Multipronged strategy to reduce routine-priority blood testing in intensive care unit patients

Merkeley, Hayley; Hemmett, Juliya; Cessford, Tara A.; Amiri, Nasrin; Geller, Georgia; Baradaran, Nazli; Norena, Monica; Wong, Hubert; Ayas, Najib; Dodek, Peter

doi:10.1016/j.jcrc.2015.09.013

Cited by 28 publications

(22 citation statements)

References 23 publications

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“…Interestingly, however, past stewardship efforts have often favoured technology-based interventions including blood conservation devices to reduce waste during vascular access16–21 and small volume blood collection tubes 22–24. Interventions that target routine test ordering practices in the ICU have had mixed effects,16 25–28 partly owing to the challenge of changing clinician behaviour 29 30…”

Section: Introductionmentioning

confidence: 99%

“…Multimodal interventions with electronic order set modification and audit and feedback appear effective in curbing unnecessary testing 28 36. One 2016 example using education, an ICU rounds checklist and an electronic order set prompt, successfully reduced routine complete blood count and electrolyte panel tests by 0.13–0.14 tests/day (a 7%–9% reduction) 28.…”

Section: Introductionmentioning

confidence: 99%

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Reducing unnecessary diagnostic phlebotomy in intensive care: a prospective quality improvement intervention

et al. 2023

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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.

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Section: Introductionmentioning

confidence: 99%

Section: Introductionmentioning

confidence: 99%

Reducing unnecessary diagnostic phlebotomy in intensive care: a prospective quality improvement intervention

et al. 2023

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“…Many behaviors within critical care (test ordering, transfusion ordering) can become routine [ 12 ] such that those ordering may not be as aware of the frequency with which orders are being made. This may in turn lead to potentially unnecessary blood draws, putting patients at risk for anemia, and increased cost of care and resources to collect, run, and interpret tests [ 13 – 18 ], or potentially unnecessary use of precious blood products [ 18 – 25 ]. Providing performance data on routinized behaviors may help to highlight the frequency with which these orders are placed and flag them for improvement.…”

Section: Introductionmentioning

confidence: 99%

How well do critical care audit and feedback interventions adhere to best practice? Development and application of the REFLECT-52 evaluation tool

et al. 2021

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Background Healthcare Audit and Feedback (A&F) interventions have been shown to be an effective means of changing healthcare professional behavior, but work is required to optimize them, as evidence suggests that A&F interventions are not improving over time. Recent published guidance has suggested an initial set of best practices that may help to increase intervention effectiveness, which focus on the “Nature of the desired action,” “Nature of the data available for feedback,” “Feedback display,” and “Delivering the feedback intervention.” We aimed to develop a generalizable evaluation tool that can be used to assess whether A&F interventions conform to these suggestions for best practice and conducted initial testing of the tool through application to a sample of critical care A&F interventions. Methods We used a consensus-based approach to develop an evaluation tool from published guidance and subsequently applied the tool to conduct a secondary analysis of A&F interventions. To start, the 15 suggestions for improved feedback interventions published by Brehaut et al. were deconstructed into rateable items. Items were developed through iterative consensus meetings among researchers. These items were then piloted on 12 A&F studies (two reviewers met for consensus each time after independently applying the tool to four A&F intervention studies). After each consensus meeting, items were modified to improve clarity and specificity, and to help increase the reliability between coders. We then assessed the conformity to best practices of 17 critical care A&F interventions, sourced from a systematic review of A&F interventions on provider ordering of laboratory tests and transfusions in the critical care setting. Data for each criteria item was extracted by one coder and confirmed by a second; results were then aggregated and presented graphically or in a table and described narratively. Results In total, 52 criteria items were developed (38 ratable items and 14 descriptive items). Eight studies targeted lab test ordering behaviors, and 10 studies targeted blood transfusion ordering. Items focused on specifying the “Nature of the Desired Action” were adhered to most commonly—feedback was often presented in the context of an external priority (13/17), showed or described a discrepancy in performance (14/17), and in all cases it was reasonable for the recipients to be responsible for the change in behavior (17/17). Items focused on the “Nature of the Data Available for Feedback” were adhered to less often—only some interventions provided individual (5/17) or patient-level data (5/17), and few included aspirational comparators (2/17), or justifications for specificity of feedback (4/17), choice of comparator (0/9) or the interval between reports (3/13). Items focused on the “Nature of the Feedback Display” were reported poorly—just under half of interventions reported providing feedback in more than one way (8/17) and interventions rarely included pilot-testing of the feedback (1/17 unclear) or presentation of a visual display and summary message in close proximity of each other (1/13). Items focused on “Delivering the Feedback Intervention” were also poorly reported—feedback rarely reported use of barrier/enabler assessments (0/17), involved target members in the development of the feedback (0/17), or involved explicit design to be received and discussed in a social context (3/17); however, most interventions clearly indicated who was providing the feedback (11/17), involved a facilitator (8/12) or involved engaging in self-assessment around the target behavior prior to receipt of feedback (12/17). Conclusions Many of the theory-informed best practice items were not consistently applied in critical care and can suggest clear ways to improve interventions. Standardized reporting of detailed intervention descriptions and feedback templates may also help to further advance research in this field. The 52-item tool can serve as a basis for reliably assessing concordance with best practice guidance in existing A&F interventions trialed in other healthcare settings, and could be used to inform future A&F intervention development. Trial registration Not applicable.

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“…Indications for Mg testing accepted by our attending physicians were: 1) suspected hypomagnesemia in the setting of renal failure and 2) optional testing per clinician in suspected hypermagnesemia. We used the following change strategies: 4 1) monthly education sessions about Mg testing, 2) a prompt in the computer order-entry system to encourage only accepted indications, and 3) reminder posters. A before-and-after observational cohort design was used.…”

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confidence: 99%

Improving the appropriateness of serum magnesium testing in an intensive care unit

Zhao

Rajapakse

et al. 2020

Can J Anesth/J Can Anesth

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Multipronged strategy to reduce routine-priority blood testing in intensive care unit patients

Cited by 28 publications

References 23 publications

Reducing unnecessary diagnostic phlebotomy in intensive care: a prospective quality improvement intervention

Reducing unnecessary diagnostic phlebotomy in intensive care: a prospective quality improvement intervention

How well do critical care audit and feedback interventions adhere to best practice? Development and application of the REFLECT-52 evaluation tool

Improving the appropriateness of serum magnesium testing in an intensive care unit

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