Best practices in phlebotomy …in an ACO environment

Accountable Care Organizations (ACOs) are designed to improve patient compliance, outcomes, and care as the foundation to providers’ reimbursement by linking payment for services to quality metrics and cost reductions for predetermined patient populations. This approach to fee for services will affect the budgets of healthcare systems.

Laboratory medicine is a crucial element of the healthcare system. The contribution of laboratory tests and services as an essential component and partner in the healthcare system remains under-recognized.¹ With a majority of medical decisions being made based upon laboratory results, spending on laboratory services is 2.3% of the national healthcare spending and 2% of Medicare expenditures.¹ Though the laboratory’s costs are a small percentage of a healthcare system’s operating budget, the laboratory’s performance has an influence over the entire budget. Laboratory professionals have the means to help meet the performance demands in an Accountable Care Organization (ACO) environment.

This article will offer measures relating to preanalytics and phlebotomy that laboratory professionals can investigate to determine if any can be implemented to benefit the laboratory’s contribution to its entire healthcare system’s operating budget.

Use of small-volume tubes

Specimen collection using small-volume blood collection tubes (small-volume defined as a drawing between 1 mL to 2.5 mL of specimen) by themselves will not reduce costs or improve patient outcome. In fact, Wisser² concluded that “blood loss from laboratory diagnostic testing is not likely to pose a problem for most hospitalized patients.”

Iatrogenic anemia in hospitalized patients, not an uncommon occurrence, has been traced in studies to the amount of blood drawn over time. The total amount of blood drawn while the patient is hospitalized has many contributing factors, including the selection in the volume draw size of the blood collection tube.

The use of small-volume blood collection tubes can indirectly provide a healthcare system with improved patient care and reduced cost of treating patients. An area in which the laboratory can affect patient outcomes is with ICU patients, where anemia, phlebotomy, and transfusion are common long after admission. Small decreases in phlebotomy volume are associated with significantly reduced transfusion requirements in patients with prolonged ICU lengths of stay.² In a three-year study (January 1, 2001 through December 31, 2003) by Chant et al³ on anemia and transfusion practices on ICU patients, it was noted that phlebotomy does have a relation to transfusion where even small decreases in phlebotomy volumes [on ICU patients] appear to be associated with significant reductions in the number of PRBC (Packed Red Blood Cell) transfusions. Reducing the number of PRBCs is an effective means toward helping reduce costs in the healthcare system.

A critical concern laboratories face when collecting patient specimens is having enough sample for analysis. There are important reasons for collecting more specimen than the analytic volume (e.g., collection tube dead space, variation in hematocrit, repeat analyses, dilutions and add-on tests). As noted by Dale and Ruby,⁴ most laboratories could decrease collection volumes without compromising their ability to report reliable and timely results. As Sanchez-Giron and Alvarez-Mora⁵ also found, all tests requested could be performed using SVTs (small volume tubes), and no additional blood collections were required. The use of SVTs reduced overall blood loss from laboratory testing per patient by 73% and 74% in critical care patients.⁵

A review of the literature on blood loss from laboratory testing found that the blood collection tube itself is an impediment to laboratories moving to small volume tubes. Reasons cited are issues with limitations of instrument sampling, the fact that smaller tubes may be more difficult to manipulate [during venipuncture], and the fact that they may result in longer phlebotomy times and more needlesticks.⁴

These perceptions, however, are incorrect. Laboratories do have at their disposal standard blood collection tubes that will draw between 1 mL and 2.5 mL of patient specimen in the same standard size tubes used to draw 4 mL of specimen for sample analysis. This means the laboratory does not need to compromise good phlebotomy practices due to instrument limitations. Having access to small volume tubes leaves the laboratory only with the questions of how or where to implement small volume blood tubes and how much it can reduce blood loss in its healthcare facility, which contributes to reduction in cost and better patient outcomes.

Transporting the patient specimen

Chances are you have received or seen the home delivery of a pizza with the delivery person carrying the pizza in a specially designed transport container. Pizza restaurants know that the way they transport their product is directly tied to the customers’ experience, and thus critical to their financial success. Should a customer receive a less-than-warm pizza, this will result in customer dissatisfaction and added costs to the pizza restaurant. Laboratories do not deliver pizzas, but the same general principle applies. Poor transport conditions for patient specimens from a hospital laboratory’s outreach facilities will lead to added costs and patient dissatisfaction due to specimen rejection and the subsequent need to redraw the patient.

One of the numerous successes laboratories have had over the past decade is the development of horizontal and meta (vertical) networks to process patient specimens and sample testing. Many hospital-based laboratories have developed outreach programs for reference laboratory work to maintain profitability in the face of competition. By implementing a centralized core laboratory, the North Shore-Long Island Health System (New York) established a regional laboratory network and reduced overall laboratory costs while improving overall laboratory efficiency.⁶ As laboratory services are consolidated and integrated, the benefits realized have been the reduction of excess capacity, fragmentation, and redundancy.⁶

As hospital-based labs become core and regional laboratories for clinics, doctor offices, and outreach/patient service centers, more and more patient specimens are being transported over distances and time. The industry does not provide descriptive procedures or dedicated detailed guidelines on how patient specimens are to be transported from facilities outside a hospital and/or reference laboratory. However, in the Clinical and Laboratory Standards Institute document CLSI H21-A5, guidance and procedures are provided for collecting, transporting, processing, and storing blood specimens. Specific to transporting, the guidance affords some direction for specimens. Section 6.1 refers laboratories back to the Centers for Disease Control and Prevention (CDC), International Air Transport Association (IATA), and Department of Transportation (DOT) for information on the packaging and shipment of hazardous goods. In addition, CLSI provides guidance on the various types of samples, such as Plasma-Based Coagulation Assays, noting possible problems that may occur through improper transport, problems that can lead to a sample being rejected and a new patient specimen being required.

