Background Intensive care unit (ICU) patients are at high risk of anemia, and phlebotomy is a potentially modifiable source of blood loss. Our objective was to quantify daily phlebotomy volume for ICU patients, including blood discarded as waste during vascular access, and evaluate the impact of phlebotomy volume on patient outcomes. Methods This was a retrospective observational cohort study between September 2014 and August 2015 at a tertiary care academic medical-surgical ICU. A prospective audit of phlebotomy practices in March 2018 was used to estimate blood waste during vascular access. Multivariable logistic regression was used to evaluate phlebotomy volume as a predictor of ICU nadir hemoglobin < 80 g/L, and red blood cell transfusion. Results There were 428 index ICU admissions, median age 64.4 yr, 41% female. Forty-four patients (10%) with major bleeding events were excluded. Mean bedside waste per blood draw (144 draws) was: 3.9 mL from arterial lines, 5.5 mL central venous lines, and 6.3 mL from peripherally inserted central catheters. Mean phlebotomy volume per patient day was 48.1 ± 22.2 mL; 33.1 ± 15.0 mL received by the lab and 15.0 ± 8.1 mL discarded as bedside waste. Multivariable regression, including age, sex, admission hemoglobin, sequential organ failure assessment score, and ICU length of stay, showed total daily phlebotomy volume was predictive of hemoglobin <80 g/L (p = 0.002), red blood cell transfusion (p<0.001), and inpatient mortality (p = 0.002). For every 5 mL increase in average daily phlebotomy the odds ratio for nadir hemoglobin <80 g/L was 1.18 (95% CI 1.07–1.31) and for red blood cell transfusion was 1.17 (95% CI 1.07–1.28). Conclusion A substantial portion of daily ICU phlebotomy is waste discarded during vascular access. Average ICU phlebotomy volume is independently associated with ICU acquired anemia and red blood cell transfusion which supports the need for phlebotomy stewardship programs.

BackgroundCritically ill patients receive frequent routine and recurring blood tests, some of which are unnecessary.AimTo reduce unnecessary routine phlebotomy in a 30-bed tertiary medical-surgical intensive care unit (ICU) in Toronto, Ontario.MethodsThis prospective quality improvement study included a 7-month preintervention baseline, 5-month intervention and 11-month postintervention period. Change strategies included education, ICU rounds checklists, electronic order set modifications, an electronic test add-on tool and audit and feedback. The primary outcome was mean volume of blood collected per patient-day. Secondary outcomes included the number blood tubes used and red cell transfusions. Balancing measures included the timing and types of blood tests, ICU length of stay and mortality. Outcomes were evaluated using process control charts and segmented regression.ResultsPatient demographics did not differ between time periods; total number of patients: 2096, median age: 61 years, 60% male. Mean phlebotomy volume±SD decreased from 41.1±4.0 to 34.1±4.7 mL/patient-day. Special cause variation was met at 13 weeks. Segmental regression demonstrated an immediate postintervention decrease of 6.6 mL/patient-day (95% CI 1.8 to 11.4 p=0.009), which was sustained. Blood tube consumption decreased by 1.4 tubes/patient-day (95% CI 0.4 to 2.4, p=0.005) amounting to 13 276 tubes (95% CI 4602 to 22 127 tubes) saved over 11 months. Red blood cell transfusions decreased from 10.5±5.2 to 8.3±4.4 transfusions/100 patient-days (incident rate ratio 0.56, 95% CI 0.35 to 0.88, p=0.01). There was no impact on length of stay (2 days, IQR 1–5) and mortality (18.1%±2.0%).ConclusionIterative improvement interventions targeting clinician test ordering behaviour can reduce ICU phlebotomy and may impact red cell transfusions. Frequent stakeholder consultation, incorporating stewardship into daily workflow, and audit and feedback are effective strategies.

