make sure you have the best protocols in place, that you understand the protocols, and that you feel comfortable with the protocols.

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Successful strategies
Also get the training, get the drug reps in, and have them help educate staff, the patients, and the physicians. Also, make sure your physicians are part of the process - I mean even if they are not involved, we still keep them in the loop. Still, even though we have had them in many, many a times, our drug representatives are still involved in my clinics. The outcome directors for us are definitely part of our success in our process, and we are having one or two meetings scheduled in 2 weeks, and I am making all my CDs and anemia managers, who have gone to such training before, to continue to go, to stay fresh and on top of everything.

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Strategies: Managing anemia managers
I think the key success for us is that - I am sort of their cheerleader - because medically I enjoy these presentations, although some aspects are over my head.

I just say - "Let's just do it. Come on guys, we can do this, you are slipping"! Try to instill and empower them.

Also, we set goals. Last year, our goal was 20% or fewer patients with sub-11 Hbs. This year, it is 18% of our patients. We also try to get that competitive edge, I put graphs up and show everybody where they stand. Overall, the main thing is staying positive and on top of everything and that really is the key to success. I know it sounds easier said than done or, "God, that seems so basic"!- but if we all have the medical knowledge and you all know about anemia and iron, then how come all of our patients are not healthy and how come all of them do not have great sub-11 results, how come all of our clinics have, at times, high percentages of patients with sub-11 Hbs? Because I think that sometimes we can miss that focus and not take the time that we need and say, " I have always done it this way." So I think that we really need to look outside the box.

Thank you. I think now that this has ended our presentation part. We really encourage you all to have questions and Dr. Van Wyck will be heading that process. I thank you all.

Dr. Van Wyck:
This is an important piece of information: You know that the FDA approved dosing for IV iron products is 100 mg for iron dextran over 2 minutes, 100 mg iron sucrose over 5 minutes, and ferric gluconate 125 over 10 minutes. That means that everything we do in CKD and PD, we tend to be outside FDA-approved limits. But there are lots and lots of data on IV iron dosing in these patient groups in the literature.


Next - PANEL DISCUSSION


This satellite symposium is sponsored by an unrestricted educational grant from American Regent Laboratories, Inc.
This activity has been planned and produced in accordance with CE guidelines and policies. From a CE symposium held on October 17, 2004 at the American Nephrology Nurses' Association (ANNA) Fall Meeting in New Orleans, LA.
This symposium was approved by ANNA. It was not part of the official ANNA Annual Meeting.


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