In Part 2 of the series on data-driven solutions to common preanalytical issues, Dr. Block describes the process used at Mayo Clinic to reduce the specimen redraw rate in the emergency department (ED). By gathering data in a systematic way, involving all stakeholders, and using open communication, the redraw rate in the ED was greatly reduced.
Presenter and Credentials:
Darci Block, Ph.D., Director Laboratory Services and Co-Director Central Clinical Laboratory in the Department of Laboratory Medicine and Pathology at Mayo Clinic in Rochester, Minnesota
Our speaker for this program is Darci R. Block, PhD, Director Laboratory Services and Co-Director Central Clinical Laboratory in the Department of Laboratory Medicine and Pathology at Mayo Clinic in Rochester, MinnesotaWelcome to Mayo Medical Laboratories Hot Topics. These presentations provide short discussion of current topics and may be helpful to you in your practice. Today our topic is data-driven solutions to the redraw rate and turnaround time in the emergency department.
Dr. Block, thank you for presenting today.
I have no disclosures.
During part 2 of this series we will discuss the data needed to gather for a process improvement project. The case I will share is probably one you can relate to which will focus on dissatisfaction with redraws in the emergency department.
This diagram is meant to show all the possible sources of data that may have value for various process improvement projects. Not every piece of data will be needed for every project.
Through process improvements within the ED, they discovered that the turnaround time for redraws was negatively impacting the length of stay and at the same time we wondered if the frequency was also a contributor.
The data we aimed to gather to address this concern included the redraw turnaround times as well as the redraw rate itself. Luckily, these were relatively easy things to gather from the lab information system. In the ED, nurses and phlebotomists start IVs, phlebotomists collect the blood. One major practice that we identified of potential concern was collecting blood from IV starts. Ultimately, the goals were to reduce redraws as we were able and the turnaround time for results to support the need to move patients efficiently through the ED. We hoped to maintain or improve the relationship between nursing and phlebotomy in any event.
First we studied the turnaround time and found that from the time of the original collection to the final result from the redraw collection; only 10% were completed with 60 minutes. This suggested that the primary concern about delays with redraws was real and there was room for improvement.
Using the 5-why method for conducting root cause analysis, we asked the first question:“why are ED redraws taking significantly longer than 60 minutes?” and the answer was that all redraws were routed through the same mechanism and there was nothing differentiating a STAT redraw from all other redraws. Next we asked ourselves “why are all redraws handled the same way?” and the answer pointed towards limitation of our previous lab information system.. ü So our hypothesis was that there must be a more efficient way to handle priority redraws from the Emergency Department within the confines of a new LIS. The next steps were to work on improving the turnaround time and determine the redraw rate.
The new improved process was implemented whereby the redraw that was initiated by the lab would print to different locations based on where the order originated. For the ED, it printed to a control desk where ED staff who was accustomed to scheduling patient services within the ED were able to prioritize and dispatch the phlebotomist to collect redraws in a timely manner. ü And the result was a dramatic improvement in redraw turnaround times. Though the improvements were appreciated, ideally they wanted a majority completed within 20 to 30 minutes, which we have difficulty meeting. So the next step was to evaluate the redraw rate itself.
Up to this point, we hadn’t evaluated the ED separate from the rest of the hospital, again limitation of the previous LIS. So now that we were able to distinguish them, it revealed a redraw rate approximately 4-fold higher than the rest of the hospital over a 10 month period. ü The fortunate part of the story was that 4% was much lower than reported ED redraw rates of 6 to 19%.
Using the 5-why method we ask ourselves “why are ED redraws more prevalent?” and we soon honed in on the IV start blood collections. ü “why is blood collected from IV starts?” ü and the answers included saving the patient a poke when both labs and IV placement are needed and that the practice is more prevalent in the ED than the rest of the hospital. There are publications that suggest separate venipunctures should be used for the 2 services as a best practice, particularly in the ED so we suggested stopping blood collections from IV starts. ü The obvious benefit being a significant decrease in the redraw rate due to hemolysis, while the resistance included how common this practice is and we can’t simply discontinue it.
