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Abstract
Discussion Forum (0)
ePoster
Topic: Improving Patient and Health Systems Quality
Levi, Olga RN MSc1,2; Chan, Maverick1; Bodley, Thomas MD3,4; Smith, Orla RN PhD3,4,5; Sholzberg, Michelle MD MSc4,5,6,7; Swift, Shannon RN MSc2; Yip, Drake3,6, Chaudhry, Hina6, Friedrich, Jan O. MD DPhil3,4,5; Hicks, Lisa K. MD MSc4,5,7
1 Hematology/Oncology Clinical Research Group, St. Michael's Hospital, Toronto, ON
2 Medical Surgical Intensive Care Unit, St. Michael's Hospital, Toronto, ON
3 Interdepartmental Division of Critical Care Medicine, University of Toronto, Toronto, ON
4 Department of Medicine, University of Toronto, Toronto, ON
5 Li Ka Shing Knowledge Institute, St. Michael's Hospital, Toronto, ON
6 Department of Laboratory Medicine, St. Michael's Hospital, Toronto, ON
7 Division of Hematology/Oncology, Department of Medicine, St. Michaels Hospital, Toronto, ON
University of Toronto
Introduction:
Critically ill patients receive a high volume of blood tests due to their need for intensive intervention and monitoring,(1) However, blood loss from phlebotomy is associated with anemia and higher transfusion burden, both of which are associated with increased mortality.(2, 3) some of which is reflexive and unnecessary.(4, 5) Modeling indicates reducing phlebotomy volume may result in clinically meaningful decrease in ICU anemia.(6)
Objectives:
We aimed to reduce the average volume of blood collected per patient-day by 15% by June 30, 2019 (project start February 2020) by developing and implementing a patient-centered, diagnostic phlebotomy strategy in the Medical-Surgical Intensive Care Unit (MSICU) at St. Michael's Hospital.
Methods:
A series of change strategies were implemented in a single 25-bed MSICU in Toronto, Ontario, between February and June 2019. The strategies included: stake-holder engagement, education sessions, work-flow process changes, electronic order set modifications, initiation of add-on testing, and audit and feedback regarding the average volume of blood collected per patient-day. The intervention period was compared to baseline data from July 2018 to January 2019. The main outcome measure was average volume of blood collected per patient-day in the MSICU. Balance measures included average discrete blood draws, ICU length of stay and mortality. The statistical stability of the main outcome measure over time was explored with Sewhart chart (I-chart) analysis. The student's T-Test was also used to compare the mean blood collected and transfusion burden pre-post intervention.
Results:
Figure 1 summarizes the study results. Baseline data from July 2018 to January 2019 revealed a mean of 41.3 mL of blood was collected per patient-day (including waste at bedside during vascular access). The volume of blood collected per patient-day was stable during the baseline observation period. Direct observations and process mapping of the blood ordering processes suggested that repetitive and reflexive blood testing was common in the MSICU. During the intervention period average blood volume collected decreased from 41.3 mL per patient-day to 36.0 mL per patient day. Special cause variation was observed 6 weeks into the intervention (p < 0.01). The average number of discrete blood draws also decreased from 3.2 to 2.8 per patient day. Reduction in phlebotomy volume has been sustained during post-intervention monitoring out to December 2019.
CONLCUSION:
Iterative improvement interventions to reduce unnecessary blood testing in an ICU setting were associated with a significant decrease in average blood volumes collected per patient-day. Further analysis is needed to determine if decreased phlebotomy volume was also associated with decreased transfusion burden and/or reduction in ICU acquired anemia. Frequent consultation of key stakeholders and incorporating audit and feedback post intervention was integral to the project's success.
Image 1
1. Vincent JL, Baron JF, Reinhart K, Gattinoni L, Thijs L, Webb A, et al. Anemia and blood transfusion in critically ill patients. JAMA. 2002;288(12):1499-507.
2. Thavendiranathan P, Bagai A, Ebidia A, Detsky AS, Choudhry NK. Do blood tests cause anemia in hospitalized patients? The effect of diagnostic phlebotomy on hemoglobin and hematocrit levels. J Gen Intern Med. 2005;20(6):520-4.
3. Chant C, Wilson G, Friedrich JO. Anemia, transfusion, and phlebotomy practices in critically ill patients with prolonged ICU length of stay: a cohort study. Crit Care. 2006;10(5):R140.
4. Musca S, Desai S, Roberts B, Paterson T, Anstey M. Routine coagulation testing in intensive care. Crit Care Resusc. 2016;18(3):213-7.
5. Martinez-Balzano CD, Oliveira P, O'Rourke M, Hills L, Sosa AF, Critical Care Operations Committee of the UMHC. An Educational Intervention Optimizes the Use of Arterial Blood Gas Determinations Across ICUs From Different Specialties: A Quality-Improvement Study. Chest. 2017;151(3):579-85.
6. Lyon AW, Chin AC, Slotsve GA, Lyon ME. Simulation of repetitive diagnostic blood loss and onset of iatrogenic anemia in critical care patients with a mathematical model. Comput Biol Med. 2013;43(2):84-90.
