UCSF physicians launch national 'Think Twice, Stick Once' campaign to decrease unnecessary blood draws. Patients dislike blood tests and may even be harmed.
Doctors, stop sticking your patients so many times for redundant blood work during their hospital stays, especially when results won't affect your clinical decisions.
Daniel Wheeler, MD |
It's not always so urgent. Blood draws add costs, and it's not so much fun for patients to get poked with a sharp needle multiple times a day. I know it would make me grouchy.
Besides, you might be causing or hastening their anemia.
Those are among the themes in the UCSF Medical Center's "Think Twice, Stick Once" campaign that began last July through the efforts of young University of California, San Francisco internal medicine house staff doctors led by Daniel Wheeler, MD.
The practice of testing patients' blood every morning, every evening, and sometimes repeatedly in between—an average of more than twice per day—has evolved in hospital practice over decades, regardless of patients' condition or fragility, says Wheeler, a third-year resident slated to be chief resident starting in June.
Today, there's a general consensus that some of those blood draws are unnecessary, yet the repeat lab work beat goes on in most organizations around the country, he says.
So when last year's UCSF Medical Center residents huddled to decide on a quality improvement project, they picked this one. "We all felt that phlebotomy was so common, it could be very easily reduced in a safe manner," Wheeler says
A quick 10% decrease in blood tests
Launched last June, the project initially aimed to reduce blood draws among medical service patients by 5% in the 2014-2015 academic year, compared to the prior year when draws averaged 2.1 per patient per day. Obstetric, pediatric, surgical, and ICU patients are excluded because such patients may have more rapid fluctuations.
So far the team is way ahead of its goal. As of the five months since October 1, Wheeler says, the hospital's electronic database shows the count is down 10%, from 2.1 draws per day to 1.9.
"That doesn't seem like a huge change, but when you're working with an intervention that happens with as much frequency as phlebotomy, you're talking about a lot."
A draw on patient experience scores
Besides, says Wheeler, continual venipunctures are so annoying to patients that they're believed to drag down patient experience scores, which can affect up to 30% of a hospital's standing in the federal value based-purchasing program, which now affects up to 1.5% of Medicare payments, and up to 2% starting in October of 2016.
"Phlebotomy blood draws are not very pleasant. They require being poked with a needle, sometimes at odd hours of the day or night while they're resting or sleeping. And it's uncomfortable."
Hospital leadership, he says, got on board quickly with the Think Twice, Stick Once campaign.
Throughout the units, posters hang in resident work areas, while red buttons sporting the slogan have been distributed to internal medicine residents and interns.
The campaign seeks to prompt doctors "to ask ourselves, for each patient, 'will the result of this particular test affect the way I care for this patient?" Wheeler adds.
Beware exsanguination
Overly aggressive blood testing can cause harm.
Wheeler points to data suggesting that repeat draws can lead to anemia or drop patients' blood counts, which can affect their recovery. "If we can reduce phlebotomy, we can reduce the risk of hospital-acquired anemia, especially in someone who already has low blood counts or someone who has been in the hospital undergoing a lot of testing for a while," he says.
Too many unnecessary tests also can provoke false positives that require longer stays and "a cascade of more testing," and more worry for the patient. And of course, more costs. How much money the hospital will save is yet unclear and is a candidate for a future "big data" project.
If a patient's medical expenses are paid under a flat Medicare rate based on his or her diagnosis, the hospital could save. But if the patient's medical expenses are paid by the service provided, decreasing blood draws may actually decrease revenue.
Wheeler hopes to make a more detailed investigation of what types of blood tests are most likely safely avoided. Most importantly, the project is monitoring any misses, in which a blood draw that was avoided would have caught a significant, sudden deterioration in health status that could have been caught sooner. A bigger project would use EHRs to see if reduced testing affects outcomes.
"One of the things we want to figure out is by reducing the number of sticks, are we having a positive impact on patient health? That will require another level of investigation," he says.
Curb your tests
UCSF Medical Center physicians know this much: certain blood tests can be curbed
- With a patient suspected of internal bleeding, clinicians may test for hemoglobin frequently the first day, but they routinely continue those intervals several days unnecessarily. "We notice that people who are doing these tests lose track of how frequently they are testing, and even when the patient becomes more stable, we continue to check at unnecessarily close intervals. We ask the team to identify those times when lab work can be spaced out," Wheeler says.
- Other tests, such as basic metabolic panels and prothrombin times, should be conducted more than once a day for some patients in certain situations, but only checked daily for others. "For some patients, these tests need not be checked at all." The idea is to think twice about the needs of that patient before rotely ordering another test.
- After a patient is cleared for discharge, the patient no longer needs lab work, even on the morning the patient is scheduled to leave.
- Some blood levels just don't change much during hospitalization, so there's no reason to repeatedly test. "Lipid panels, A1c’s, thyroid tests, and others generally may be ordered once and not checked again." Likewise, some serology screens, like HIV and gamma-glutamyl transferase tests, won't change at all and should be done only once at most, he says.
Levels that change slowly "aren't going to change overnight, and so we encourage those draws be postponed until the routine draw the next day," he says.
Wheeler emphasizes the campaign aims only to reduce unnecessary blood testing. "We're challenging the residency house staff to separate the wheat from the chaff."
The campaign and Wheeler recently received a $7,000 Young Innovator grant from the Lown Institute in Brookline, MA, funded by the Robert Wood Johnson Foundation.
Wheeler says the project's notoriety has provoked hospital staff to "spread this line of thinking" to ways of reducing other unnecessary services. "We're now thinking of ways to reduce other sorts of tests, such as in radiology, questioning the appropriateness of all testing," he says.
"Now, this is a metric that's being tracked by our hospitalist division. Each month, we give a facilitator's guide to the attending physician, which guides the attending [physicians] to work with the residency team to reduce unnecessary phlebotomy throughout the hospital."
"Our hope is that this campaign will catch on, become a part of our clinical culture," and be extended to other medical services.
By coincidence, a similar but unrelated project is being run out of Boston University Medical Center by Faisal Rahman, another third-year resident. He also was awarded a Lown Young Innovators grant.