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April 2, 2015

How one hospital is sticking it to excess blood tests

Daily Briefing

A quality improvement initiative aimed at stopping unnecessary patient blood tests at one California hospital led to a 10% decrease in phlebotomies in just five months, HealthLeaders Media's Cheryl Clark writes in MedPage Today.

According to Clark, taking patients' blood multiple times per day can be unnecessary and cost hospitals points on their patient experience scores, which can affect up to 30% of a hospital's standing in Medicare's Value-Based Purchasing program

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"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," says Daniel Wheeler, a physician at the University of California-San Francisco Medical Center.

Moreover, excess blood testing can sometimes cause harm to patients, such as hospital-acquired anemia caused by repeat draws, and can "provoke false positives that require longer stays and 'a cascade of more testing,'" Clark writes.

Nonetheless, the practice has become commonplace in hospital settings.

Details of the campaign

Last year, UCSF medical residents decided to focus their quality improvement efforts on decreasing use of phlebotomy procedures.  According to Wheeler, the goal of the campaign is "to ask ourselves, for each patient,'will the result of this particular test affect the way I care for this patient?'"

The "Think Twice, Stick Once" campaign began last July and initially sought to reduce patient blood draws by 5% during the 2014-2015 academic year. In the five months since October 2014, the hospital has reduced its draws from 2.1 per day to 1.9 draws per day—a 10% reduction.

"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," says Wheeler.

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Specifically, the program encourages physicians to:

  • Check patients suspected of internal bleeding for hemoglobin frequently the first day, but space out further tests when the patient becomes more stable;
  • Not test patients' blood after they have been cleared for discharge;
  • Think twice before checking some tests—like lipid panels, A1c's, and thyroid tests—because such levels likely will not change significantly during hospitalization.

According to Clark, the hospital's leadership has committed itself to the reduction, and posters hang in resident work areas, encouraging physicians to continue their efforts. In addition, red buttons bearing the slogan have been passed out to interns and residents.

"We're challenging the residency house staff to separate the wheat from the chaff," says Wheeler, noting he hopes to "spread this line of thinking" to reduce other unnecessary services and that it will "become part of our clinical culture" (Clark, HealthLeaders Media/MedPage Today, 3/29).

The takeaway: A hospital in California has reduced unnecessary blood tests by 10%—which could be good news for both patient experience scores and the bottom line.

Are you 'Choosing Wisely?'

While some institutions are actively incorporating the recommendations, which identify tests and procedures that may be unnecessary or overused, others worry that the recommendations will put undue pressure on physicians and cause them to divert care away from necessary tests and treatment.

Hear what our Imaging Performance Partnership experts had to say about this "step in the right direction."


More from today's Daily Briefing
  1. Current ArticleHow one hospital is sticking it to excess blood tests

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