Topic: Improving Patient and Health Systems Quality
Levi, Olga RN MSc1,2; Chan, Maverick1; Bodley, Thomas MD3,4; Smith, Orla RN PhD3,4,5; Sholzberg, Michelle MD MSc4,5,6,7; Swift, Shannon RN MSc2; Yip, Drake3,6, Chaudhry, Hina6, Friedrich, Jan O. MD DPhil3,4,5; Hicks, Lisa K. MD MSc4,5,7
1 Hematology/Oncology Clinical Research Group, St. Michael's Hospital, Toronto, ON
2 Medical Surgical Intensive Care Unit, St. Michael's Hospital, Toronto, ON
3 Interdepartmental Division of Critical Care Medicine, University of Toronto, Toronto, ON
4 Department of Medicine, University of Toronto, Toronto, ON
5 Li Ka Shing Knowledge Institute, St. Michael's Hospital, Toronto, ON
6 Department of Laboratory Medicine, St. Michael's Hospital, Toronto, ON
7 Division of Hematology/Oncology, Department of Medicine, St. Michaels Hospital, Toronto, ON
University of Toronto
Introduction:
Critically ill patients receive a high volume of blood tests due to their need for intensive intervention and monitoring,(1) However, blood loss from phlebotomy is associated with anemia and higher transfusion burden, both of which are associated with increased mortality.(2, 3) some of which is reflexive and unnecessary.(4, 5) Modeling indicates reducing phlebotomy volume may result in clinically meaningful decrease in ICU anemia.(6)
Objectives:
We aimed to reduce the average volume of blood collected per patient-day by 15% by June 30, 2019 (project start February 2020) by developing and implementing a patient-centered, diagnostic phlebotomy strategy in the Medical-Surgical Intensive Care Unit (MSICU) at St. Michael's Hospital.
Methods:
A series of change strategies were implemented in a single 25-bed MSICU in Toronto, Ontario, between February and June 2019. The strategies included: stake-holder engagement, education sessions, work-flow process changes, electronic order set modifications, initiation of add-on testing, and audit and feedback regarding the average volume of blood collected per patient-day. The intervention period was compared to baseline data from July 2018 to January 2019. The main outcome measure was average volume of blood collected per patient-day in the MSICU. Balance measures included average discrete blood draws, ICU length of stay and mortality. The statistical stability of the main outcome measure over time was explored with Sewhart chart (I-chart) analysis. The student's T-Test was also used to compare the mean blood collected and transfusion burden pre-post intervention.
Results:
Figure 1 summarizes the study results. Baseline data from July 2018 to January 2019 revealed a mean of 41.3 mL of blood was collected per patient-day (including waste at bedside during vascular access). The volume of blood collected per patient-day was stable during the baseline observation period. Direct observations and process mapping of the blood ordering processes suggested that repetitive and reflexive blood testing was common in the MSICU. During the intervention period average blood volume collected decreased from 41.3 mL per patient-day to 36.0 mL per patient day. Special cause variation was observed 6 weeks into the intervention (p < 0.01). The average number of discrete blood draws also decreased from 3.2 to 2.8 per patient day. Reduction in phlebotomy volume has been sustained during post-intervention monitoring out to December 2019.
CONLCUSION:
Iterative improvement interventions to reduce unnecessary blood testing in an ICU setting were associated with a significant decrease in average blood volumes collected per patient-day. Further analysis is needed to determine if decreased phlebotomy volume was also associated with decreased transfusion burden and/or reduction in ICU acquired anemia. Frequent consultation of key stakeholders and incorporating audit and feedback post intervention was integral to the project's success.
Image 1
1. Vincent JL, Baron JF, Reinhart K, Gattinoni L, Thijs L, Webb A, et al. Anemia and blood transfusion in critically ill patients. JAMA. 2002;288(12):1499-507.
2. Thavendiranathan P, Bagai A, Ebidia A, Detsky AS, Choudhry NK. Do blood tests cause anemia in hospitalized patients? The effect of diagnostic phlebotomy on hemoglobin and hematocrit levels. J Gen Intern Med. 2005;20(6):520-4.
3. Chant C, Wilson G, Friedrich JO. Anemia, transfusion, and phlebotomy practices in critically ill patients with prolonged ICU length of stay: a cohort study. Crit Care. 2006;10(5):R140.
4. Musca S, Desai S, Roberts B, Paterson T, Anstey M. Routine coagulation testing in intensive care. Crit Care Resusc. 2016;18(3):213-7.
5. Martinez-Balzano CD, Oliveira P, O'Rourke M, Hills L, Sosa AF, Critical Care Operations Committee of the UMHC. An Educational Intervention Optimizes the Use of Arterial Blood Gas Determinations Across ICUs From Different Specialties: A Quality-Improvement Study. Chest. 2017;151(3):579-85.
