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Abstract
A common practice exists in hospitals where extra tubes of blood are collected for possible add-on testing, this practice contributes to wastage of consumables. Baseline estimates from a 5-month local lab information system audit revealed that ~65 extra tubes per day were being collected, with an additional 2-week manual audit of all extra tubes received in the laboratory confirming the practice. The audits showed that the majority of the tubes (~99%) were being drawn from the adult emergency department (ED). Furthermore, only 5% of the extra tubes were being used for add-on testing, whereas the remaining tubes had no testing performed on them and were discarded at the end of the day. This translates to over 23 000 extra tubes being wasted annually.
After initial discussion with ED leadership, the practice was identified as primarily nurse driven. An educational intervention was created and entitled ‘Every Tube Counts’, with the aim to reduce extra tube collections in the adult ED by 50% within the first month of intervention. First, a memo with initial findings and a request to stop the practice of extra tube collection was sent out to all ED staff. After 2 weeks of additional data collection, it was noticed that extra tubes were still being collected. A second intervention, which consisted of another communication and utilisation of nurse educators to disseminate the information to nursing staff, saw a remarkable ~80% reduction in collection of extra tubes in the following few months after the second intervention. The practice was followed for an additional 15 months, which saw a slight increase of extra tube collections over time with a levelling off towards the latter period of the study. However, the target goal was maintained over the entire study period.
- Emergency department
- Laboratory medicine
- PDSA
- Quality improvement
Data availability statement
All data relevant to the study are included in the article or uploaded as online supplemental information.
This is an open access article distributed in accordance with the Creative Commons Attribution Non Commercial (CC BY-NC 4.0) license, which permits others to distribute, remix, adapt, build upon this work non-commercially, and license their derivative works on different terms, provided the original work is properly cited, appropriate credit is given, any changes made indicated, and the use is non-commercial. See: http://creativecommons.org/licenses/by-nc/4.0/.
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WHAT IS ALREADY KNOWN ON THIS TOPIC
Collecting extra blood tubes from patients is common in hospitals; however, it is considered both dangerous for the patient and a wasteful practice. Moreover, the COVID-19 pandemic has caused a burden on the global supply chain of clinical laboratory reagents and consumables, including blood collection tubes.
WHAT THIS STUDY ADDS
By using educational interventions with key-stakeholder engagement, this study provides a rudimentary approach to a quality improvement project that can easily be undertaken by hospitals to successfully and significantly reduce a wasteful process of collecting extra blood tubes from patients.
HOW THIS STUDY MIGHT AFFECT RESEARCH, PRACTICE OR POLICY
This study may impact policy-making and decision-making practices surrounding preanalytical processes in clinical laboratories and hospitals. Laboratory professionals and key clinical stakeholders could implement a policy to reduce a common practice of collecting extra blood tubes from patients, which profoundly impacts a wasteful process by preserving blood collections tubes and improving patient safety.
Problem
Many hospitals collect extra blood tubes on patients just in-case additional or add-on testing may be required at a later time. This practice creates inherent risks to patients, contributing to nosocomial anaemia and the possibility of erroneous test results if the extra tubes are inadequately processed or stored. Moreover, this practice stands as wasteful as many unused tubes often end up being discarded. The COVID-19 pandemic triggered a ripple effect in the global supply-demand of consumables, resulting in clinical laboratories experiencing disruptions in critical laboratory supplies, including reagents and blood collection tubes. To help alleviate some of the supply chain shortages, we examined blood collection tube wastage at our two large tertiary/quaternary care centres: Victoria Hospital and University Hospital, London Health Sciences Centre, which provide service to over two million people in Southwestern Ontario, Canada. A pRoject Ethics Community Consensus Initiative Ethics Guideline Tool was used to conduct an ethical risk assessment.1 Wastage was defined as extra blood tubes that were collected on a patient where no additional or add-on testing was ordered or performed. Baseline audits were conducted to determine the scope of the problem, and it was estimated that on average ~65 extra tubes per day were being ordered. It was quickly identified that this was a common practice almost exclusively limited to the adult emergency departments (ED). Moreover, only ~5% of the extra tubes were being used for add-on testing, resulting in ~95% of the tubes being discarded, which translates to a wastage of over 23 000 tubes per year. The aim of this laboratory quality improvement (QI) project was to reduce collection of extra blood tubes in the adult ED by 50% within 1 month.
