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Right Decision Service newsletter: April 2024

Welcome to the Right Decision Service (RDS) newsletter for April 2024. 

Issues with RDS and Umbraco access

Tactuum has been working hard to address the issues experienced during the last week. They have identified a series of three mitigation measures and put the first of these in place on Friday 3rd May.  If this does not resolve the problems, the second mitigation will be actioned, and then the third if necessary.

Please keep a lookout for any slowing down of the system or getting locked out. Please email myself, mbuchner@tactuum.com and onivarova@tactuum.com if you experience any problems, and also please raise an urgent support ticket via the Support Portal.

Thank you for your patience and understanding while we achieve a full resolution.

Promotion and communication resources

A rotating carousel presenting some of the key RDS tools and capabilities, and an editable slideset, are now available in the Resources for RDS providers section of the Learning and Support toolkit.

Redesign and improvements to RDS

The redesign of RDS Search and Browse is still on-track for delivery by mid-June 2024. We then plan to have a 3-week user acceptance testing phase before release to live. All editors and toolkit owners on this mailing list will be invited to participate in the UAT.

The archiving and version control functionality is also progressing well and we will advise on timescales for user acceptance testing shortly.

Tactuum is also progressing with the deep linking to individual toolkits within the mobile RDS app. There are several unknowns around the time and effort required for this work, which will only become clear as the work progresses. So we need to be careful to protect budget for this purpose.

New feature requests

These have all been compiled and effort estimated. Once the redesign work is complete, these will be prioritised in line with the remaining budget. We expect this to take place around late June.

Evaluation

Many thanks to those of you completed the value and impact survey we distributed in February. Here are some key findings from the 65 responses we received.

Figure 1: Impact of RDS on direct delivery of care

Key figures

  • 93% say that RDS has improved evidence-informed practice (high impact 62%; some impact 31%)
  • 91% report that RDS has improved consistency in practice (high impact 65%, some impact 26%)
  • 85% say that RDS has improved patient safety (high impact 59%, some impact 26%)
  • Although shared decision-making tools are only a recent addition to RDS, and only represent a small proportion of the current toolset, 85% of respondents still said that RDS had delivered impact in this area (53% high impact, 32% some impact.) 92% anticipate that RDS will deliver impact on shared decision-making in future and 85% believe it will improve delivery of personalised care in future.

Figure 2 shows RDS impact to date on delivery of health and care services

 

Key figures

These data show how RDS is already contributing to NHS reform priorities and supporting delivery of more sustainable care.

Saving time and money

  • RDS clearly has a strong impact on saving practitioner time, with 90% of respondents reporting that this is the case. 65% say it has a high impact; 25% say it has some impact on time-saving.
  • It supports devolved decision-making across the multi-professional team (85% of respondents)
  • 76% of respondents confirm that it saves money compared, for example, to investing in commercial apps (54% high impact; 22% some impact.)
  • 72% believe it has impacted already on saving money and reducing waste in the way services are delivered – e.g. reducing costs of referral management, prescribing, admissions.

Quality assurance and governance

  • RDS leads are clear that RDS has improved local governance of guidelines, with 87% confirming that this is the case. (62% high impact; 25% some impact.)

Service innovation and workforce development

  • RDS is a major driver for service innovation and improvement (83% of respondents) and has impacted significantly on workforce knowledge and skills (92% of respondents – 66% high impact; 26% some impact).

New toolkits

A few examples of toolkits published to live in the last month:

Toolkits in development

Some of the toolkits the RDS team is currently working on:

  • SARCS (Sexual Assault Response Coordination Service)
  • Staffing method framework – Care Inspectorate.
  • SIGN 171 - Diabetes in pregnancy
  • SIGN 158 – British Guideline on Management of Asthma. Selected sections will be incorporated into the RDS, and complemented by a new chronic asthma pathway being developed by SIGN, British Thoracic Society and NICE.
  • Clinical pathways from NHS Fife and NHS Lanarkshire

Please contact his.decisionsupport@nhs.scot if you would like to learn more about a toolkit. The RDS team will put you in touch with the relevant toolkit lead.

Quality audit of RDS toolkits

Thanks to all of you who have responded to the retrospective quality audit survey and to the follow up questions.  We still have some following up to do, and to work with owners of a further 23 toolkits to complete responses. An interim report is being presented to the HIS Quality and Performance Committee.

Implementation projects

Eight clinical services and two public library services are undertaking tests of change to implement the Being a partner in my care app. This app aims to support patients and the public to become active participants in Realistic Medicine. It has a strong focus on personalised, person-centred care and a library of shared decision aids, as well as simple explanations and videoclips to help the public to understand the aims of Realistic Medicine.  The tests of change will inform guidance and an implementation model around wider adoption and spread of the app.

With kind regards

Right Decision Service team

Healthcare Improvement Scotland

Ferinject Infusion (438)

Please report any inaccuracies or issues with this guideline using our online form

Ferinject® Infusion (Ferric carboxymaltose)
Injection, iron (as ferric carboxymaltose) 50mg/ml
Available as 2ml, 10ml or 20ml vials

Ferinject is indicated for the treatment of iron deficiency in women with a serum ferritin of <30ug/l when:

  • oral iron preparations are ineffective
  • oral iron preparations cannot be used
  • there is a clinical need to deliver iron rapidly

The diagnosis of iron deficiency must be based on laboratory tests.

All care providers should discuss the option to use Ferinject® with a Senior Obstetrician.