6. Lyon AW, Chin AC, Slotsve GA, Lyon ME. Simulation of repetitive diagnostic blood loss and onset of iatrogenic anemia in critical care patients with a mathematical model. Comput Biol Med. 2013;43(2):84-90.
ePoster
Topic: Improving Patient and Health Systems Quality
Levi, Olga RN MSc1,2; Chan, Maverick1; Bodley, Thomas MD3,4; Smith, Orla RN PhD3,4,5; Sholzberg, Michelle MD MSc4,5,6,7; Swift, Shannon RN MSc2; Yip, Drake3,6, Chaudhry, Hina6, Friedrich, Jan O. MD DPhil3,4,5; Hicks, Lisa K. MD MSc4,5,7
1 Hematology/Oncology Clinical Research Group, St. Michael's Hospital, Toronto, ON
2 Medical Surgical Intensive Care Unit, St. Michael's Hospital, Toronto, ON
3 Interdepartmental Division of Critical Care Medicine, University of Toronto, Toronto, ON
4 Department of Medicine, University of Toronto, Toronto, ON
5 Li Ka Shing Knowledge Institute, St. Michael's Hospital, Toronto, ON
6 Department of Laboratory Medicine, St. Michael's Hospital, Toronto, ON
7 Division of Hematology/Oncology, Department of Medicine, St. Michaels Hospital, Toronto, ON
University of Toronto
Introduction:
Critically ill patients receive a high volume of blood tests due to their need for intensive intervention and monitoring,(1) However, blood loss from phlebotomy is associated with anemia and higher transfusion burden, both of which are associated with increased mortality.(2, 3) some of which is reflexive and unnecessary.(4, 5) Modeling indicates reducing phlebotomy volume may result in clinically meaningful decrease in ICU anemia.(6)
Objectives:
We aimed to reduce the average volume of blood collected per patient-day by 15% by June 30, 2019 (project start February 2020) by developing and implementing a patient-centered, diagnostic phlebotomy strategy in the Medical-Surgical Intensive Care Unit (MSICU) at St. Michael's Hospital.
Methods:
A series of change strategies were implemented in a single 25-bed MSICU in Toronto, Ontario, between February and June 2019. The strategies included: stake-holder engagement, education sessions, work-flow process changes, electronic order set modifications, initiation of add-on testing, and audit and feedback regarding the average volume of blood collected per patient-day. The intervention period was compared to baseline data from July 2018 to January 2019. The main outcome measure was average volume of blood collected per patient-day in the MSICU. Balance measures included average discrete blood draws, ICU length of stay and mortality. The statistical stability of the main outcome measure over time was explored with Sewhart chart (I-chart) analysis. The student's T-Test was also used to compare the mean blood collected and transfusion burden pre-post intervention.
Results:
Figure 1 summarizes the study results. Baseline data from July 2018 to January 2019 revealed a mean of 41.3 mL of blood was collected per patient-day (including waste at bedside during vascular access). The volume of blood collected per patient-day was stable during the baseline observation period. Direct observations and process mapping of the blood ordering processes suggested that repetitive and reflexive blood testing was common in the MSICU. During the intervention period average blood volume collected decreased from 41.3 mL per patient-day to 36.0 mL per patient day. Special cause variation was observed 6 weeks into the intervention (p < 0.01). The average number of discrete blood draws also decreased from 3.2 to 2.8 per patient day. Reduction in phlebotomy volume has been sustained during post-intervention monitoring out to December 2019.
CONLCUSION:
Iterative improvement interventions to reduce unnecessary blood testing in an ICU setting were associated with a significant decrease in average blood volumes collected per patient-day. Further analysis is needed to determine if decreased phlebotomy volume was also associated with decreased transfusion burden and/or reduction in ICU acquired anemia. Frequent consultation of key stakeholders and incorporating audit and feedback post intervention was integral to the project's success.
Image 1
1. Vincent JL, Baron JF, Reinhart K, Gattinoni L, Thijs L, Webb A, et al. Anemia and blood transfusion in critically ill patients. JAMA. 2002;288(12):1499-507.
2. Thavendiranathan P, Bagai A, Ebidia A, Detsky AS, Choudhry NK. Do blood tests cause anemia in hospitalized patients? The effect of diagnostic phlebotomy on hemoglobin and hematocrit levels. J Gen Intern Med. 2005;20(6):520-4.
3. Chant C, Wilson G, Friedrich JO. Anemia, transfusion, and phlebotomy practices in critically ill patients with prolonged ICU length of stay: a cohort study. Crit Care. 2006;10(5):R140.
4. Musca S, Desai S, Roberts B, Paterson T, Anstey M. Routine coagulation testing in intensive care. Crit Care Resusc. 2016;18(3):213-7.
5. Martinez-Balzano CD, Oliveira P, O'Rourke M, Hills L, Sosa AF, Critical Care Operations Committee of the UMHC. An Educational Intervention Optimizes the Use of Arterial Blood Gas Determinations Across ICUs From Different Specialties: A Quality-Improvement Study. Chest. 2017;151(3):579-85.
6. Lyon AW, Chin AC, Slotsve GA, Lyon ME. Simulation of repetitive diagnostic blood loss and onset of iatrogenic anemia in critical care patients with a mathematical model. Comput Biol Med. 2013;43(2):84-90.