Background
The COVID-19 pandemic had significantly impacted the global supply chain and identified many essential items taken for granted in day-to-day operations of clinical laboratories. While toilet paper, medical masks and ventilators made headlines, the clinical laboratories struggled with a critical shortage in supplies, such as blood vacutainer tubes, blood gas syringes, pipette tips, reagents and many other consumables. The tube shortage globally was exacerbated by a number of factors, including an increase in demand for testing as direct result of hospitalisations, hording of supplies leading to rolling shortages and general lack of awareness by healthcare professionals of the supply shortage. In response to this global burden, the Canadian Society of Clinical Chemists (CSCC) and other laboratory professionals started to spread the news and define the scope of the concern, and made users aware that this was not just a ‘lab problem’, but a bigger problem that could have direct impact on patient care. Specifically, CSCC issued a Practice Alert in March 2022 stating ‘Only perform blood draws for requested testing. Do not collect additional tubes (‘just in case’/‘rainbow draws’), in anticipation of future orders’ (https://www.cscc.ca/en/categories/77-news/1634-cscc-collaborates-on-tube-shortage-statement.html).2 The practice of drawing a ‘rainbow’ of blood tubes (drawing tubes with wide variety of coloured stoppers/additives) is not new and is commonly practised at many institutions based on the assumption that additional tests may be required at a later time and to avoid subsequent venipunctures. Studies have demonstrated this practice to be common, suggesting that only 2%–7% of the extra tubes were actually used for add-on testing.3 4 In turn, this translates to 93%–98% of the extra tubes were wasted/discarded. Therefore, the practice of collecting extra tubes is wasteful of precious resources further brought to light by global supply chain shortages during the pandemic. More importantly, collecting extra tubes may adversely affect patient care by causing nosocomial anaemia, or by generating erroneous test results if the extra tubes were not processed or stored appropriately which could cause changes in analyte concentrations or introduce interfering substances (eg, haemolysis or metabolic byproducts).
Baseline measurement
Baseline measurement and data capturing occurred in two phases. The first phase was through a 5-month audit (1 September 2021 to 31 January 2022) of the local laboratory information system (LIS; Cerner Millennium). LIS auditing was possible because of an existing ‘.extracolour’ orderable (eg, .extrablue, .extragreen, .extrared). When the ‘.extracolour’ is ordered, it prints an extra label that is then affixed to an extra tube collection. It is this tube that is then sent to the core laboratory along with other tubes that may be collected and used for patient testing. From this LIS audit, it was determined that on average, there were ~65 ‘.extracolour’ orders per day. The second phase included manually counting and auditing all extra tubes received in the specimen receiving area (SRA) of the core laboratories at Victoria Hospital and University Hospital. SRA is the specific function of the laboratory that is responsible for receiving, triaging and processing all patient specimens prior to being analysed. During the second phase audit, dedicated medical laboratory assistants maintained a manual log of the number of extra tubes received, the tube colour/additive type, along with the location of where the tubes were collected from. The manual audit occurred from 4 February 2022 for 2 weeks. The 2-week manual audit confirmed the LIS audit. It was also determined that extra tube collections were primarily occurring in the adult ED, which was responsible for ~99% of all extra tube collections. No significant extra tube collections were observed from the paediatric ED or inpatient wards. Additional LIS auditing of the extra tube collections for add-on testing demonstrated that only 5% of extra tubes were used for add-on patient testing. The remainder of the extra tubes, ~95%, were unused and discarded at the end of the day.
Design
The aim of the QI project was to reduce extra tube collections in the adult ED by 50% in the first month of the intervention. The laboratory team organised a meeting with stakeholders from the adult ED, which included the chief of adult ED for all sites and nurse educators. The concern and scope of the problem were discussed and baseline data were presented. In the first meeting, it was identified that the collection of extra tubes was primarily a nurse-driven procedure, as opposed to physician requested or part of a clinical care set. An educational memo outlining the practice and initial audit of the findings, as well as a request to stop the practice of extra tube collection, was sent out to all ED staff (physicians, nurses and nurse educators) on 17 February 2022. The memo was considered the first intervention in this QI project and it constituted the first Plan-Do-Study-Act (PDSA#1) cycle. After an additional 2-week audit following the first intervention, a second memo providing feedback on the extra tube reduction was circulated on 4 March 2022. The second memo targeted nursing staff with reinforcement of the QI goal by nurse educators; this comprised the second intervention (PDSA#2). To monitor the impact of the two interventions, regular audits were performed for an additional period of 15 months. Regular and periodic feedback on the number of extra tube collections and add-on testing frequency was provided to the adult ED team.
