Rapid response, constant surveillance, critically thought out investigation tool for anmeia management.

1. Tracey George, RN CDN CM
D.O.M.I.N.O.-Anemia Management
D.O.M.I.N.O. is an acronym to create a mental image of thousands of dominos lined up and when one is
tipped over; quickly in succession, they fall down, creating a picture of something else. With anemia
management the dominos that are falling is hemoglobin. The picture you get at the end depends upon
how quickly the staff and patient react to the changes and correct them together.
The words of Sun Tzu taken from The Art of War were the foundation of D.O.M.I.N.O. First Sun Tzu said
that “speed is the essence of war”. It is the essence of anemia management also, turnaround time from
lab draw to medication changes needs to be shortened as much as possible. Labs drawn on patients
who run on Monday need to be monitored and meds adjusted on Wednesday of the same week. The
same for the Tuesday patient’s labs those need to adjusted on Thursday of the same week.
Sun Tzu also said to “treat your men as you would your own beloved sons”. Each of our patients is
someone important to someone. They are also important to us. The trust that they place in us should
not be misplaced. We have an obligation to treat them with the same diligence we would if they were
our own family.
In learning about anemia management we should next follow what Sun Tzu says about knowing
ourselves and our enemy, in this case, anemia. “If you know your enemy and know yourself you will not
be imperiled in one hundred battles.” We must know what is causing the anemia; we must know how
to treat it.
Anemia management is a concern of all dialysis patients and the staff that cares for them in their unit.
Each unit must have dedicated staff that monitor anemia, investigate the cause and treat the symptoms.

2. D is for discovery. The dialysis unit must have dedicated staff monitoring the labs and changes in the
patient’s status. Assign someone who will responsible for monitoring the lab results. The RN who is
responsible for monitoring labs should be scheduled to work when lab draws result. They should also be
scheduled out of staffing so that they can focus on the labs and the protocols. This will also give them
opportunity to speak with the patients who have low labs so that they can investigate the cause.
The patient needs to be educated regarding anemia. They have the right to know the results of their
labs. When patients start at the unit they are given their rights and responsibilities; they also have the
right to know the results of all of labs, including anemia and any medication adjustments that have been
made.
Being included in the process will help earn the patient’s trust, ensure the patient’s cooperation and
maintain the patient’s interest. Adults are capable of learning; it has been relevant to them and they
must be motivated.
Dialysis patients do face some obstacles with learning and retention. Depression, uremia and the
incidence of cardiovascular disease all work against the staff and patient when discussing patient
educations. The American Academy of Neurology reported that 13.9% of dialysis patients were classified
as having a mild cognitive impairment due to the prevalence of stroke and cardiovascular risk factors.
Iron deficiency and malnutrition also negatively impact a patient’s ability to retain information. Some
good strategies for patient education are to wait until the end of the week so that they have dialyzed
twice clearing up any uremia and aiding in retention.

3. Adult learners need reinforcement and motivation to overcome health illiteracy issues. As kidney
function declines patients self diagnose and develop a mental picture of the disease process that the
staff must overcome during patient education.
Stephen Lieb reported the Principles of the Adult Learner containing the special needs and requirements
of adult learners including:
• Adults are goal oriented.
• Adults are self-directed.
• Adults are relevancy-oriented.
• Adults are practical.
Also, try to hit all 5 senses to greater impact retention. Sight: a handout, colorful, not to busy. Hearing:
discuss the handout and the labs. Taste and smell: a small treat, mints or a lollipop. Touch: something
to hold on to associate with what you are talking about if you can find something relevant to the subject
or theme of QAI project. All of the things together will help your patient to associate what you are
discussing and help them to retain the information.
O is for onset. Trending labs will pinpoint the onset of the lab changes. Discussing this with the target
date will help the patient to remember any issues that might have occurred. This is also helpful to
further educate the patient on how something that does not seem related to dialysis; for example, a
toothache, can actually impact the labs that the two of you are discussing.
Also discussing these labs and the target with the staff can help trigger their collective memories as to a
minor complaint that a patient may have made that did not get communicated. Or how after treatment

