Results
The survey was sent to thirteen people at eleven sites (RCH was omitted after two unsuccessful attempts to obtain a contact name). There were 12 responses, however the response from MMH stated only the site name and no other answers therefore it was omitted. Of the eleven complete responses from eight different hospitals (response rate of 73%), there were three sites with two respondents. The remaining six responses were from six different hospitals. No responses were received from FCC and RMH.
The definitions of an urgent referral varied from site to site (Table 1). Some factors in assigning urgency to a referral include a hemoglobin value, prescriber assigning an urgent status to the prescription, an upcoming procedure or delivery date, a ferritin value or evidence of symptoms of iron deficiency or anemia. Hemoglobin threshold values varied from 80 to 100 g/L as a definition of an urgent referral.
Non-urgent referrals were defined based on the hemoglobin value at three sites, with one site stating a value of greater than 90 g/L. If a prescriber stated a referral was non-urgent and the ferritin levels were additional factors; the ferritin level cut-off for a non-urgent referral was not specified by the survey respondent. Two sites stated that there is no triage process so infusions are administered on a first come, first served basis. Missing information on a referral automatically designates a referral as non-urgent at one site.
If a referral was considered urgent, an infusion appointment is booked within the same week or at the very most within 1-2 weeks in FHA. Non urgent wait times varied from same week booking to up to 3 months after the referral was received. Most sites stated that these were typical wait times with the exception of ARHCC and ERH where there was usually a longer wait time (Table 1). ERH noted a significant reduction in iron infusion wait times from three months to same week booking; it is important to note is that this wait time reduction coincides with the implementation of the pilot SSO.
Factors contributing to longer wait times for iron infusion appointments included missing referral information, limited patient availability, and limited appointment availability (only a particular designated time of day or designated day of the week for iron infusions) and lack of human resources to triage referrals. In addition, if the patient’s referring physician is not available by phone due to holidays or outside of office hours, the patient’s appointment is delayed. Since most outpatient units have a policy that the referring physician is the attending physician, they must be available by phone in case there is an adverse reaction.
Aside from iron infusions, respondents stated that their outpatient units provide a multitude of services that require urgent appointment times that may require scheduling ahead of non-urgent iron infusion referrals (Appendix 2). Anticoagulation Program, Community IV Program, minor procedure, minor procedure recovery, bloodwork from central venous catheters, and phlebotomy patients receive care in these same outpatient units. In addition, patients rely on timely treatment with intravenous products such as blood, electrolyte infusions, hydration, immune globulin G, and medications for non-oncological indications at these units.