Strategy
The strategy used in this QI project used simple information gathering, it did not require the use of in-depth QI tools such as fishbone or process mapping for root-cause analysis. The baseline data were collected on the number of extra tubes ordered and number of add-on tests performed through LIS and confirmed by manual audits. The audits not only provided baseline measurements, but also identified the adult ED as the key target for the intervention as they were the primary hospital location ordering and collecting extra tubes. Laboratory and adult ED stakeholders were gathered through a series of virtual meetings to plan and execute the appropriate interventions. It was during the initial meeting that the root cause for extra tube collections was identified. The adult ED stakeholders were engaged, cooperative and genuinely appreciative of being able to do something to improve supply chain shortages brought on by the pandemic. During the initial meeting, it was identified that the collection of extra tubes was a nurse-driven behaviour, more commonly a habit of more senior nurses as opposed to recently trained nursing staff. A more detailed root cause analysis was felt to be unnecessary by the adult ED stakeholders, as the root cause was quickly identified. The proposed intervention, PDSA#1, was an educational memo sent to all adult ED staff outlining the problem, baseline data, aim of the QI project and the request to stop extra tube collections. Two weeks following the first educational memo, the number of extra tubes and add-on tests was measured. There was a modest reduction of 10% in extra tube collections, but it did not meet the QI project’s target reduction by 50%. A second intervention (PDSA#2) was planned, which reiterated the first, with nurse educators in each of the adult ED locations taking on primary responsibility for circulating the memo to ensure all nursing staff received the memo with any additional education surrounding it. Response to PDSA#2 was dramatic, with greater than 80% reduction in extra tubes being collected at all ED sites. Given the results after PDSA#2 surpassed the QI project’s goal, no additional PDSA cycles were planned or performed.
Results
Figure 1 depicts a run chart for this QI project. PDSA#1 was initiated on 17 February 2022 with some reduction in extra tube collections observed. PDSA#2 was approximately 2 weeks following PDSA#1 (4 March 2022), and the impact following PDSA#2 was dramatic, with ~80% reduction in collection of extra tubes in the following few months after the second intervention (averaging ~12 extra tubes per day). The practice was followed for an additional 15 months, which saw a slight increase of extra tube collections over time with a levelling off towards the latter period of the study. Overall, on average ~20 extra tube collections occurred per day (~70% reduction) over the 15 months post-PDSA#2, with the target goal (50% reduction) maintained over the full study period. The slight increase could be due to a number of reasons. First, our hospital system may order some low volume esoteric or send out tests using the ‘.extracolour’ orderable in order to facilitate their collection and processing. Such tests may not be part of our routine panel of testing, but at times may be used for clinically important applications. It is difficult to remove these legitimate extra tube orders from the data collection, which may occur at a low frequency. Second, old habits of collecting extra tubes could return over time, which may require further interventions at periodic intervals, to affirm the process. As a balancing measure, we also tracked the number of add-on tests, which remained relatively stable. Given the similarities of PDSA#1 and #2, there are several potential explanations for the differing response. As with our experience in other QI projects, a general educational memo is always the first step but may have little impact on actual behaviour unless it is brought to the attention of target audience and reinforced in person. In our QI project, on site nurse educators played a crucial role in raising awareness of the campaign and providing support for the change in practice. Audit and feedback also played a critical role notifying users that we were monitoring outcomes providing added incentive to nursing to follow the memo’s advice.
Run chart for the quality improvement project aimed at reducing extra tube collections in the adult emergency department (ED). Plan-Do-Study-Act (PDSA) #1 and PDSA#2 are educational interventions that took place on 17 February 2022 and 4 March 2022, which were approximately twoweeks apart. There was a dramatic ~80% reduction in extra blood collections after PDSA#2 and was sustained below target goal long term.
