Reducing Phlebotomy Utilization With Education and Changes to Computerized Provider Order Entry.

INTRODUCTION: Daily phlebotomy is often a standard procedure in hospitalized patients. Recently, this practice has begun receiving attention as a potential target for efforts focused on eliminating overuse. Several organizations have published their efforts in this arena. Interventions have included education, feedback, and changes to computerized provider order entry (CPOE) but have yielded mixed results. METHODS: A quality improvement initiative to reduce the utilization of daily phlebotomy was conducted at a 505-bed Academic Medical Center. This project involved a combination of educational interventions and changes to CPOE. The primary end point evaluated was the daily performance of complete blood counts (CBCs) and basic metabolic profiles (BMPs) on medical and surgery units relative to the corresponding hospital census. RESULTS: Over the course of this project from August 1, 2013, to September 23, 2016, there was a 15.2% reduction in CBCs (p < .001 for linear trend) and 13.1% reduction in BMPs. DISCUSSION: Our results suggest that layering multimodal interventions that involve both "hard-wired" changes to CPOE and education and performance feedback can result in decreased utilization of phlebotomy.

Cytoreductive treatment patterns among US veterans with polycythemia vera.

BACKGROUND: Polycythemia vera (PV) is a myeloproliferative neoplasm associated with increased thrombotic and cardiovascular risk, which are key contributors to patient morbidity and mortality. The Veterans Health Administration (VHA) is the largest integrative health network in the United States. Available data concerning patients with PV in this population are limited. METHODS: This retrospective observational study evaluated the characteristics, management, and outcomes of patients with PV in the VHA Medical SAS® Dataset (October 1, 2005, to September 30, 2012). Inclusion criteria were ≥ 2 claims for PV (ie, PV diagnostic code was recorded) ≥30 days apart during the identification period, age ≥ 18 years, and continuous health plan enrollment from ≥12 months before the index date until the end of follow-up. All data were analyzed using descriptive statistics. RESULTS: The analysis included 7718 patients (median age, 64 years; male, 98%; white, 64%). The most common comorbidities before the index date were hypertension (72%), dyslipidemia (54%), and diabetes (24%); 33% had a history of smoking. During the follow-up period (median, 4.8 years), most patients did not receive treatment with cytoreductive therapy, including phlebotomy (53%), or antiplatelet agents, such as aspirin (57%). The thrombotic and cardiovascular event rates per 1000 patient-years were 60.5 and 83.8, respectively. Among patients who received cytoreductive treatment, the thrombotic event rate was 48.9 per 1000 patient-years. The overall mortality rate was 51.2 per 1000 patient-years. CONCLUSION: The notable rates of thrombotic and cardiovascular events observed in this analysis, even among patients receiving cytoreductive treatment, highlight the important unmet clinical needs of patients with PV in the VHA.

Impact of an educational intervention on the frequency of daily blood test orders for hospitalized patients.

OBJECTIVES: During hospitalizations, blood is drawn for diagnostic laboratory tests to help guide patient care. Often, blood tests continue to be ordered even in the face of clinical and laboratory stability. Blood draws are painful and costly, and they may be associated with anemia. We hypothesized that provider education could reduce the frequency of daily blood tests ordered for hospitalized patients. METHODS: During a 2-month intervention period, internal medicine providers were educated through flyers displayed in providers' offices and periodic email communications reminding them to order daily blood tests only if the results would change patient care. Two-month preintervention data from 982 patients and 2-month postintervention data from 988 patients were analyzed. The primary outcome measured was the number of daily blood tests ordered per patient per day. RESULTS: Mean orders of CBC decreased from 1.46 to 1.37 tests per patient per day (P < .05) after the intervention. Basic metabolic panel orders were reduced from 0.91 to 0.83 tests per patient per day (P < .05). Cost analyses showed a reduction of $6.33 per patient day based on the decrease in the number of daily laboratory tests ordered. CONCLUSIONS: Provider education and reminders can reduce the frequency of daily blood tests ordered by providers for hospitalized patients. This can decrease health care costs and may reduce the risk of complications such as anemia.