Topic: Improving Patient and Health Systems Quality
Levi, Olga RN MSc1,2; Chan, Maverick1; Bodley, Thomas MD3,4; Smith, Orla RN PhD3,4,5; Sholzberg, Michelle MD MSc4,5,6,7; Swift, Shannon RN MSc2; Yip, Drake3,6, Chaudhry, Hina6, Friedrich, Jan O. MD DPhil3,4,5; Hicks, Lisa K. MD MSc4,5,7
1 Hematology/Oncology Clinical Research Group, St. Michael's Hospital, Toronto, ON
2 Medical Surgical Intensive Care Unit, St. Michael's Hospital, Toronto, ON
3 Interdepartmental Division of Critical Care Medicine, University of Toronto, Toronto, ON
4 Department of Medicine, University of Toronto, Toronto, ON
5 Li Ka Shing Knowledge Institute, St. Michael's Hospital, Toronto, ON
6 Department of Laboratory Medicine, St. Michael's Hospital, Toronto, ON
7 Division of Hematology/Oncology, Department of Medicine, St. Michaels Hospital, Toronto, ON
University of Toronto
Introduction:
Critically ill patients receive a high volume of blood tests due to their need for intensive intervention and monitoring,(1) However, blood loss from phlebotomy is associated with anemia and higher transfusion burden, both of which are associated with increased mortality.(2, 3) some of which is reflexive and unnecessary.(4, 5) Modeling indicates reducing phlebotomy volume may result in clinically meaningful decrease in ICU anemia.(6)
Objectives:
We aimed to reduce the average volume of blood collected per patient-day by 15% by June 30, 2019 (project start February 2020) by developing and implementing a patient-centered, diagnostic phlebotomy strategy in the Medical-Surgical Intensive Care Unit (MSICU) at St. Michael's Hospital.
Methods:
A series of change strategies were implemented in a single 25-bed MSICU in Toronto, Ontario, between February and June 2019. The strategies included: stake-holder engagement, education sessions, work-flow process changes, electronic order set modifications, initiation of add-on testing, and audit and feedback regarding the average volume of blood collected per patient-day. The intervention period was compared to baseline data from July 2018 to January 2019. The main outcome measure was average volume of blood collected per patient-day in the MSICU. Balance measures included average discrete blood draws, ICU length of stay and mortality. The statistical stability of the main outcome measure over time was explored with Sewhart chart (I-chart) analysis. The student's T-Test was also used to compare the mean blood collected and transfusion burden pre-post intervention.
Results:
Figure 1 summarizes the study results. Baseline data from July 2018 to January 2019 revealed a mean of 41.3 mL of blood was collected per patient-day (including waste at bedside during vascular access). The volume of blood collected per patient-day was stable during the baseline observation period. Direct observations and process mapping of the blood ordering processes suggested that repetitive and reflexive blood testing was common in the MSICU. During the intervention period average blood volume collected decreased from 41.3 mL per patient-day to 36.0 mL per patient day. Special cause variation was observed 6 weeks into the intervention (p < 0.01). The average number of discrete blood draws also decreased from 3.2 to 2.8 per patient day. Reduction in phlebotomy volume has been sustained during post-intervention monitoring out to December 2019.
CONLCUSION:
Iterative improvement interventions to reduce unnecessary blood testing in an ICU setting were associated with a significant decrease in average blood volumes collected per patient-day. Further analysis is needed to determine if decreased phlebotomy volume was also associated with decreased transfusion burden and/or reduction in ICU acquired anemia. Frequent consultation of key stakeholders and incorporating audit and feedback post intervention was integral to the project's success.
Image 1
1. Vincent JL, Baron JF, Reinhart K, Gattinoni L, Thijs L, Webb A, et al. Anemia and blood transfusion in critically ill patients. JAMA. 2002;288(12):1499-507.
2. Thavendiranathan P, Bagai A, Ebidia A, Detsky AS, Choudhry NK. Do blood tests cause anemia in hospitalized patients? The effect of diagnostic phlebotomy on hemoglobin and hematocrit levels. J Gen Intern Med. 2005;20(6):520-4.
3. Chant C, Wilson G, Friedrich JO. Anemia, transfusion, and phlebotomy practices in critically ill patients with prolonged ICU length of stay: a cohort study. Crit Care. 2006;10(5):R140.
4. Musca S, Desai S, Roberts B, Paterson T, Anstey M. Routine coagulation testing in intensive care. Crit Care Resusc. 2016;18(3):213-7.
5. Martinez-Balzano CD, Oliveira P, O'Rourke M, Hills L, Sosa AF, Critical Care Operations Committee of the UMHC. An Educational Intervention Optimizes the Use of Arterial Blood Gas Determinations Across ICUs From Different Specialties: A Quality-Improvement Study. Chest. 2017;151(3):579-85.
6. Lyon AW, Chin AC, Slotsve GA, Lyon ME. Simulation of repetitive diagnostic blood loss and onset of iatrogenic anemia in critical care patients with a mathematical model. Comput Biol Med. 2013;43(2):84-90.