Patients that meet the criteria for Ferinject® infusion should read the patient information leaflet and have any questions answered before proceeding with treatment (See appendix 1 – Patient information Leaflet) 

IMPORTANT NOTES

  • Ferinject® may cause anaphylactoid reactions, which can be immediate, severe and potentially life-threatening. Resuscitative medication and trained personnel should be available whenever Ferinject® is administered. The risk of anaphylaxis is enhanced for patients with known (medical) allergies. Fetal bradycardia may occur following administration of Ferinject®. This bradycardia is usually transient and as a consequence of a hypersensitivity reaction in the mother. Fetal monitoring should be carried out in any patients who experience a hypersensitivity reaction. CTG if ≥28 weeks fetal auscultation if <28 weeks.
  • There is a risk of extravasation that can result in long-term brown discolouration of the surrounding skin. Appendix 2 – Extravasation monitoring and management - outlines the symptoms of extravasation and its management should this occur.
  • Patients should be observed carefully during and for at least 30 minutes after administration of Ferinject®

Total Dose Infusion

  • Ferinject® should be administered during a planned daytime admission, to a locally agreed area, from Monday to Friday only. 
  • Administration can only be undertaken in a clinical area where emergency equipment is available as there is a risk of anaphylaxis and should be controlled via an infusion pump.
  • Please contact pharmacy to check total dose if required.
  • If, at any time, during the IV administration of Ferinject®, any signs of a hypersensitivity reaction, intolerance or extravasation are detected, administration must be stopped immediately.
  • The cumulative dose for repletion of iron using Ferinject® is based on the patient’s body weight and haemoglobin (Hb) level and must NOTbe exceeded.

The amount of Ferinject® required should be determined from the dosage table below.

Table 1: Determination of the cumulative iron dose

Hb

Patient body weight

g/L

Below 35 kg

35 kg to <70 kg

70kg and over

<100

500 mg

1,500 mg

2,000 mg

100 to 140

500 mg

1,000 mg

1,500 mg

For doses greater than 1000mg see maximum tolerated single dose below

Maximum tolerated single dose

A single dose of Ferinject should not exceed 1,000 mg of iron per day. 

Do NOT administer 1,000 mg of iron more than once a week

If the total dose is >1000 mg of iron, then the total dose should be divided and administered each week over a total of two weeks.

Post-iron repletion assessments

Re-assessment should be performed by the clinician based on the individual patient's condition. The Hb level should be re-assessed no earlier than 4 weeks following completion of the first treatment cycle to allow adequate time for erythropoiesis and iron utilisation. In the event the patient requires further iron repletion, the iron need should be recalculated using Table 1 above.

IV Infusion

Ferinject® is administered by intravenous infusion, via an infusion pump, up to a maximum single dose of 1,000mg of iron (up to maximum of 20mg/kg body weight). Ferinject® must be diluted only in sterile 0.9% sodium chloride infusion as shown in Table 2 below. See appendix 3 - checklist for prescribing and administration.

Table 2: Dilution plan of Ferinject® for intravenous infusion

Ferinject®

Iron

Volume of 0.9% sodium chloride infusion

 Minimum administration time

10ml

500mg

100ml

6 minutes

20ml

1,000mg

250ml

15 minutes

Contraindications:  It is important to read the current SPC for this product.

Extra Precautions for Use

Oral iron should be stopped at least 24 hours before infusion of Ferinject® and should not be started for at least 5 days following the last infusion of Ferinject®.

Extravasation of ferric carboxymaltose at the infusion site may lead to brown discolouration and irritation of the skin. In the case of extravasation, the administration of Ferinject® must be stopped immediately. See Appendix 2.

Licensed Status

Not licensed for use during the first trimester of pregnancy but can be used during the second and third  trimester and during  lactation if oral iron is ineffective or impracticable.

Appendix 1: Iron infusions - patient/relative information leaflet

Iron infusions - patient/relative information leaflet (pdf)

Appendix 2: Extravasation monitoring and management

Extravasation monitoring

Caution should be exercised to avoid paravenous leakage when administering IV iron. Paravenous leakage at the infusion site may lead to irritation of the skin and potentially long lasting brown discolouration at the site of infusion. It should be suspected if one or more of the following is observed:

  • The infusion is not flowing freely or has stopped.
  • Swelling, discomfort, burning or pain occurs at the infusion site.

There is no published evidence to suggest that extravasation correlates with the use of positive pressure devices. It is widely thought that gravity devices minimise the risk of extravasation. Yet it is difficult to find the evidence in the literature to support this view and recent studies suggest there is no such link. The most effective safeguard against extravasation is to visually inspect the infusion site regularly. Patients should be informed about the possibility of discolouration and advised to report any signs of irritation or pain at the infusion site.

Extravasation reactions

Data supporting the management of extravasation reactions for non-cytotoxic agents are limited, and management is often extrapolated from other drugs with variable results. The guidance below is extrapolated from the West of Scotland Cancer Network guideline for the management of extravasation reactions with systemic anti-cancer therapy. For further information please refer to the guideline available here.

In case of suspected paravenous leakage, treatment requires prompt attention:

  • Stop the infusion immediately and disconnect the drip, do not remove
    the cannula.
  • Inform medical staff immediately.
  • Aspirate the extravasated drug by connecting a clean syringe to the cannula and drawing back.
  • Mark the extravasation area with a pen and remove the cannula.
  • Elevate the limb (if possible).
  • Cool the area for 24-48 hours and closely monitor the skin and underlying tissues for changes.
  • Consider referral to plastic surgery team.
  • Clearly document the management plan in the patient’s medical records.
  • Complete a clinical incident form (Datix).

Appendix 3: Checklist for prescribing and administration of Ferinject® (ferric carboxymaltose)

Checklist for prescribing and administration of Ferinject® (ferric carboxymaltose) (pdf)

Editorial Information

Last reviewed: 16/03/2021

Next review date: 01/03/2024

Author(s): Susan Kafka.

Version: 3

Approved By: Maternity Clinical Governance Group

Document Id: 438