Eliminate Unnecessary Laboratory Work to Mitigate Iatrogenic Anemia and Reduce Cost for Patients on Extracorporeal Membrane Oxygenation.

Laboratory testing is a helpful tool for clinicians, but can be costly and harmful to patients. A quality improvement project was initiated to reduce laboratory testing for patients receiving extracorporeal membrane oxygenation (ECMO) in a pediatric intensive care unit (PICU) at a tertiary care center. Preliminary data was gathered to demonstrate preimplementation practice, cost, and patient need for packed red blood cell (pRBC) transfusions. A new protocol was created by an interprofessional team based on best practice and benchmarking with high-performing organizations. The project was evaluated using two comparison groups, pre- and postimplementation for anyone receiving ECMO therapy in the PICU. The average laboratory tests per ECMO day decreased by 52% (128.4 vs. 61.1), cost per case decreased by 14.7%, pRBC transfusions decreased from 100% to 85%, length of stay (LOS) decreased by 8 days, and mortality rates decreased by 9.5%. The revised pediatric ECMO laboratory testing guidelines were successfully implemented and reduced laboratory cost without adverse effects on mortality rates or LOS.

Preparing prelicensure and graduate nursing students to systematically communicate bad news to patients and families.

Communicating bad news, otherwise known as difficult conversations, is a complex communication skill that requires didactic learning and practical application. Students learn that what may be interpreted as bad news is determined by the recipient and not by the person who is delivering the news. Learning a systematic approach, such as the SPIKES (Setting, Perception, Invitation, Knowledge, Empathy, Strategy/Summary) mnemonic, prepares prelicensure and graduate nursing students for difficult conversations with patients and families in the clinical setting. Role-playing commonly includes clinical scenarios, and using video recording and playback of the encounters in such scenarios is one method of learning the systematic approach to communicating bad news. Follow-up practice after application in the clinical setting and feedback from faculty and mentors are essential for nursing students to achieve competence in this complex set of communication skills.