Introduction: Frequent blood testing in the intensive care unit (ICU) is instrumental to patient diagnosis, monitoring, and titration of invasive therapies. However, there is a growing appreciation that a significant proportion of ICU blood tests are reflexive and unnecessary.1,2 Serial phlebotomy is associated with extended hospital length of stay and acquired anemia in the general hospital population.3 Since patients in the ICU are prone to developing anemia,4,5 they are likely at increased risk of harm from serial phlebotomy. In response, multiple recent campaigns advocate for physician restraint in laboratory test ordering.6,7 However, relatively little is known about the effect of excessive phlebotomy on outcomes in critically ill patients. Better understanding of ICU phlebotomy practices, and harms associated with serial testing, is important in planning, implementing, and evaluating phlebotomy reduction interventions. Objectives: 1) Quantify average daily phlebotomy volume for ICU patients including blood discarded as waste when accessing vascular devices. 2) Identify if average daily phlebotomy volume is an independent risk factor for ICU acquired anemia (hemoglobin &lt; 80 g/L) or the need for red blood cell transfusion. 3) Explore the relationship between daily phlebotomy volume and hospital mortality. Methods: This was a retrospective cohort study at an academic tertiary care center in Toronto, Ontario, utilizing hospital administrative data, laboratory data, and select chart review. Index Medical Surgical ICU admissions between September 2014 and August 2015 with an ICU stay of three days or greater were included. Major bleeding events were defined as a hemoglobin drop of 30 g/L within a 24 hour period. Average daily phlebotomy volumes were calculated using the number of samples received by the lab multiplied by standard blood volumes required for each sample type. A bedside prospective audit was conducted in March 2018 to quantify average blood volume discarded as waste during phlebotomy. Blood discard/waste data were summarized with descriptive statistics, but not included in further analysis. Multivariable logistic regression was used to study the association between average daily phlebotomy volume and each of: nadir hemoglobin (&lt; 80 g/L), the need for red blood cell transfusion, and hospital mortality. Patients with a major bleeding event were excluded from the regression. Control variables included sex, age, ICU length of stay, admission hemoglobin, and admission Sequential Organ Failure Assessment (SOFA) score. Results: There were a total of 525 index patient admissions, mean age 62.1 yr, 41% female (Table 1). Fifty-two (52) patients had a major bleeding event in the ICU. Mean phlebotomy volume per patient day was 28.3 mL (95% CI 27.4 - 29.1 mL, stdev 10.1 mL). Mean bedside waste during the phlebotomy audit (total of 144 blood draws) varied by vascular access: 3.9 mL for arterial, 5.5 mL for central venous, and 6.25 mL for peripherally inserted catheters. The mean estimated daily bedside waste for phlebotomy was 14.8 mL per patient day. Outcomes of logistical regression, excluding patients with major bleeding events, are summarized in Table 2. Average daily phlebotomy volume (mL) was predictive of nadir hemoglobin &lt; 80 g/L (parameter estimate 0.091, p &lt;0.001), the need for red blood cell transfusion (0.092, p&lt;0.001), and inpatient mortality (0.053, &lt;0.001). For every 5 mL increase in average daily phlebotomy, the odds ratio (OR) for nadir hemoglobin &lt; 80 g/L was 1.58 (95% CI 1.31 - 1.90) and the OR for a red cell transfusion was 1.58 (95% CI 1.33 - 1.87). Conclusion: Daily ICU phlebotomy volume is associated with ICU acquired anemia and the need for red blood cell transfusion, including in a multivariable model with patient demographics, major bleeding events, and severity of illness as estimated by day 1 SOFA score. However, the ICU admission SOFA score was only weakly predictive of mortality, and the unexpected association between average daily phlebotomy and mortality needs to be further explored. It is possible that in this data set day 1 SOFA score did not completely control for severity of illness. Our findings support the need for ongoing phlebotomy stewardship interventions in the ICU. We suggest ICU acquired anemia and the need for red blood cell transfusion are appropriate patient outcome measures to evaluate stewardship interventions. Disclosures No relevant conflicts of interest to declare.

Background Laboratory testing is a core component of contemporary medical care. However, repetitive diagnostic phlebotomy has been associated with anemia and higher transfusion burden, both of which are associated with increased mortality. The potential harm of repetitive blood testing is particularly pronounced in the intensive care unit (ICU). Critically ill patients receive a high volume of blood tests due to their need for intensive intervention and monitoring. In addition, ICU patients often suffer from anemia of inflammation which impairs effective erythropoiesis and may exacerbate net red cell loss resulting from repetitive blood testing. Aim Modeling data suggests that a 15% decrease in the amount of blood drawn may result in clinically meaningful decrease in ICU anemia.We aimed to reduce the average volume of blood collected per patient-day by 15% by June 30, 2019 by developing and implementing a patient-centered, diagnostic phlebotomy strategy in the Medical-Surgical Intensive Care Unit (MSICU) at an academic tertiary care center in Toronto, Canada. Methods A series of change strategies were implemented in a single-site, 25-bed MSICU between February and July 2019. The strategy included: stake-holder engagement, education sessions, process changes to encourage patient-centered lab ordering, electronic order set modifications to deter open-ended and unnecessary lab ordering, order changes to facilitate add-on testing, and audit and feedback regarding the average volume of blood collected per patient-day in the MSICU. Baseline data from July 2018 to January 2019 was collected retrospectively using administrative data. The main outcome measure was average volume of blood collected per patient-day in the MSICU. Balance measures included average discrete blood draws, ICU length of stay and mortality. The statistical stability of the main outcome measure over time was explored with Shewhart chart (I-chart) analysis. The student's T-Test was also used to compare the mean blood collected per patient-day in the ICU at baseline versus post-intervention. Results Baseline data from July 2018 to January 2019 revealed a mean of 46.8 mL of blood was collected per patient-day (including wastage). The volume of blood collected per patient-day was stable during the baseline observation period. Direct observations and process mapping of the blood ordering processes suggested that repetitive and reflexive blood testing was common in the MSICU. Change strategies were successively introduced between February and June 2019. During the study period average blood volume collected decreased from 46.8ml per patient-day to 36.0 mL per patient day. Special cause variation was observed 6 weeks into the intervention (p &lt; 0.001). The average number of discrete blood draws also decreased from 4.1 to 3.7 per patient day. Conclusion Sequential, patient-centered interventions discouraging reflexive and unnecessarily repetitive blood testing in an ICU were associated with a significant decrease in average blood volumes collected per patient-day. Future analyses will explore whether the observed decrease in daily phlebotomy volumes was associated with any changes in patient outcomes such as transfusion burden, ICU length of stay and mortality. Disclosures Sholzberg: Novartis: Honoraria; Amgen: Honoraria, Research Funding.