Reducing Repetitive and Reflexive Diagnostic Phlebotomy in an Intensive Care Unit: A Quality Improvement Project
Dr. Thomas Bodley
Affiliations:
University of Toronto
University of Toronto
Abstract
Discussion Forum (0)
ePoster
Topic: Improving Patient and Health Systems Quality
Levi, Olga RN MSc1,2; Chan, Maverick1; Bodley, Thomas MD3,4; Smith, Orla RN PhD3,4,5; Sholzberg, Michelle MD MSc4,5,6,7; Swift, Shannon RN MSc2; Yip, Drake3,6, Chaudhry, Hina6, Friedrich, Jan O. MD DPhil3,4,5; Hicks, Lisa K. MD MSc4,5,7
1 Hematology/Oncology Clinical Research Group, St. Michael's Hospital, Toronto, ON
2 Medical Surgical Intensive Care Unit, St. Michael's Hospital, Toronto, ON
3 Interdepartmental Division of Critical Care Medicine, University of Toronto, Toronto, ON
4 Department of Medicine, University of Toronto, Toronto, ON
5 Li Ka Shing Knowledge Institute, St. Michael's Hospital, Toronto, ON
6 Department of Laboratory Medicine, St. Michael's Hospital, Toronto, ON
7 Division of Hematology/Oncology, Department of Medicine, St. Michaels Hospital, Toronto, ON
University of Toronto
Introduction:
Critically ill patients receive a high volume of blood tests due to their need for intensive intervention and monitoring,(1) However, blood loss from phlebotomy is associated with anemia and higher transfusion burden, both of which are associated with increased mortality.(2, 3) some of which is reflexive and unnecessary.(4, 5) Modeling indicates reducing phlebotomy volume may result in clinically meaningful decrease in ICU anemia.(6)
Objectives:
We aimed to reduce the average volume of blood collected per patient-day by 15% by June 30, 2019 (project start February 2020) by developing and implementing a patient-centered, diagnostic phlebotomy strategy in the Medical-Surgical Intensive Care Unit (MSICU) at St. Michael's Hospital.
Methods:
A series of change strategies were implemented in a single 25-bed MSICU in Toronto, Ontario, between February and June 2019. The strategies included: stake-holder engagement, education sessions, work-flow process changes, electronic order set modifications, initiation of add-on testing, and audit and feedback regarding the average volume of blood collected per patient-day. The intervention period was compared to baseline data from July 2018 to January 2019. The main outcome measure was average volume of blood collected per patient-day in the MSICU. Balance measures included average discrete blood draws, ICU length of stay and mortality. The statistical stability of the main outcome measure over time was explored with Sewhart chart (I-chart) analysis. The student's T-Test was also used to compare the mean blood collected and transfusion burden pre-post intervention.
Results:
Figure 1 summarizes the study results. Baseline data from July 2018 to January 2019 revealed a mean of 41.3 mL of blood was collected per patient-day (including waste at bedside during vascular access). The volume of blood collected per patient-day was stable during the baseline observation period. Direct observations and process mapping of the blood ordering processes suggested that repetitive and reflexive blood testing was common in the MSICU. During the intervention period average blood volume collected decreased from 41.3 mL per patient-day to 36.0 mL per patient day. Special cause variation was observed 6 weeks into the intervention (p < 0.01). The average number of discrete blood draws also decreased from 3.2 to 2.8 per patient day. Reduction in phlebotomy volume has been sustained during post-intervention monitoring out to December 2019.
CONLCUSION:
Iterative improvement interventions to reduce unnecessary blood testing in an ICU setting were associated with a significant decrease in average blood volumes collected per patient-day. Further analysis is needed to determine if decreased phlebotomy volume was also associated with decreased transfusion burden and/or reduction in ICU acquired anemia. Frequent consultation of key stakeholders and incorporating audit and feedback post intervention was integral to the project's success.
Image 1
1. Vincent JL, Baron JF, Reinhart K, Gattinoni L, Thijs L, Webb A, et al. Anemia and blood transfusion in critically ill patients. JAMA. 2002;288(12):1499-507.
2. Thavendiranathan P, Bagai A, Ebidia A, Detsky AS, Choudhry NK. Do blood tests cause anemia in hospitalized patients? The effect of diagnostic phlebotomy on hemoglobin and hematocrit levels. J Gen Intern Med. 2005;20(6):520-4.
3. Chant C, Wilson G, Friedrich JO. Anemia, transfusion, and phlebotomy practices in critically ill patients with prolonged ICU length of stay: a cohort study. Crit Care. 2006;10(5):R140.
4. Musca S, Desai S, Roberts B, Paterson T, Anstey M. Routine coagulation testing in intensive care. Crit Care Resusc. 2016;18(3):213-7.
5. Martinez-Balzano CD, Oliveira P, O'Rourke M, Hills L, Sosa AF, Critical Care Operations Committee of the UMHC. An Educational Intervention Optimizes the Use of Arterial Blood Gas Determinations Across ICUs From Different Specialties: A Quality-Improvement Study. Chest. 2017;151(3):579-85.
6. Lyon AW, Chin AC, Slotsve GA, Lyon ME. Simulation of repetitive diagnostic blood loss and onset of iatrogenic anemia in critical care patients with a mathematical model. Comput Biol Med. 2013;43(2):84-90.
