Microcytosis (Guidelines) | Right Decisions

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HAEMATOLOGY
Microcytosis (Guidelines)

Announcements and latest updates

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

Contingency planning for RDS outages

Following the recent RDS outages, Tactuum and the RDS team have been reviewing the learning from these incidents. We are committed to doing all we can to ensure a positive outcome by strengthening the RDS to make it fully robust and clinically resilient for the future.

We would like to invite you to a webinar on 26^th September 3-4 pm on national and local contingency planning for future RDS outages. Tactuum and the RDS team will speak about our business continuity plans and the national contingency arrangements we are putting in place. This will also be a space to share local contingency plans, ideas and existing good practice. We would also like to gather your views on who we should send communications to in the event of future outages.

I have sent a meeting request for this date to all editors – please accept or decline to indicate attendance, and please forward on to relevant contacts. You can also contact Olivia.graham@nhs.scot directly to register your interest in participating.

2.National IV fluid prescribing calculator

This UK CA marked calculator is now live at https://righdecisions.scot.nhs.uk/ivfluids . It has been developed by a multiprofessional steering group of leads in IV fluids management, as part of the wider Modernising Patient Pathways Programme within the Centre for Sustainable Delivery. It aims to address a known cause of clinical error in hospital settings, and we hope it will be especially useful to the new junior doctors who started in August.

Please do spread the word about this new calculator and get in touch with any questions.

New toolkits

The following toolkits are now live;

Gender identity healthcare: adults and young people standards. (https://rightdecisions.scot.nhs.uk/genderidentity ) Note that this toolkit includes self-evaluation forms for each standard. A Scottish Government launch of these standards, together with the toolkit and NES educational resources, is planned for 3^rd September.
Care Inspectorate staffing method framework.
Vascular surgery pathways from the Modernising Patient Pathways Programme within the Centre for Sustainable Healthcare Delivery.

Updated guidance on current and future Medical Device Regulations

We have updated and simplified this guidance within our standard operating procedures. We have clarified the guidance on how to determine whether an RDS tool is a medical device, and have provided an interactive powerpoint slideset to steer you through the process.

Guide to six stages of RDS toolkit development

We have developed a guide to support editors and toolkit leads through the process of scoping, designing, delivering, quality assuring and implementing a new RDS toolkit. We hope this will help in project planning and in building shared understanding of responsibilities throughout the full development process. The guide emphasises that the project does not end with launch of the new toolkit. Implementation, communication and evaluation are ongoing activities throughout the lifetime of the toolkit.

Training sessions for new editors (also serve as refresher sessions for existing editors) will take place on the following dates:

Thursday 5 September 1-2 pm
Wednesday 24 September 4-5 pm
Friday 27 September 12-1 pm

To book a place, please contact Olivia.graham@nhs.scot, providing your name, organisation, job role, and level of experience with RDS editing (none, a little, moderate, extensive.)

7 Evaluation projects

Dr Stephen Biggart from NHS Lothian has kindly shared with us the results of a recent survey of use of the Edinburgh Royal Infirmary of Edinburgh Anaesthesia toolkit. This shows that the majority of consultants are using it weekly or monthly, mainly to access clinical protocols, with a secondary purpose being education and training purposes. They tend to find information by navigating by specialty rather than keyword searching, and had some useful recommendations for future development, such as access to quick reference guidance.

We’d really appreciate you sharing any other local evaluations of RDS in this way – it all helps to build the evidence base for impact.

If you have any questions about the content of this newsletter, please contact his.decisionsupport@nhs.scot If you would prefer not to receive future newsletters, please email Olivia.graham@nhs.scot and ask to be removed from the circulation list.

With kind regards

Right Decision Service team

Healthcare Improvement Scotland

Audience

Highland HSCP

The normal MCV depends on age but generally 83 to 101 fL.

Causes

Iron deficiency
Thalassaemia and haemoglobinopathy
Anaemia of chronic disease
Lead poisoning (rare)
Inherited sideroblastic anaemia (rare)

History and examination

Look for signs of anaemia. Ask about diet, weight loss and potential blood loss. Review older blood tests.

This table can help differentiate between iron deficiency and thalassaemia (trait).

Factor	Iron deficiency	Thalassaemia (trait)
Haemoglobin	Low or normal	Low or normal
MCV/MCH	Low but can be normal	Low – often lower than would expect from haemoglobin concentration
RBC	Low or normal	High
RDW	Elevated	Normal
Previous FBC	May be normal	Persistently low MCV/MCH
Family FBC	May be normal	If inherited may have similar abnormalities
Blood film	May be normal or may show hypochromia and pencil cells.	Depends on type.
Ethnicity	Any	More common in certain ethnic groups

Suggested Investigations

Ferritin
If iron deficiency suspected but ferritin normal then check inflammatory markers (e.g. CRP) as inflammation may elevate ferritin into the normal range.
Haemoglobinopathy screen if suspected thalassaemia or haemoglobinopathy. Please note that alpha thalassaemia trait is the most common disorder and will not be picked up by a haemoglobinopathy screen. Alpha thalassaemia trait is a benign, asymptomatic disorder. The only two considerations are that firstly the MCV cannot (easily) be used to infer the cause of anaemia as it will always be low and secondly, depending on the level of MCH and ethnicity, partner testing may be required when family planning as per National Screening Programme.
If lead poisoning is suspected please check Zincprotoporphoryn, serum lead level and blood film
In some patients a trial of iron may be a diagnostic and therapeutic manoeuvre

Management

We do not review patients with iron deficiency in haematology.
See section on iron deficiency for more
We do not review patients with thalassaemia trait but happy to be contacted via Clinical Dialogue if concerns or further questions.

Last reviewed: 29/01/2024

Next review date: 31/01/2027

Author(s): Haematology Department .

Version: 2

Approved By: APPROVED TAM Subgroup of the ADTC

Reviewer name(s): Dr P Forsyth, Consultant Haematologist .

Document Id: TAM218