Asking Why: Daily Bloodwork at Providence

Sep 3, 2019 | News

While inquisitive minds are often drawn to health care, it can still prove difficult to ask why or admit when we don't know something. This can ring especially true when it comes to routine practices that we simply go through the motions of.

Sometimes it can take a patient or a resident to remind us to question.

“We had an anemic patient, and were doing daily routine blood work on him to monitor his hemoglobin. One morning he said to me, ‘I don’t have enough blood and yet you keep taking blood away from me.’ And that really got me thinking. Why were we doing daily blood draws on him, knowing that likely from day-to-day, we wouldn’t see a rise in hemoglobin,” recalls medical biochemist and internist Dr. Janet Simons.

For Dr. Janet Simons, Site Medical Lead for Pre and Post Analysis at St. Paul’s Laboratory, asking “why?” about routine bloodwork catapulted a change that has already resulted in 10 to 15% fewer morning collections and 15 to 20 fewer patients a day experiencing unnecessary bloodwork that added no value to their care or experience with us.

But why?

When a physician orders “Daily” bloodwork, the specifics around how long this “daily” extends to had previously never been defined – was it for just that day, or was it to be daily draws over the duration of the patients’ stay?

A quick glance of the past two years of routine bloodwork quickly revealed to Dr. Simons that this issue was more significant than she had anticipated with the longest unbroken run of daily bloodwork being 202 days.

“I went to the Unit Coordinators (UC) to see what the process was and how this daily order was being rolled over day after day,” says Dr. Simons. “Lacking clarity on when “daily” stops and starts for an inpatient, the UCs came up with a solution: they created a bloodwork Kardex for daily orders, and every day at 5pm, they would take out the Kardex and would put all the daily bloodwork orders in for the next day.”

And no one, except for the patients, was aware that this was happening.

Dr. Simons’ analysis also revealed high variability in practice, including variation in what orders replace or override previous orders, and physicians being unaware of daily orders that had been placed days or weeks prior.

After discovering this process and the variabilities around routine bloodwork, Dr. Simons’ next thought was, perhaps these repeated orders are clinically indicated. She took to doing a chart review to see what had instigated the order. She randomly selected one file to look at and stopped after her third random file.

She knew all that she needed to.

Moved to Action

“We have ample literature supporting the avoidance of ordering repeated bloodwork on inpatients who are clinically stable. In all three cases I looked at, there wasn’t anything that clinically indicated the need for daily blood draws,” explains Dr. Simons. “Further analysis showed that over two years, one patient had same order 200 days in a row. Hundreds of patients had daily draws for a month, and thousands had runs for at least 14 days.”

So how do we stop a system that has naturally evolved, but has evolved in a way that doesn't need to exist and has been built based on assumption?

“It’s our role as leaders and those who provide care for others to question one another -- we want to be questioned,” says Dr. Simons. “Most of this was happening in a way that no one intended but the system assumes something and has grown up around it.”

Dr. Simons’ first step was to make people aware that this was happening and as she suspected, few were aware of it. Her second step was to draft a guideline, which has been endorsed and was introduced on June 3, putting an automatic stop on “daily” bloodwork orders.

“Orders for ‘daily’ bloodwork should be interpreted as an order for the requested bloodwork to be done once daily with routine morning rounds for a maximum of three days,” Dr. Simons’ new guideline explains. “If further bloodwork is desired, further specific orders are required. This includes orders for daily bloodwork, even if the duration is specified.”

Read the guideline in full.

What’s to Gain?

Reducing ‘routine’ bloodwork stands to offer the following benefits:

  • Increased patient comfort and more patient-centred care – for our patients, unnecessary bloodwork means uncomfortable pokes, risk of infection, blood loss, and a less positive hospital experience.
  • Less iatrogenic anemia.
  • Fewer morning collections (~10%), meaning morning bloodwork can be done sooner, which aids in our flow work and supporting earlier patient discharges.
  • Freed up Nursing, Phlebotomy and Unit Coordinator time.
  • Less physician time spent worrying about or following up on incidental findings or small variations.
  • More thoughtful and deliberate ordering.
  • Learning opportunities for students and resident physicians.
  • Reduced costs for the hospital and Providence.
  • Preparation for upcoming CST changes.

The Value of It All

“It’s still early as the guideline only went ‘live’ in early June but my analysis of data from June and July reflects a 10% reduction in morning collections, which translates into about 15 to 20 fewer per day,” reports Dr. Simons. The estimated cost savings of this reduction are on the order of thousands of dollars per month.

Dr. Simons is hoping to do a more in-depth analysis, once the guideline has been in effect a bit longer.

“I feel like the need for this guideline speaks to something larger about culture change; more collaboration is needed,” reflects Dr. Simons. “We all need to ask why we are doing things that cost money and add no value for patients.”

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Our Mission: Forward is defined by four strategic directions: Quality-Forward, People-Forward, Learning-Forward and Partnership-Forward.

Our Quality-Forward direction is all about delivering exceptional quality, safety and value to the people we serve. Dr. Simons’ work moves us ahead in our Quality-Forward direction and our desire to continuously learn about how to deliver, quality, safety, and value.

It also shines a light on our need to bolster our Learning-Forward culture and what it means to be focused on value-based health care (a concept that we are in the early stages of defining at Providence; right now, we’re working on simply starting to think about it in the work we do. Later in our journey we will start to better socialize it and determine what it means for us and looks like here.)

And finally, Dr. Simons’ efforts shows us how important work outside of our identified Year One Accomplishments can, and should, still be embraced. If you want more information on the intake process for new work, please connect with Josephine Jung and/or check out this chart: Pilot Approach to Intake New Work.

Mission Forward

Comments

This important work led by Dr. Janet Simons is going to have an important impact on patient care and diagnostic stewardship. This reminds us to question the value of testing so that we can better help patients and the system

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