Topic: Improving Patient and Health Systems Quality
Levi, Olga RN MSc1,2; Chan, Maverick1; Bodley, Thomas MD3,4; Smith, Orla RN PhD3,4,5; Sholzberg, Michelle MD MSc4,5,6,7; Swift, Shannon RN MSc2; Yip, Drake3,6, Chaudhry, Hina6, Friedrich, Jan O. MD DPhil3,4,5; Hicks, Lisa K. MD MSc4,5,7
1 Hematology/Oncology Clinical Research Group, St. Michael's Hospital, Toronto, ON
2 Medical Surgical Intensive Care Unit, St. Michael's Hospital, Toronto, ON
3 Interdepartmental Division of Critical Care Medicine, University of Toronto, Toronto, ON
4 Department of Medicine, University of Toronto, Toronto, ON
5 Li Ka Shing Knowledge Institute, St. Michael's Hospital, Toronto, ON
6 Department of Laboratory Medicine, St. Michael's Hospital, Toronto, ON
7 Division of Hematology/Oncology, Department of Medicine, St. Michaels Hospital, Toronto, ON
University of Toronto
Introduction:
Critically ill patients receive a high volume of blood tests due to their need for intensive intervention and monitoring,(1) However, blood loss from phlebotomy is associated with anemia and higher transfusion burden, both of which are associated with increased mortality.(2, 3) some of which is reflexive and unnecessary.(4, 5) Modeling indicates reducing phlebotomy volume may result in clinically meaningful decrease in ICU anemia.(6)
Objectives:
We aimed to reduce the average volume of blood collected per patient-day by 15% by June 30, 2019 (project start February 2020) by developing and implementing a patient-centered, diagnostic phlebotomy strategy in the Medical-Surgical Intensive Care Unit (MSICU) at St. Michael's Hospital.
Methods:
A series of change strategies were implemented in a single 25-bed MSICU in Toronto, Ontario, between February and June 2019. The strategies included: stake-holder engagement, education sessions, work-flow process changes, electronic order set modifications, initiation of add-on testing, and audit and feedback regarding the average volume of blood collected per patient-day. The intervention period was compared to baseline data from July 2018 to January 2019. The main outcome measure was average volume of blood collected per patient-day in the MSICU. Balance measures included average discrete blood draws, ICU length of stay and mortality. The statistical stability of the main outcome measure over time was explored with Sewhart chart (I-chart) analysis. The student's T-Test was also used to compare the mean blood collected and transfusion burden pre-post intervention.
Results:
Figure 1 summarizes the study results. Baseline data from July 2018 to January 2019 revealed a mean of 41.3 mL of blood was collected per patient-day (including waste at bedside during vascular access). The volume of blood collected per patient-day was stable during the baseline observation period. Direct observations and process mapping of the blood ordering processes suggested that repetitive and reflexive blood testing was common in the MSICU. During the intervention period average blood volume collected decreased from 41.3 mL per patient-day to 36.0 mL per patient day. Special cause variation was observed 6 weeks into the intervention (p < 0.01). The average number of discrete blood draws also decreased from 3.2 to 2.8 per patient day. Reduction in phlebotomy volume has been sustained during post-intervention monitoring out to December 2019.
CONLCUSION:
Iterative improvement interventions to reduce unnecessary blood testing in an ICU setting were associated with a significant decrease in average blood volumes collected per patient-day. Further analysis is needed to determine if decreased phlebotomy volume was also associated with decreased transfusion burden and/or reduction in ICU acquired anemia. Frequent consultation of key stakeholders and incorporating audit and feedback post intervention was integral to the project's success.
Image 1
1. Vincent JL, Baron JF, Reinhart K, Gattinoni L, Thijs L, Webb A, et al. Anemia and blood transfusion in critically ill patients. JAMA. 2002;288(12):1499-507.
2. Thavendiranathan P, Bagai A, Ebidia A, Detsky AS, Choudhry NK. Do blood tests cause anemia in hospitalized patients? The effect of diagnostic phlebotomy on hemoglobin and hematocrit levels. J Gen Intern Med. 2005;20(6):520-4.
3. Chant C, Wilson G, Friedrich JO. Anemia, transfusion, and phlebotomy practices in critically ill patients with prolonged ICU length of stay: a cohort study. Crit Care. 2006;10(5):R140.
4. Musca S, Desai S, Roberts B, Paterson T, Anstey M. Routine coagulation testing in intensive care. Crit Care Resusc. 2016;18(3):213-7.
5. Martinez-Balzano CD, Oliveira P, O'Rourke M, Hills L, Sosa AF, Critical Care Operations Committee of the UMHC. An Educational Intervention Optimizes the Use of Arterial Blood Gas Determinations Across ICUs From Different Specialties: A Quality-Improvement Study. Chest. 2017;151(3):579-85.