An innovative approach to near-infrared spectroscopy using a standard mobile device and its clinical application in the real-time visualization of peripheral veins.

BACKGROUND: Excessive venipunctures are a significant problem both in emergency rooms and during hospital stays. Near-infrared (NIR) illumination devices improve venipuncture success rate but their usage is limited by their availability and economic cost. The objectives of this study were to develop a low-cost NIR spectroscopy prototype from a standard mobile device, to evaluate its efficacy and acceptance as an educational tool, and in a clinical setting. METHODS: Through a user-centric design process a prototype device was developed. Its educational efficacy was evaluated through a non-invasive, observational study (20 student clinicians, 25 subjects) and its acceptance was assessed using quantitative and qualitative analysis. A smaller clinical trial was performed by a group of 4 medical professionals over a period of 6 weeks that involved 64 patients. RESULTS: The prototype enables real-time visualization of peripheral veins on a variety of Android-based devices. The prototype was 35.2% more successful in visualizing and locating veins (n = 500 attempts) than the nursing students. The acceptance assessment revealed high perception of usefulness, satisfaction, and ease of use. In the clinical trial, 1.6 (SD 1.3) additional veins per patient were identified compared with the traditional visualization methods. CONCLUSIONS: To the best of our knowledge this is the first study that describes the design, feasibility and application of an NIR spectroscopy prototype developed on a standard mobile device.

Office-based procedures among urban and rural family physicians in Ontario.

OBJECTIVE: To compare FP and GP performance of office-based procedures between urban and rural practices. DESIGN: Descriptive cohort study using health administrative data. SETTING: Ontario. PARTICIPANTS: All FPs and GPs who billed the Ontario Health Insurance Plan for at least 1 office-based procedure between January 1 and December 31, 2006 (N = 8648). MAIN OUTCOME MEASURES: Ontario Health Insurance Plan billings for office-based procedures were adjusted by full-time equivalent (FTE) so that the means are for 1 FTE. Office-based procedures were grouped into 1) surgical procedures, 2) injections and immunizations, 3) electrocardiograms (ECGs), and 4) venipunctures and laboratory tests. The analyses were stratified for FP and GP age, sex, rurality of practice, and participation in a primary care model. RESULTS: There were no substantial differences between FPs and GPs in rural practices compared with those in more urban practices with respect to surgical procedures. Rural FPs and GPs had lower mean numbers of injections and immunizations, ECGs, and venipunctures and laboratory tests than FPs and GPs practising in urban areas. Family physicians and GPs in primary care models had a lower mean number of surgical procedures but a higher adjusted mean number of injections and immunizations, ECGs, and venipunctures and laboratory tests. CONCLUSION: For those procedures that are not dependent on specialist backup or access to more advanced technology, there were no substantial differences between rural and urban FPs and GPs. All comprehensive FPs and GPs should be able to provide these services to their patients. Training programs for all family medicine residents should ensure future FPs and GPs are able to perform these procedures.

Blood, sweat, and tears: embedding biological samples in social science research on children.

In the first decade of the 21st Century, calls for interdisciplinary research are commonplace. Yet, relatively few papers discuss how to complete such research successfully. In this paper, I describe the details of data collection focused on five, six and seven-year old children. The project examined the effect of environmental contaminants on children's educational outcomes. It included a primary caregiver interview, a skill test with the child, and a venous blood draw from the child to test for lead, mercury, cadmium, arsenic, nicotine, and cotinine. This paper describes key issues and the solutions I adopted. Challenges discussed here include navigating the Institutional Review Board Process, analyzing the blood, obtaining the supplies needed to draw blood, banking blood for future research, hiring a phlebotomist, and recruiting subjects. While not all details will apply directly to other research projects, this paper provides some perspective on the current realities facing social scientists who decide to collect biological samples.

Fainting and hemolysis during blood sampling in youngsters: prevalence study.

