BEST PRACTICES :: BLOOD CONSERVATION in the hospital.6


But consider this: the next two units with the


most hemolysis are the ICU and pediatrics. All three of these departments report higher rates than the gold standard of less than 2% standard set by the American Society for Clinical Pa- thology.4


Another variable found indicative of hemolysis is the size of blood collection tubes used throughout the hospital.7


The


standard vacuum tubes measure at 16mm in length and are the most common tube utilized in emergency departments to acquire blood from a new IV start.6


Traditional thinking would tell us this


tube would be more relevant since it can capture more blood (average of 6ml) to run more tests in the lab. However, some manufacturers produce smaller vacuum tubes (13mm) with lower pressure and can slow the turbidity of blood flow from the catheter to the tube. For example, moving from a 16mm tube to collect a sample of 6ml of blood, to a 13mm tube to collect 3ml of blood would yield a 50% reduction in collection volume while reducing stress of the red blood cells, yielding less hemolysis.7 Several journal publications (such as Transfusion Medicine


Reviews and Clinical Laboratory News) have provided evidence that repeated diagnostic testing is a leading cause of hospital acquired anemia.8,9


Frequency in blood draws is also a major


source of excess red blood cell (RBC) transfusions, and studies show that transfused RBCs correlate to a higher mortality rate, as well as an extended length of stay.5


Anderson’s Cancer Center in Texas focused on identifying ways to reduce the amount of blood drawn on critically ill patients. Their goal was to reduce blood draws per patient by 20%. They concluded the greatest denominator that led to unnecessary blood collections on those critical patients was associated with insuf- ficient communication.5


One new procedure the hospital added


was a cross departmental huddle into their daily checklist during rounding to include a blood draw and lab test item. They formed this with the ICU team first and have now seen enough success to implement this throughout most departments in the hospital. They also worked with the lab technicians to figure out ways to decrease redundant ordered tests, occasions of one-off blood collections, and lessen standing blood draws during electrolyte administration. These actions gave the nursing and laboratory staff the independence to reschedule all nonemergent blood draws, and in some cases, the staff clustered the blood draw events together from the previous day unless otherwise specified.


Automated Ordering Prior to the pandemic, healthcare systems were transitioning from a fee-for-service model to a value-based care model. This restructuring is an effort to lower medical costs, while improv- ing patient outcomes. In this value-based model, the Institute of Healthcare Improvement’s “Triple Aim” emerged, where a hospital must show efforts toward simultaneously improving patient experience of care, improving population health, and reducing costs per capita. Unfortunately, while facilities were changing over, the pandemic hit and now, two years later, we have reports of increasing levels of burnout, stress-related ill- nesses, and 20% of America’s healthcare staff leaving the industry. Investigating a standing order policy has the potential to lower medical costs for the patient and the healthcare organization and to also improve efficiency.10


This implementation can also aid in


reducing the length of stay by improving the time to treatment. As well, it will lower processing expenses and help reorganize the old diagnostic ordering methods. Employing standing orders can improve productivity, employee retention, and patient outcomes.10


Outlook Overall, this multifaceted approach for reducing diagnostic blood loss can be adapted for routine lab testing throughout


40 AUGUST 2022 MLO-ONLINE.COM REFERENCES A study done by M.D.


1. Newman M. The weakest link: How supply chain shortages are creating challenges at the bench. Endocrine News. https://endocrinenews.endocrine. org/the-weakest-link-how-supply-chain-shortages-are-creating-challenges-at- the-bench/. Published January 24, 2022. Accessed June 22, 2022.


2. Stone J. We’re facing a critical shortage of medical laboratory profession- als. Forbes. https://www.forbes.com/sites/judystone/2022/04/28/were-facing- a-critical-shortage-of-medical-laboratory-professionals/?sh=34c1acba260c. Published April 29, 2022. Accessed June 25, 2022.


3. Hagen A. Laboratory supply shortages are impacting COVID-19 and non- COVID diagnostic testing. ASM.org. https://asm.org/Articles/2020/September/ Laboratory-Supply-Shortages-Are-Impacting-COVID-19. Published March 20, 2020. Accessed June 30, 2022.


4. Gio J. The preanalytical errors: A continuous challenge for clinical labo- ratories. American Society of Clinical Laboratory Science. https://ascls.org/ the-preanalytical-errors/#:~:text=The%20preanalytical%20errors%20refer%20 to,on%20requisition%2C%20and%20so%20on. Published March 11, 2020. Accessed June 30, 2022.


5. McLenon M. Reducing blood draws in critically ill patients. www.utsystem. edu. https://view.officeapps.live.com/op/view.aspx?src=https%3A%2F%2Fwww. utsystem.edu%2Fsites%2Fdefault%2Ffiles%2Fsites%2Fshared-visions %2Fpresentations%2FReducing-Blood-Draws-In-Critically-Ill-Patients. docx&wdOrigin=BROWSELINK. Published July 1, 2012. Accessed June 30, 2022.


6. Phelan MP, Reineks EZ, Berriochoa JP, et al. Impact of use of smaller volume, smaller vacuum blood collection tubes on hemolysis in emergency department blood samples. Am J Clin Pathol. 2017;148(4):330-335. doi:10.1093/ajcp/aqx082.


7. Wu Y, Spaulding AC, Borkar S, et al. Reducing blood loss by changing to small volume tubes for laboratory testing. Mayo Clinic Proceedings: Innova- tions, Quality & Outcomes. https://www.sciencedirect.com/science/article/pii/ S2542454820301594. Published November 19, 2020. Accessed June 29, 2022.


8. Shander A, Corwin HL. A narrative review on hospital-acquired anemia: Keep- ing blood where it belongs. Transfus Med Rev. 2020;34(3):195-199. doi:10.1016/j. tmrv.2020.03.003.


9. Noguez, Jamie. Tackling hospital-acquired anemia. www.aacc.org. https:// www.aacc.org/cln/articles/2016/april/tackling-hospital-acquired-anemia-lab- based-interventions-to-reduce-diagnostic-blood-loss. Published April 2016. Accessed July 11, 2022.


10. Robinson L. Implementing standing orders to meet the quadruple aim. https:// www.mgma.com/resources/operations-management/implementing-standing- orders-to-meet-the-quadruple. Published March 15, 2022. Accessed June 22, 2022.


Dr. Michael O’Bryan is a board-certified medical affairs specialist and has been in healthcare for seventeen years. His career includes teaching, medical practice, and in vitro diagnostics. He is currently the Medical Affairs Officer for Greiner Bio-One North America.


the healthcare facility, resulting in limiting hospital-acquired anemia and increasing patient satisfaction from reduced blood draws and improved sample quality. There is no way any of us could have predicted the turmoil that the pandemic has caused both in our professional and personal lives over the last two years. As soon as lockdowns began, COVID-19 threatened not only the healthcare industry, but our public health, economic stability, and social progress worldwide. While some activities seem to be resetting to a level of relative normalcy, there is still no guarantee when we as a country will stabilize. This is even more true in the healthcare landscape because of overburdening from all sides. Clinical practice has changed. This clinical diagnostic testing in the laboratory has changed. After two years, it is time that we as healthcare professionals rethink what has transpired, and what is still occurring, to avoid repeating mistakes for the sake of the future of laboratory medicine. We must create relationships with suppliers, look for alternative, innovative ways to control the variables in the supply chain process, and make nontraditional workflow improvements central to the quality of patient care.


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