Reducing Blood Draws in Critically Ill Patients Melissa McLenon, DNP, APRN, ACNP-BC, Gregory Botz, MD Natalie Clanton, RN, CCRN, Latoi Tatum, MHA, Blake Brookshire, MD

Introduction • Diagnostic laboratory testing is a significant contributor to anemia in critically ill patients • Phlebotomy practices contribute to the frequency of red blood cell transfusions, and is associated with higher

mortality and longer ICU LOS • We recognized the need to decrease the frequency of blood draws among critically ill patients in our ICU. Aim Statement

To reduce the frequency of blood draw events, per 24 hours, per critically ill patient, by 20% within 3 months of implementation of our intervention

Measure of Success

• Our team collected 4 weeks of baseline data to determine the frequency and volume of blood draws per 24 hours, per critically ill patient in a 10 bed medical ICU pod

• We then collected an additional 3 months of data

PLAN the Improvement

6am – 12pm 12pm – 6pm 6pm – 12am 12am – 6am Room 1

Number of Vials/Tubes

cc of Blood

Number of Draws

Room 2

Number of Vials/Tubes

cc of Blood

Number of Draws

Room 3

Number of Vials/Tubes

cc of Blood

Number of Draws

Room 4

Number of Vials/Tubes

cc of Blood

Number of Draws

Room 5

Number of Vials/Tubes

cc of Blood

Number of Draws

DO the Implementation

Communication

• Enhance communication among ICU team, Use of the daily rounding checklist

Education

• Education of all staff members through in-services. Give autonomy to key staff members

Awareness

• Increase overall awareness including the necessity of labs to be done daily and the complications of frequent lab draws

STUDY the Results

0

10

20

30

40

50

60

70

2/13

2/14

2/15

2/16

2/17

2/18

2/19

2/20

2/21

2/22

2/23

2/24

2/25

2/26

2/27

2/28

2/29 3/

13/

23/

33/

43/

53/

63/

73/

83/

93/

103/

11

5/14

5/15

5/16

5/17

5/18

5/19

5/20

5/21

5/22

5/23

5/24

5/25

5/26

5/27

5/28

5/29

5/30

5/31 6/

16/

26/

36/

46/

56/

66/

76/

86/

96/

10

ml o

f Blo

od D

raw

n (p

er p

t per

day

)

Average Daily Volume of Blood Draws Post- intervention MEAN = 36.84 Pre-intervention MEAN = 46.79

Inte

rven

tion

00.5

11.5

22.5

33.5

44.5

55.5

66.5

7

2/13

2/14

2/15

2/16

2/17

2/18

2/19

2/20

2/21

2/22

2/23

2/24

2/25

2/26

2/27

2/28

2/29 3/

13/

23/

33/

43/

53/

63/

73/

83/

93/

103/

11

5/14

5/15

5/16

5/17

5/18

5/19

5/20

5/21

5/22

5/23

5/24

5/25

5/26

5/27

5/28

5/29

5/30

5/31 6/

16/

26/

36/

46/

56/

66/

76/

86/

96/

10

Fre

quen

cy o

f Dra

ws (

per p

t per

day

)

Average Frequency of ICU Blood Draws Post-Intervention MEAN = 2.97 Pre-intervention MEAN = 3.99

Inte

rven

tion

Return on Investment • Decrease costs associated

with laboratory tests • Reallocation of resources

(LLTs) • Decrease in PRBC

transfusions • Decrease in costs and

complications of PRBC transfusions

• Decrease in catheter related blood stream infections

• Improved ICU “throughput” • Improved communication

among the team

• Brainstorm session with key players to identify factors that were important to blood draws in the ICU

• Developed an affinity diagram into

clusters that became the elements of the Ishikawa diagram

• Developed a process map to identify

where we may have the greatest impact

• Generated run charts to reflect the

data over time Figure 1. Ishikawa Diagram

Figure 2. Sample Data Collection Spreadsheet Figure 3. Process for Lab Ordering

Challenges and Barriers Difficulty with data

collection Multiple causes of variation Inconsistent support from

leadership “Open” ICU

Expand scope of project to include critically ill surgical patients

Explore other process steps that were identified by the team

Efforts to improve communication and coordination of laboratory ordering among the healthcare team

Create a decision support tool for use on daily rounds to address laboratory ordering strategies

ACT on Next Steps

Graph 1: Average Daily Volume of Blood Draws

Graph 2: Average Frequency of ICU Blood Draws