6. Lyon AW, Chin AC, Slotsve GA, Lyon ME. Simulation of repetitive diagnostic blood loss and onset of iatrogenic anemia in critical care patients with a mathematical model. Comput Biol Med. 2013;43(2):84-90.
ePoster
Topic: Improving Patient and Health Systems Quality
Levi, Olga RN MSc1,2; Chan, Maverick1; Bodley, Thomas MD3,4; Smith, Orla RN PhD3,4,5; Sholzberg, Michelle MD MSc4,5,6,7; Swift, Shannon RN MSc2; Yip, Drake3,6, Chaudhry, Hina6, Friedrich, Jan O. MD DPhil3,4,5; Hicks, Lisa K. MD MSc4,5,7
1 Hematology/Oncology Clinical Research Group, St. Michael's Hospital, Toronto, ON
2 Medical Surgical Intensive Care Unit, St. Michael's Hospital, Toronto, ON
3 Interdepartmental Division of Critical Care Medicine, University of Toronto, Toronto, ON
4 Department of Medicine, University of Toronto, Toronto, ON
5 Li Ka Shing Knowledge Institute, St. Michael's Hospital, Toronto, ON
6 Department of Laboratory Medicine, St. Michael's Hospital, Toronto, ON
7 Division of Hematology/Oncology, Department of Medicine, St. Michaels Hospital, Toronto, ON
University of Toronto
Introduction:
Critically ill patients receive a high volume of blood tests due to their need for intensive intervention and monitoring,(1) However, blood loss from phlebotomy is associated with anemia and higher transfusion burden, both of which are associated with increased mortality.(2, 3) some of which is reflexive and unnecessary.(4, 5) Modeling indicates reducing phlebotomy volume may result in clinically meaningful decrease in ICU anemia.(6)
Objectives:
We aimed to reduce the average volume of blood collected per patient-day by 15% by June 30, 2019 (project start February 2020) by developing and implementing a patient-centered, diagnostic phlebotomy strategy in the Medical-Surgical Intensive Care Unit (MSICU) at St. Michael's Hospital.
Methods:
A series of change strategies were implemented in a single 25-bed MSICU in Toronto, Ontario, between February and June 2019. The strategies included: stake-holder engagement, education sessions, work-flow process changes, electronic order set modifications, initiation of add-on testing, and audit and feedback regarding the average volume of blood collected per patient-day. The intervention period was compared to baseline data from July 2018 to January 2019. The main outcome measure was average volume of blood collected per patient-day in the MSICU. Balance measures included average discrete blood draws, ICU length of stay and mortality. The statistical stability of the main outcome measure over time was explored with Sewhart chart (I-chart) analysis. The student's T-Test was also used to compare the mean blood collected and transfusion burden pre-post intervention.
Results:
Figure 1 summarizes the study results. Baseline data from July 2018 to January 2019 revealed a mean of 41.3 mL of blood was collected per patient-day (including waste at bedside during vascular access). The volume of blood collected per patient-day was stable during the baseline observation period. Direct observations and process mapping of the blood ordering processes suggested that repetitive and reflexive blood testing was common in the MSICU. During the intervention period average blood volume collected decreased from 41.3 mL per patient-day to 36.0 mL per patient day. Special cause variation was observed 6 weeks into the intervention (p < 0.01). The average number of discrete blood draws also decreased from 3.2 to 2.8 per patient day. Reduction in phlebotomy volume has been sustained during post-intervention monitoring out to December 2019.
CONLCUSION:
Iterative improvement interventions to reduce unnecessary blood testing in an ICU setting were associated with a significant decrease in average blood volumes collected per patient-day. Further analysis is needed to determine if decreased phlebotomy volume was also associated with decreased transfusion burden and/or reduction in ICU acquired anemia. Frequent consultation of key stakeholders and incorporating audit and feedback post intervention was integral to the project's success.
Image 1
1. Vincent JL, Baron JF, Reinhart K, Gattinoni L, Thijs L, Webb A, et al. Anemia and blood transfusion in critically ill patients. JAMA. 2002;288(12):1499-507.
2. Thavendiranathan P, Bagai A, Ebidia A, Detsky AS, Choudhry NK. Do blood tests cause anemia in hospitalized patients? The effect of diagnostic phlebotomy on hemoglobin and hematocrit levels. J Gen Intern Med. 2005;20(6):520-4.
3. Chant C, Wilson G, Friedrich JO. Anemia, transfusion, and phlebotomy practices in critically ill patients with prolonged ICU length of stay: a cohort study. Crit Care. 2006;10(5):R140.
4. Musca S, Desai S, Roberts B, Paterson T, Anstey M. Routine coagulation testing in intensive care. Crit Care Resusc. 2016;18(3):213-7.
5. Martinez-Balzano CD, Oliveira P, O'Rourke M, Hills L, Sosa AF, Critical Care Operations Committee of the UMHC. An Educational Intervention Optimizes the Use of Arterial Blood Gas Determinations Across ICUs From Different Specialties: A Quality-Improvement Study. Chest. 2017;151(3):579-85.
6. Lyon AW, Chin AC, Slotsve GA, Lyon ME. Simulation of repetitive diagnostic blood loss and onset of iatrogenic anemia in critical care patients with a mathematical model. Comput Biol Med. 2013;43(2):84-90.