Lessons and limitations
The simplicity of the intervention and success of this QI project likely reflects a number of factors. First, the pandemic had created a widespread awareness of supply chain shortages creating the general willingness to improve processes. This crisis environment is supportive of change in behaviour. Second, the root cause of the behaviour appeared to be limited to a single group—adult ED nursing staff—thus a targeted intervention aimed at this group was planned. Finally, reinforcement by peers and dedicated adult ED nurse educators, including audit and feedback, were crucial in facilitating change. The study was limited to adult patients in the ED and, therefore, not generalisable to paediatrics. Other studies have focused on excessive phlebotomy in paediatric population where it can be a significant cause of iatrogenic anaemia, but less likely impacting extra tubes collections.5 We intentionally excluded this group because of the difficulty and trauma of repeat phlebotomy in children, but also our audits did not show a significant extra collection practice from paediatric ED. The study could have been improved by documenting countermeasures such as how many adult patients required a repeat blood sample collection because of failure to draw an extra tube at presentation. Based on the number of add-on orders on extra tubes being only minimally changed, we anticipate that the number was actually extremely low, namely the extra tube is indeed most commonly discarded in greater than 90% of the time. Since this was primarily an adult ED practice, the patient turnover is very high in that department, and the high rate of discharge and disposition would make it very difficult to capture the true reflection of the recollection rate. This study may not be generalisable to other organisations or EDs where samples are drawn by dedicated phlebotomy or lab-driven collection teams. Discussion with smaller regional hospital sites suggested that extra tube draws are much less common practice (data not shown), due to direct laboratory involvement and quality oversight of these functions.
Conclusions
Drawing extra tubes of blood is a long-standing common practice particularly in the ED setting where there may be considerable diagnostic uncertainty, the need for expediency to maintain workflow and the desire to avoid repeat phlebotomy on their patients. Prior to the emergence of the COVID-19 pandemic and supply chain shortages, the practice was deemed as ‘acceptable’ and had only minor financial impact. Campaigns such as Choosing Wisely have focused on the downstream impact of drawing repeat blood test including risk of nosocomial anaemia and suggested that as much of 30% of tests are unnecessary.6 7 The problem of extra tube collections without associated testing, not only contributes to patient risk, but represents an additional healthcare resource wastage during a time of critical supply shortages. We suspect this problem would largely have continued to be ignored if not for the global supply chain shortage creating a crisis situation and opportunity to change a wasteful habit. This QI project exceeded its aim for 50% reduction in tube wastage, which observed an astonishing drop in extra tubes by 70%–80% and maintained the reduction below target goal over the study period. Most remarkable was the ease with which this target was reached without extensive process mapping and root cause analysis, and it only required two PDSA cycles with an educational focus. The key to success was recognising that extra tube collecting was primarily driven by nursing staff and local nursing champions/educators who could appeal directly to their peer group. This change may be sustained with intermittent audit and feedback, ensuring the lasting impact of this transformative initiative. Given the simplicity and success of this QI project, we strongly believe that this project could be readily replicated at other hospitals with similar practice. We are concerned that the opportunity for change may be transient and pandemic limited, but we also hope this opportunity can lead to a positive improvement in laboratory practice.
Data availability statement
All data relevant to the study are included in the article or uploaded as online supplemental information.
Ethics statements
Patient consent for publication
Ethics approval
The work was conducted as a laboratory quality improvement project and was deemed exempt from institutional research ethics board review. This work highlights improvements made in a local system and may not be generalisable to other organisations.
Acknowledgments
We would like to thank all of the lab staff, client support, emergency department staff and clinical educators for playing an important role in this quality improvement project.
Footnotes
Twitter @mjknauer
Contributors IC-Y, MK, IS and VB conceptualised and designed the study and drafted the initial manuscript. All authors performed data analysis and assisted with interpretation of data or were involved with the Interventions. All authors have critically appraised and reviewed the manuscript for accuracy and have approved the manuscript for publication. IC-Yis acting as the guarantor and accepts full responsibility for the finished work and/or the conduct of the study, had access to the data, and controlled the decision to publish.
Funding The authors have not declared a specific grant for this research from any funding agency in the public, commercial or not-for-profit sectors.
Competing interests None declared.
Patient and public involvement Patients and/or the public were not involved in the design, or conduct, or reporting, or dissemination plans of this research.
Provenance and peer review Not commissioned; externally peer reviewed.