Discussion
What hasn’t been considered is most outpatient units treat patients with a multitude of conditions that require consideration for urgent appointments for services ahead of iron infusions. Some iron infusion patients require appointments urgently while others do not. To further complicate matters, some hospitals do not have a designated unit for outpatient care and these services are provided in busy emergency departments.
The survey results helped explain the unexpected result of decreased wait times with the implementation of an SSO even before the addition of iron isomaltoside. What we learned was that clinic staff schedule appointments based on urgency, which is determined based on information available in referrals. Iron referrals are triaged by clinic staff based on multiple pages of information provided by the prescriber; a complete prescription, laboratory data, consultation reports on underlying medical conditions, consent for health care, allergy documentation, as well as prescriber and patient contact information is required. Clinic staff have to scour these lengthy referral packages for the relevant information; any missing information can result in a delay of treatment. It is possible that the first iteration of the SSO provided clinical staff with all the information they needed for triage and thereby streamlining the booking process. This is likely what led to reduced wait times at ERH. It is therefore possible the latest iteration of regional SSO will also lead to reduced wait times for the same reasons. Having pertinent information readily available on the SSO may have helped improve work flow. In other words, an improvement in the process reduced wait times and had nothing to do with the addition of a costly new formulation of IV iron.
The addition of iron isomaltoside to formulary may not have a major impact on overall clinic wait times since iron wait times are tied to how busy the hospital is, not how many other iron infusion referrals there may be. For example, a non-urgent outpatient iron infusion referral patient may have a wait time based on patients who are requiring urgent blood transfusions, phlebotomies, antibiotics, or minor procedure recovery.
Prior to addition of medications to formulary in the future, it may be valuable to consider if process improvements (e.g. carefully designed SSOs) would help with wait times.