How blood conservation can unburden the laboratory post-pandemic

Prior to the pandemic, America’s laboratories analyzed over thirteen billion medical decision-making diagnostic tests each year. Over the last twenty-four months, there have been an added one hundred million COVID-19 tests into that normal daily output.¹ This event intensified the already disrupted workflow that began a few years before when facilities started transitioning to a value-based healthcare model as the fee-for-service reimbursement model started to dissolve. Critical to delivering better patient outcomes are timely and accurate results, since over 70% of a patient’s care plan that a physician makes is directly tied back to these lab results.¹ So, while the healthcare industry continues to weigh the impact of the pandemic as it contends with a record number of employees leaving the industry, supply chain disruptions, and increasing medical mistakes, laboratorians continue to churn out crucial diagnostic tests that remain integral to the overall goal of delivering good patient care.

Roughly 13% of America’s medical professionals in the laboratory space have left. A recent Forbes article indicated burnout was the chief motivator for leaving, with staffing shortages being the next biggest cause.² This makes an unfortunate situation even more dire. Clinical laboratory testing remains an exceedingly multifaceted process (i.e., preanalytical, analytical, and postanalytical phases).³ Prior to the pandemic, the frequency for error remained stable across America’s labs at around 0.31% for all test results.⁴ Of that number, most of the mistakes occurred in the preanalytical phase. Typically, these errors refer to mistakes that occur mostly outside of the laboratory, and stem from issues such as an inappropriate sample collection, delays in transportation, or mislabeling of specimen tubes.³ Under normal working conditions, the medical laboratory staff does an excellent job of catching these sample error mistakes before being analyzed on the instruments. Since the pandemic began, the number of preanalytical errors has increased one-hundred-fold. A study in the American Journal of Clinical Pathology showed the number of preanalytical errors jumped to 3% over the last two years, with clotted samples being the biggest contributor to rejection rates.⁴

The driving force behind these large numbers could be from the before mentioned burnout and short staffing or workarounds made necessary from the nationwide blood tube shortage. In June 2021, the Food and Drug Administration (FDA) announced that due to shortages of raw materials, interruptions in manufacturer supply chains, and increased demand across the globe, sodium citrate tubes would need to be conserved. This issue became more dire when all blood collection tubes were added to the list in January 2022.3 The FDA urged laboratories to eliminate duplicate test orders and to work with physicians to only draw blood when “medically necessary.” ⁵ However, the issue is that physicians do not get training on how to determine what is medically relevant when it comes to diagnostic testing. Moreover, overall communication between laboratory and staff on the floor of the hospital has never been much more than amicable, even on a good day.

As a result of these tube shortages, increasing numbers of patients, and staffing limitations, many laboratories began to engineer a few practical workarounds. Although some of these workarounds were endorsed by the FDA and the Centers for Disease Control and Prevention (CDC), they were unsafe, outdated, less effective — and in contrast to organizations such as the Clinical and Laboratory Standards Institute (CLSI). The overall worry was whether this response would compromise patient care.¹ On the other hand, manufacturers are working around the clock to ease the burden of shortages through a number of strategies, such as allocating production lines to produce collection tubes with the highest demand. However, it will still take some time before a hospital will see any noticeable relief. Both providers and suppliers need to partner together and consider strategic ways to quicken delivery of available supplies and to approach blood collection in a more innovative way. This could be done by rethinking our continuum of care through blood conservation.

Patient Blood Management

Patient blood management is gradually becoming an integral part of a patient’s care in the hospital, but more awareness is necessary.⁴ Blood conservation is classically only mentioned when it comes to a patient on the verge of needing a transfusion; however, the question must be asked: Could this transfusion have been avoided? Anemia is a prevalent diagnostic illness when patients are admitted to the hospital. On average, it only takes three full days as an inpatient before hemoglobin and hematocrit levels drop into a borderline critical status, due to the amount of blood drawn daily.⁵ We must begin to fully optimize efficiency across all departments to limit the number of preanalytical variables that a sample goes through before arriving at the laboratory, and thus, prevent severe diagnostic blood loss and hospital-acquired anemia. Implementation should begin with the emergency department, where turn-around-time and sample quality are essential to clinical decision making. If a hemolyzed sample is drawn, this delays the treatment plan and can result in a drawn-out length of stay and overall poor experience for the patient.⁶

Reducing Hemolysis

Hemolysis can delay treatment, prolong patient stays, and negatively impact an organization’s HCAHPS (Hospital Consumer Assessment of Healthcare Providers and Systems) score for patient satisfaction. Studies show that the emergency department produces more hemolytic samples than any other department 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 Pathology.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 A study done by M.D. 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 insufficient 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 improving 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 illnesses, 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 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.

References

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 professionals. 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 laboratories. American Society of Clinical Laboratory Science. https://ascls.org/the-preanalytical-errors/#:~:text=The%20preanalytical%20errors%20refer%20to,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: Innovations, 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: Keeping 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.