Fixing bad blood tests

Here's another example of process improvement that typifies BIDMC SPIRIT, with remarkable success resulting from application of Lean principles, applied with advice from our small, but able, Business Transformation group. I supply an edited version of the narrative given to me:

What do you get when you cross well intentioned Emergency Department (ED) Nurses (RNs) with fastidious laboratory technologists? You get a problem, an opportunity, and a bevy of talented professionals poised to collaborate on a mutual solution.

Why would ED RNs do anything that might delay treatment? Why would a lab technologist take an extra 56 minutes to provide a potassium test result? Why…because each role cares deeply about the patient; but in divergent ways. This divergence spoke to us. We had two groups not understanding the impact they had on each other, and combined, their impact on patient care.

As this scenario shows, many patients cross multiple departments and value streams as they receive care. The departments knew that quality was a problem but wanted to benchmark how they stood in relation to the rest of the hospital. One measure of quality in the ED is the hemolysis rate (the rate of defect specimens that skew a patient’s laboratory test results). Data was collected by the ED nurses and laboratory technologists and was then presented in a rapid improvement event to uncover the root cause of the quality problem.

The hemolysis rate for lab specimens collected in the ED was found to be 22.4%, approximately five times their counterparts on the inpatient units (3.9%). This rate had several deleterious effects: patient’s hemolyzed specimens often had to be recollected and retested, therefore these patients had to wait on average 56 minutes longer for lab results, and frustration levels in both the ED and the laboratory were high.

As we knew, hemolysis is a byproduct of improper specimen collection and has an unintended effect on lab results. The effects on results can be can be minor, moderate, or actually cause inaccurate and incorrect results. One test in particular, potassium, is significantly impacted by hemolysis. It is a very significant test for heart patients where small changes can be noteworthy. We saw an opportunity to examine practice, past studies, and identify opportunities for improvement. A decreased hemolysis rate would result in improved ED throughput, reduced length of stay for the patient, fewer recollections (savings in both time and materials), and better patient satisfaction.

To address the high rate of hemolysis in the ED, two in-depth studies were completed. The first was to obtain the hemolysis rates for collections via an IV insertion versus a peripheral blood draw (venipuncture). The second study focused on hemolysis for specimens drawn through the IV using one of three methods: Vacutainer, extension tubing, or syringe. The data indicated that specimens collected during IV insertion showed a much higher rate of hemolysis, especially when using a vacutainer (the ED’s current preferred method).

We also assembled other hospital experts. The phlebotomy manager and a venous access nurse came to our event to observe, comment, and critique our ED nurses and ED techs as they simulated current practices (on a dummy arm). Each of us learned a lot and took note of areas in the process where we noticed a lack of standardization. We were most struck by the variability of practice, not only staff in the ED but of staff around the medical center. Thus, we had a great opportunity to standardize and create best practice for the medical center. A mistake-proof, proper technique is the key to preventing hemolysis.

Our goals were simple: develop a standardized method of drawing labs in the ED by engaging the ED and lab staff who do the work and strive for the common goal of reducing the hemolysis rate by over 18%. This would generate a cost and time savings as a result of fewer patient re-sticks, fewer repeat tests, improved quality due to better sample integrity, and potentially contribute to higher patient and staff satisfaction.

Our intent was not to place blame but rather to really understand the root of the problem. We gathered data from other areas of the hospital which also collected specimens during an IV insertion. Each area reported no problems with hemolysis, but our investigation uncovered they did, in fact, have a problem. None of the tests they ordered were impacted by hemolysis; so these groups were unintentionally blind to the problem. But this showed us that the individual technique of the person collecting the specimens although variable, is less of the root cause.

As we talked about hemolysis, we broadened our outlook and realized how complicated this is to operations. Due to the unpredictable patient flow, changing clinical needs of each patient, and variability of each RN, ED Tech and MD practice-styles, this was a very complex process to define. But we were committed to finding a solution. Each area owned this problem and for various reasons wanted to find a solution. The lab would have fewer critical values to repeat, call, and document. The ED would have fewer patients to re-stick, faster results, and happier patients.

During our time working on this issue we learned and communicated the following to the respective Lab, and ED staff:

• Long tourniquet time (>1 minute) increases Hemolysis
• IV product manufacturer does not support blood draws from IV equipment.
• Medical center IV and Phlebotomy Experts do not teach or recommend IV Draws
• Most ED staff worried about sticking the patient twice (once to set-up an IV and again to draw blood through venipuncture) - creating a negative experience for the patient. However, almost 30% of the time they did stick people twice due to Hemolysis which created a 56 minute delay.

We embarked on a pilot project after the event. Our intent was to stop collecting blood specimens at the time of IV insertion. To accomplish that goal, the ED techs (who only can draw via venipuncture) would draw all of the blood. Prior to the implementation, our phlebotomy team retrained the ED techs according to the Pathology venipuncture standards. Once this process was in full swing, the plan was to review all specimens from the ED and check the tubes for hemolysis and feedback the data to all of the parties on a daily basis. Each day the lab reviews over 100 specimens collected from the ED needing potassium results. We post the daily hemolysis rates and investigate each hemolyzed specimen with the RN caring for the patient. The average hemolysis rate over the past few weeks is now averaging 6.5%. As of this past Monday, this trial becomes the official way we draw blood in the ED.

We realized these incredible results by walking in each other’s shoes, touring each other’s areas, and understanding impacts by using data. We talked to each other and brainstormed together and cooperatively moved forward. Lab staff now attend the ED huddles so continued learning and sharing can take place; even after we solve the hemolysis problem.

In the end, it was our collective actions, willingness to put departmental issues aside, strong desire to improve the patient experience, and ultimate respect for each other’s talents and expertise that propelled our project forward.

Name, Role, Title
Gina McCormack, Pathology Admin, Operations Director
Kirsten Boyd, ED Director, Director of ED
Larry Mottley, ED MD, Quality MD
Jane Dufresne, ED CA, Clinical Advisor ED
Steve Wood, ED RN, RN Staff ED
Tammy Galloway, Chemistry, MGN Chem
Manny Alves, Lab West, Lab Supervisor
Blanche Murphy, Venous Access Nurse, RN Staff ED
Susie Fontes, ED RN, RN Staff ED
Pam Hulme, Phlebotomy, Customer Service manager
Kellie Glynn, ED RN, RN Staff ED
Christine Yennaco, ED Tech, Staff Tech ED
Brian Orsatti, ED Tech Supervisor, Tech Supervisor
Alice Lee, Lean, Office of the President
Kimberly Eng, Lean, Office of the President
Brandan Holbrook, Lean, Office of the President
Bonnie Baker, Lean, Office of the President