Title : Improving Screening and Treatment of Iron Deficiency in Patients with Heart Failure with Reduced Ejection Fraction: A Two-Cycle Quality Improvement Project
Abstract:
Background: Iron deficiency is common in patients with heart failure with reduced ejection fraction (HFrEF) and is associated with worse symptoms, reduced exercise capacity, and increased hospitalisation. Contemporary guidelines recommend assessment of iron status using serum ferritin and transferrin saturation (TSAT), with intravenous iron recommended for eligible patients. We evaluated adherence to these recommendations among cardiology inpatients and implemented interventions to improve recognition and treatment of iron deficiency.
Methods: A two-cycle retrospective quality improvement project was conducted among adult cardiology inpatients with documented left ventricular ejection fraction <45%. Patients receiving end-of-life care or recent intravenous iron were excluded. 30 patients were included in each cycle. Electronic records were reviewed to determine whether iron studies were performed and whether eligible patients received iron replacement. Following cycle 1, targeted educational interventions were introduced, comprising posters displayed on cardiology wards highlighting appropriate investigation and management of iron deficiency in HFrEF, alongside teaching sessions delivered to resident doctors. A 2nd cycle was subsequently undertaken to assess change in practice.
Results: In cycle 1, 12/30 (40%) patients underwent assessment of iron status. 9/12 screened patients (75%) met criteria for iron deficiency, of whom only 1/9 (11.1%) received treatment. Following intervention, screening increased to 24/30 (80%) patients in cycle 2, representing a doubling in the proportion of HFrEF inpatients assessed for iron deficiency. 13/24 screened patients (54.2%) were iron deficient, of whom 4/13 (30.8%) received treatment. Across both cycles, 22/36 (61.1%) adequately screened patients were iron-deficient. Despite improved screening, a substantial treatment gap remained, with fewer than one-third of iron-deficient patients receiving treatment in cycle 2.
Conclusion: Iron deficiency was common but underrecognised and undertreated among HFrEF inpatients. Following ward-based posters and targeted teaching for resident doctors, appropriate iron screening increased from 40% to 80%, while treatment of identified iron deficiency increased from 11.1% to 30.8%. However, persistent treatment gaps remain. Further interventions including a standardised HFrEF admission blood bundle incorporating ferritin and TSAT, alongside a dedicated pathway for intravenous iron administration, may improve delivery of care.