OBJECTIVE: To assess the incidence of fainting and hemolysis in taking blood samples from adolescents in a school setting. DESIGN: A cross-sectional school-based survey. All blood samples and data were collected during September and October 2005. SUBJECTS: A community sample of 869 youngsters attending third grade secondary education in 14 secondary schools in the Flemish province of Antwerp, Belgium (mean age: 17.3 years, +/-1.2 years). MEASUREMENTS: Fasting blood samples were obtained on-site for measurement of levels of glucose, high density lipoprotein cholesterol and triglycerides. The incidence of fainting and hemolysis was assessed. RESULTS: In 60% of the total sample a blood sample was taken, 15% refused. In the remaining 25%, taking a blood sample was not possible due to problems in drawing blood from the vein (4%) or not fasting (21%). The incidence of fainting was 2.5%. Hemolysis occurred in 2.4% of the blood samples. CONCLUSION: When taking blood samples in this age group, there seems to be a great willingness to participate. Precaution should be taken though when taking blood samples in youngsters. In this study, about 1 in 40 students fainted. When blood samples are taken on-site and transported to a laboratory, an incidence of hemolysis of 2.4% should be taken into account.

Reducing unnecessary inpatient laboratory testing in a teaching hospital.

After an inpatient phlebotomy-laboratory test request audit for 2 general inpatient wards identified 5 tests commonly ordered on a recurring basis, a multidisciplinary committee developed a proposal to minimize unnecessary phlebotomies and laboratory tests by reconfiguring the electronic order function to limit phlebotomy-laboratory test requests to occur singly or to recur within one 24-hour window. The proposal was implemented in June 2003. Comparison of fiscal year volume data from before (2002-2003) and after (2003-2004) implementation revealed 72,639 (12.0%) fewer inpatient tests, of which 41,765 (57.5%) were related directly to decreases in the 5 tests frequently ordered on a recurring basis. Because the electronic order function changes did not completely eliminate unnecessary testing, we concluded that the decrease in inpatient testing represented a minimum amount of unnecessary inpatient laboratory tests. We also observed 17,207 (21.4%) fewer inpatient phlebotomies, a decrease sustained in fiscal year 20042005. Labor savings allowed us to redirect phlebotomists to our understaffed outpatient phlebotomy service.

Blood gas analysis: a study of blood loss in intensive care.

This paper describes a quantitative study conducted on an intensive care unit in the north of England. It involved the collection of data from the existing records of 65 patients consecutively sampled from a predetermined date provided that they stayed more than 24 hours and had an arterial line in situ. As patient records were used, ethical approval was not necessary. The objectives of the study were to quantify the mean number of blood gas samples taken per patient and estimate the mean blood loss resulting from this, including discard volume. Limitations include reliance on records and lack of an economic evaluation. The results show that blood loss in this study was greater than that reported elsewhere. Patients who were ventilated for 24 hours or more had a statistically significant greater blood loss when compared to those who were not (P < 0.001). A subgroup of patients undergoing renal replacement therapy had the greatest blood loss (mean 55.18 ml per day). This loss was statistically significant when compared to patients not in acute renal failure (P=0.007). When patients undergoing multiple therapies normally associated with increased sampling were compared to patients not receiving such therapies, there was no statistically significant difference in blood loss. The need to change current nursing practice to reduce iatrogenic anaemia is emphasized.

Intravenous access in newborn infants: impact of extended umbilical venous catheter use on requirement for peripheral venous lines.

Central venous lines are used to care for critically ill neonates in cases of limited peripheral venous access. This prospective, randomized study evaluated the risks and benefits of the use of single- and double-lumen umbilical venous catheters for up to 14 days. Patients were randomized to one of three treatment arms: (1) single-lumen umbilical catheter, (2) double-lumen umbilical catheter, or (3) no umbilical catheter; peripheral intravenous lines only. Infants in the groups treated with an umbilical venous catheter had significantly fewer venipunctures and peripheral intravenous lines placed during their first 2 weeks of life than those in the peripheral line only group. Less time and money were spent obtaining peripheral line placement in the umbilical venous catheter groups. The incidence rates of sepsis and complications were not higher in treated patients than in control patients. The double-lumen catheter further reduced peripheral venipunctures and lines. We conclude that an umbilical venous catheter used during the first 2 weeks of life is a relatively safe, less stressful, cost-effective means of providing intravenous therapy to neonates.