4. the patient’s access started bleeding in the lobby and the patient bleed all the way back into the
treatment room to get help from the staff.
Identifying onset will keep you from working in the dark.
M is for management. Change the medications. Adjust the ESA as quickly as you can after the labs have
resulted. Shortening the ESA dosing change is a very important step. Once the medications have been
adjusted then the symptoms causing the anemia should be managed.
I is for investigate. Reviewing the lab trends with the patient and the staff to try to determine any
causes in the drop of the anemia labs is one step of the investigation. Send home stool cards to
investigate GI bleeding. Speak with female patients about menstrual cycles and the possible need to
reduce heparin during their cycle. Also look for signs and symptoms of infection. Expand your
examination of the labs to include Albumin, Adequacy, MCV, PTH, Tsat and Ferritin.
Once you identify the root cause if the hemoglobin does not improve, continue to investigate. Meet
with the direct patient care staff, dietitian and social worker to search for root causes to the drop in
anemia status.
N is for notify. The patient has the right to be made aware of their lab results. The physician and the
physician extender need to be made aware of anemia status changes so they can aid in investigation and
direct the course of care in managing the symptoms to treat the root cause.
O is for outcome. As we discussed at the beginning of the article all of these different dominos should
be done rapidly and together as our dominos topple over to create a design. Patients whose anemia is
managed can be turned around and the patient’s overall well being will be positive.
Case Studies

5. Patient C.C. when initially presented with monthly lab results denied any issues or complaints, after
three months there was no improvement in labs, when presented with a 3 month lab trending report
she was able to remember a broken tooth that have been repaired with a temporary crown. Once the
permanent crown was in place; her hemoglobin improved.
Patient S.A. when presented with monthly lab results he denied any issues discussed concerns with
physician extender who reported writing antibiotic prescriptions for the patient’s sinus infection. Once
the course of antibiotics finished and the sinus infection resolved, then the patient’s hemoglobin
improved.
Patient T.G. transferred to unit after a hospitalization when hemoglobin did not improve discussed with
MSW who reported having recently enrolled the patient in a donated dental service and patient had a
tooth extraction. Once the dental issues were resolved the hemoglobin improved.
References
Robinson BM, Joffe MM, Berns JS, Pisoni RL, Port FK, Feldman HI. Anemia and mortality in
hemodialysis patients: accounting for morbidity and treatment variables updated over time.
Kidney International, 2005 Nov; 68(5):2323-30.
Negley, K., Ness, S., Fee-Schroeder K., Kokal, J., Voll, J., Building a Colloborative Nursing Practice to
Promote Patient Education: An Inpatient & Outpatient Partnership, http://www.medscape.com,

6. Retrieved 4/7/2009.
Loxton, M., Patient Education the Nurse as Source of Actionable Information, Advanced Practice Nursing
eJournal 3(2), 2003 Medscape, http:www.medscape.com, Retrieved 4/7/2009.
Chang, M., Kelly, A., Patient Education: Addressing Cultural Diversity and Health Literacy Issues, Urology
Nursing 2007; 27(5): 411-417, http: www.medscape.com, Retrieved 4/7/2009.
Rothrock, J., Parade, V., Sims, C., Key, K., Walkters, N., Zweifler, R., The Impact of Intensive Patient
Education on Clinical Outcomes in a Clinic-Based Migraine Population,
http://www.medscape.com, Retrieved 4/7/2009.
Issues in Patient Education, http://www.medscape.com, Retrieved 4/9/2009.
Sun Tzu, The Art of War, 6th Century.
Lieb, Stephen. Principles of Adult Learning. http://honolulu.hawaii.edu. Retrieved 4/9/2009.