Laboratories have the opportunity to investigate just how the patient specimens are arriving at their facility for testing. Once specimens arrive at the testing laboratory, improper transport may lead to specimen rejection upon inspection, or, in the worst case, problems with analytical results. Any rejection will result in cost to the laboratory and a poor experience for the patient relating to a redraw. If your patient specimens can be delivered with a better mode of protection from outreach areas, you may have an opportunity to reduce costs and improve patient experience.

Laboratory staff education and safety

In all businesses, personnel are a major and essential part of an operating budget. A portion of this operating budget for employees should be their continuing training and education. In the laboratory, the individuals with the appropriate education and training specific to patient specimen handling will have the skills and knowledge needed to ensure that preanalytic quality is maintained.⁷

Preanalytical errors have been reported by Plebani and Carraro to be as high as 68.2% of laboratory testing mistakes,⁸ while Ross and Boone report preanalytical errors at 46% of laboratory mistakes, with 28.6% of these occurring with nonlaboratory personnel.⁹ These errors result in sample rejection and lead to patient redraws.

To help laboratories ensure training and education of the staff on processing and handling patient specimens, independent organizations and manufacturers provide instruction and materials through seminars, webinars, online videos, and training programs covering subject matters such as Addressing Preanalytical Variables, Reducing Sharp Injuries, and Patient Safety. These educational programs typically carry continuing education credit.

Keeping the laboratory staff safe is vital not only to the employees’ health, but also to avoiding costs associated with work-related injuries. A major concern among healthcare systems is sharps-related injuries. Even with legislation and the advancements in safety designs, needlestick injuries still occur. In phlebotomy procedures, 62% of injuries occur within seconds after the device is removed from the vein, but before manual activation of the safety device by the healthcare worker during the termination of a venipuncture. Laboratories have an opportunity to focus on processes to make these few seconds safer by employing the CDC guidelines for sharps injury prevention and considering the value of safety-engineered devices that provide the best level of protection against needlestick injuries at the termination of a venipuncture.¹⁰

Safety-engineered devices employing passive technology with automatic safety-shielding are available for phlebotomy procedures. Passive technology with automatic safety-shielding eliminates a key factor contributing to needlestick injuries after drawing a patient’s specimen: manually activating the safety shield.

A recent study conducted from January 2005 through December 2006 on various types of safety-engineered devices to prevent needlestick injuries concluded that automatic (passive) safety-engineered devices are more effective to reduce needlestick injuries than semiautomatic and manually activated devices. Passive devices with automatic safety were shown to cause a needlestick 0.06 times for every 100,000 uses.¹¹ Extrapolated, this translates to usage of over 1.6 million passive devices with automatic safety shielding before a needlestick injury may occur.

Educating the laboratory staff and taking the measures to help protect them from work-related injuries are performance-related activities that can have a positive impact on the laboratory and healthcare system budgets.

The road ahead

With investments already being made into the Accountable Care Organization structure, the horizon for provider payments for services linked to quality metrics and cost reductions will begin to change in 2012. As these changes begin, laboratories have opportunities, including in the areas of preanalytics and phlebotomy, to find ways to contribute to favorable patient outcomes and reduction of operating costs.

References

1. The Lewin Group. Laboratory medicine: A national status report; the value of laboratory medicine in health care. May 2008;19.
2. Wisser D, van Ackern K, Knoll E, Wisser H, Bertsch, T. Blood loss from laboratory tests. Clin Chem. 2003;49(10):1651-1655.
3. Chant C, Wilson G, Friedrich JO. Anemia, transfusion, and phlebotomy practices in critically ill patients with prolonged ICU lengths of stay: a cohort study. http://ccforum.com/content/10/5/R140. Accessed February 2012.
4. Dale JC, Ruby SG. Specimen collection volumes for laboratory tests—a College of American Pathologists study of 140 laboratories. Arch Pathol Lab Med. 2003;127:163-168.
5. Sanchez-Giron F, Alvarez-Mora F. Reduction of blood loss for laboratory testing in hospitalized adult patients using small-volume (pediatric) tubes. Arch Pathol Lab Med. 2008;132:1916-1919.
6. Bossuyt X, Verweire K, Blanckaert N. Laboratory medicine: challenges and opportunities; opinion. Clin Chem. 2007;53:101730-101733.
7. Passiment E. Quality system—the role of people. LABMEDICINE. 2005;36:10:630-632.
8. Plebani M, Carraro P. Mistakes in stat laboratory: types and frequency. Clin Chem. 1997;43:8;1348-1351.
9. Ross JW, Boone DJ. Assessing the effect of mistakes in the total testing process on the quality of patient care [Abstract 102]. In: Martin L, Wagner W, Essien JDK, eds. 1989 Institute of Critical Issues in Health Laboratory Practice. Minneapolis, MN: DuPont Press. 1991.
10. US Department of Health and Human Services, Centers for Disease Control and Prevention. Evaluation of safety devices for preventing percutaneous injuries among health-care workers during phlebotomy procedures—Minneapolis-St. Paul, New York City, and San Francisco, 1993-1995. MMWR Weekly. Jan. 17, 1997:46(02):21-25.
11. Tosini W, Ciotti C, et al. Needlestick injury rates according to different types of safety-engineered devices: results of a French multicenter study. Infection Control and Hospital Epidemiology. April 2010;31:402-407.

Kevin Daugherty is Director of Marketing, Preanalytics at Greiner Bio-One North America, Inc., responsible for Product Management, Marketing Management, and Technical Marketing.