Topic: Improving Patient and Health Systems Quality
Levi, Olga RN MSc1,2; Chan, Maverick1; Bodley, Thomas MD3,4; Smith, Orla RN PhD3,4,5; Sholzberg, Michelle MD MSc4,5,6,7; Swift, Shannon RN MSc2; Yip, Drake3,6, Chaudhry, Hina6, Friedrich, Jan O. MD DPhil3,4,5; Hicks, Lisa K. MD MSc4,5,7
1 Hematology/Oncology Clinical Research Group, St. Michael's Hospital, Toronto, ON
2 Medical Surgical Intensive Care Unit, St. Michael's Hospital, Toronto, ON
3 Interdepartmental Division of Critical Care Medicine, University of Toronto, Toronto, ON
4 Department of Medicine, University of Toronto, Toronto, ON
5 Li Ka Shing Knowledge Institute, St. Michael's Hospital, Toronto, ON
6 Department of Laboratory Medicine, St. Michael's Hospital, Toronto, ON
7 Division of Hematology/Oncology, Department of Medicine, St. Michaels Hospital, Toronto, ON
University of Toronto
Introduction:
Critically ill patients receive a high volume of blood tests due to their need for intensive intervention and monitoring,(1) However, blood loss from phlebotomy is associated with anemia and higher transfusion burden, both of which are associated with increased mortality.(2, 3) some of which is reflexive and unnecessary.(4, 5) Modeling indicates reducing phlebotomy volume may result in clinically meaningful decrease in ICU anemia.(6)
Objectives:
We aimed to reduce the average volume of blood collected per patient-day by 15% by June 30, 2019 (project start February 2020) by developing and implementing a patient-centered, diagnostic phlebotomy strategy in the Medical-Surgical Intensive Care Unit (MSICU) at St. Michael's Hospital.
Methods:
A series of change strategies were implemented in a single 25-bed MSICU in Toronto, Ontario, between February and June 2019. The strategies included: stake-holder engagement, education sessions, work-flow process changes, electronic order set modifications, initiation of add-on testing, and audit and feedback regarding the average volume of blood collected per patient-day. The intervention period was compared to baseline data from July 2018 to January 2019. The main outcome measure was average volume of blood collected per patient-day in the MSICU. Balance measures included average discrete blood draws, ICU length of stay and mortality. The statistical stability of the main outcome measure over time was explored with Sewhart chart (I-chart) analysis. The student's T-Test was also used to compare the mean blood collected and transfusion burden pre-post intervention.
Results:
Figure 1 summarizes the study results. Baseline data from July 2018 to January 2019 revealed a mean of 41.3 mL of blood was collected per patient-day (including waste at bedside during vascular access). The volume of blood collected per patient-day was stable during the baseline observation period. Direct observations and process mapping of the blood ordering processes suggested that repetitive and reflexive blood testing was common in the MSICU. During the intervention period average blood volume collected decreased from 41.3 mL per patient-day to 36.0 mL per patient day. Special cause variation was observed 6 weeks into the intervention (p < 0.01). The average number of discrete blood draws also decreased from 3.2 to 2.8 per patient day. Reduction in phlebotomy volume has been sustained during post-intervention monitoring out to December 2019.
CONLCUSION:
Iterative improvement interventions to reduce unnecessary blood testing in an ICU setting were associated with a significant decrease in average blood volumes collected per patient-day. Further analysis is needed to determine if decreased phlebotomy volume was also associated with decreased transfusion burden and/or reduction in ICU acquired anemia. Frequent consultation of key stakeholders and incorporating audit and feedback post intervention was integral to the project's success.
Image 1
1. Vincent JL, Baron JF, Reinhart K, Gattinoni L, Thijs L, Webb A, et al. Anemia and blood transfusion in critically ill patients. JAMA. 2002;288(12):1499-507.
2. Thavendiranathan P, Bagai A, Ebidia A, Detsky AS, Choudhry NK. Do blood tests cause anemia in hospitalized patients? The effect of diagnostic phlebotomy on hemoglobin and hematocrit levels. J Gen Intern Med. 2005;20(6):520-4.
3. Chant C, Wilson G, Friedrich JO. Anemia, transfusion, and phlebotomy practices in critically ill patients with prolonged ICU length of stay: a cohort study. Crit Care. 2006;10(5):R140.
4. Musca S, Desai S, Roberts B, Paterson T, Anstey M. Routine coagulation testing in intensive care. Crit Care Resusc. 2016;18(3):213-7.
5. Martinez-Balzano CD, Oliveira P, O'Rourke M, Hills L, Sosa AF, Critical Care Operations Committee of the UMHC. An Educational Intervention Optimizes the Use of Arterial Blood Gas Determinations Across ICUs From Different Specialties: A Quality-Improvement Study. Chest. 2017;151(3):579-85.
6. Lyon AW, Chin AC, Slotsve GA, Lyon ME. Simulation of repetitive diagnostic blood loss and onset of iatrogenic anemia in critical care patients with a mathematical model. Comput Biol Med. 2013;43(2):84-90.
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