So as we work to improve the redraw rate, we wondered what the goal should be. As luck would have it, there was a published benchmark to refer to. My team may have thought I was a little crazy, but I thought it was quite reasonable as it was double the goal for the rest of the hospital. We had our work cut out for us, either way.
I shared with our multidisciplinary team the published data that demonstrated the risk of hemolysis comparing IV starts to straight needle collections, and there was still some resistance. ü The pros to stopping included reducing the redraw rate and lengths of stay in the ED, while the cons included potential patient dissatisfaction from 2 venipunctures and the possibility of delay when both were requested on the same patient.
The ED physician leadership and phlebotomy were convinced it was worth discontinuing IV start blood collections; however the nurses (with good reason) were hesitant. ü Together we compromised and decided to research and educate both nurses and phlebotomists to the “best practice” for performing IV start blood collections and collected data during a one-month time period. This table summarizes the evidence that went into that training. We instructed staff to use the antecube over distal sites, at least a 21-gauge needle, and collect directly into an evacuated tube (which was consistent with previous internal work we had done). We also reinforced our current policy to waste 2 mL into an evacuated tube prior to blood collection as it is consistent with evidence that tubes collected by IV start have less hemolysis in the 2nd, 3rd, and 4th tubes compared to the first.
During this time period, the redraw rate was 3.4%,ü however for just the IV starts it was higher at 4.5%. ü Since it was performed using the “best practice” we concluded that the only way to further reduce the redraw rate was to decrease the number of IV starts (which were 7.6% of total collections for the time period).
This led to a final initiative where we compromised between stopping the practice all together and allowing it in limited circumstances where it seemed to make sense. For a one-month period we collected similar data but now when IV start blood was collected, we wanted them to indicate the reason. A majority were deemed “difficult collections” with young age and trauma being the other acceptable reasons. We didn’t foresee blood cultures initially, but soon realized that there wasn’t harm in hemolyzed blood cultures. ü Ultimately we decreased the number of IV start blood collections by 2.3% with 3.8% resulting in redraw.
And what we saw for the first time was the redraw rate dip below the target for probably the first time ever. It is interesting to note that the redraw rate was less than 2% for the months preceding QI#2, we presume because of our ongoing discussions and planning leading up to implementation. The subsequent months hovered right around the target of 2% and everyone was quite proud of this accomplishment.
Obviously, the idea to discontinue IV blood starts in order to decrease the hemolysis rate is not novel, however successfully doing so turns out to be quite a feat. So why did it work? ü In this case, the data demonstrating an improvement in hemolysis or redraw rates was not sufficient to convince the nursing staff that the benefits outweighed the risks. ü However, the ED leadership team we assembled did support the practice change due partly to the fact that we couldn’t perform redraws any faster. ü By engaging the ED staff, particularly the nurses, in the process going through the efforts to educate and collect ü data we ultimately showed that in order to achieve our goals a practice change was needed.
In conclusion, it is recommended that meaningful data from multiple sources be gathered to address the issue at hand. It’s helpful to consult what has already been published on this topic. It doesn’t make sense to reinvent the wheel when we can learn from our peers. Guidelines are nice; CLSI is my go-to for most things because they provide tried and true recommendations that are very pertinent to laboratory medicine. Baseline error rates are also so important to gather because it may actually reveal the complaint you are trying to fix isn’t really as big of problem after all. And having that baseline knowledge helps to gauge whether an intervention was effective or not. Finally, flow diagrams are so helpful for seeing a bigger picture and figuring out whom all is impacted. It is important to recognize that what may seem like a small change to one may have large downstream consequences. This provides an example of engaging the stakeholders in a process change and using data to make decisions that probably would not have been made de novo.
If this topic was of interest to you please join us for the Phlebotomy Conference here in Rochester, Minnesota, April 23rd to the 24th, 2015