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Patients referred from primary care with iron-deficiency anaemia: analysis of a nurse-led service. An improvement for both doctor and patient?

Andrew Davis

Iron-deficiency anaemia (IDA) is a very common disorder. In 1998, an analysis of historical data revealed that 20 patients harbouring gastrointestinal cancer who were initially referred with IDA had an average wait of 11 weeks from referral to diagnosis.Recent government recommendations have brought this subject to the fore and are driving change in an already pressured service by insisting that IDA should be included in the indications for urgent referral as part of the two-week wait rule. With the paucity of diagnostic symptoms and clinical signs seen in most patients with IDA, a wait for consultant outpatient review prior to endoscopic evaluation seemed an unnecessary delay. In December 1998 a fast track protocoldirected nurse-led IDA clinic was established and here we evaluate the results of the first consecutive 100 patients. All 100 patients referred over 15 months were seen within two weeks. A nurse specialist followed an established protocol to elicit a structured medical history and undertake a limited physical examination. The presence of alarm symptoms or signs led to rapid investigation within two weeks. Nineteen patients were found to have gastrointestinal cancer (17 colonic, two oesophageal). In these 19 patients the mean time from general practitioner referral letter to diagnosis was four weeks and 79% had a diagnosis within three weeks. In conclusion, this nurse-led open access IDA clinic attracted appropriate referrals from primary care and greatly improved the referral-to-diagnosis time for patients harbouring gastrointestinal malignancy. In all cases it was apparent that a clinical nurse specialist was entirely capable of safely assessing these patients and planning appropriate investigations.