Hemolysis—can better processes add up to millions?

Taking a blood draw from an IV start is often thought to be an efficient way to save time and avoid subjecting patients to another venipuncture, but it’s the biggest factor contributing to high hemolysis rates in emergency rooms, Dr. Kiechle says. “It’s driven by a need to move patients through the process of registration and get them gowned up and ready to go to surgery or early admission or some other process such as chemotherapy. And the phlebotomy activity usually takes place when they put in the catheter and collect blood into a syringe.”

The amount of hemolysis will depend on the gauge of the needle, he adds. “If you use a 24-gauge needle you’ll get 100 percent hemolysis; if you use a 21-gauge needle you’ll get four percent. If you’re having problems with hemolysis, you’re probably using a needle with too large a gauge or too small a diameter. The manufacturers offer vacuum tubes with full pressure or partial pressure, so the other issue is that if you are using that small diameter needle and forcing the blood into the test tube, you’re going to hemolyze many more red blood cells than if you use one with not so much pressure. So using large-gauge needles and partial-pressure tubes are ways of avoiding the problem.”

In a recent case at Dr. Kiechle’s hospital, the patient’s iStat potassium, as tested on a whole blood specimen, was 4.1 mmol/L, which is in the normal range, but when a different serum specimen was tested upstairs in the clinical lab as part of an electrolyte panel, the actual value was 2.5 mmol/L, which is low. “So here we had hemolysis occur when collecting whole blood for the iStat through too small a needle and a full vacuum tube.”

Unfortunately, while the nursing staff in a hospital may believe they are saving the patient a second procedure, they could be delaying test results by an hour should those samples be hemolyzed, Ernst says. The CDC says it is a best practice not to draw blood during an IV start, and Ernst believes that, ideally, draws from an existing IV should be avoided as well.

At Sarasota Memorial Hospital, the laboratory found a way to translate these principles of avoiding hemolysis into concrete process improvement steps in the emergency department and throughout the hospital. “With Lean, you look at every possible way to improve,” Harris says.

Following the observation phase of its process improvement and based on BD’s recommendations, the hospital implemented changes in blood collection policy. Nursing educators and the laboratory developed a standardized protocol including “best practices”: ensuring alcohol is dry before inserting the needle, reducing tourniquet time to less than one minute, following the CLSI order of draw and filling tubes to the correct blood-to-additive ratio, gently inverting tubes to mix the blood with additives, and using a separate blood collection site when doing a re-draw.

A step-by-step “tip sheet” was developed and disseminated throughout the ECC and the nursing units, illustrating the best-practices process steps for blood collection and order of draw. In addition, the laboratory stocked different BD products for more effective draws through an IV catheter and for ensuring that tubes are filled with the correct blood-to-additive ratio.

By having BD come in to explain hemolysis and how to avoid it, and by making it a hospital initiative rather than one run by the laboratory, the process improvement team was able to get better acceptance from the nurses, Rickard says. “We actually had BD do the education, so it wasn’t the laboratory telling the nurses how to do it. It was the facility doing it, and it was based on the manufacturer’s recommendations.”

The hospital saw results immediately. “Just from our first meeting, the catheterization lab went back to their area and implemented the correct order of draw. And their hemolysis rate came down about three percentage points just from that. Then the nurses in other units started telling other staff about the order of draw and how it would lower their hemolysis rates too. So we started to have a nursing staff that felt empowered to get hemolysis under control.” Helped by one-on-one demonstrations of standardized blood collection practices housewide and in the ECC, the nurses became enthusiastic about performing draws correctly. “They had never had a formalized program on how to draw blood specimens and they wanted to do it right,” Rickard says.

But one roadblock remained. “The nursing staff still thought they were saving the patient a stick when they drew a sample from the patient’s IV in the ECC, and they continued to go on and draw the ‘rainbow’ of tubes”—a vial of every color—“at the time they initially started the patient’s IV.”

“A lot of times, the ECC nurses think starting an IV and drawing a rainbow for a possible test order is the best-case scenario for the patient” because it avoids a second venipuncture, Rickard explains. “But we found that the key reason for delay in turnaround time at the ECC was hemolysis from that initial draw. Plus those specimens are delayed while waiting for orders.” The laboratory realized it had to convince nursing to change what had become a standard practice: drawing blood at the IV start.

How did the laboratory manage that? “With data,” Harris says. Taking the value-added and workflow analysis, “we showed if they drew a rainbow before they did the actual lab orders, it increased their turnaround time by 25 minutes. We talked with the medical director of the ECC, because he didn’t understand why drawing ahead of the order would create a delay. But once we showed him the data, he was all on board, and actually spearheaded a project with the ECC to do specimen ID and bedside bar coding when they do the draws. The main goal is to have the orders entered first.”

The ECC in cooperation with the laboratory implemented a pilot project. A phlebotomist was assigned to perform all blood collections in two sections of the ECC for three months. “We had a drastic decrease in hemolysis in specimens coming out of the ECC, and that’s what convinced them that it really made a difference.” The nurses started taking fewer specimens at IV starts, and began using a different cannula that was less subject to hemolysis, Harris says.

As a result of Sarasota’s process improvement program, the ECC hemolysis rate, which was running about eight percent before the program started in June 2009, has averaged 0.88 percent from April 2011 to June 2012, while the hospital-wide rate has dropped from three percent to an average of 0.86 percent. According to Harris, based on a model created by Frost & Sullivan health care economists in conjunction with BD, which calculated the impact in terms of cost, lost time, and patient shortfall, the potential savings for the hospital was $3.7 million in avoided costs through its process improvement program in hemolysis. Conservatively estimated, the model showed, the improvements would save an average of $2 million to $3 million per year.

That was a pleasant surprise even to the process improvement team, Rickard confesses. “We approached this project more from a quality standpoint than from a financial standpoint,” she says. “We were thinking collection supplies, a little bit of nursing time, a little technologist and phlebotomist time” would add up to something modest. “We didn’t take into account how much an ECC bed was costing, how long hemolysis was delaying getting the patient to the floor, what about that person waiting out in the lobby, and the doctors’ time. I was totally blown away by all the information that was rolled into the analysis to show how much we were saving.”

“One of the reasons we started on the conference circuit with this is that, for years and years, laboratory people have expected two things,” Rickard adds. “First, you’re going to have hemolysis when somebody outside the lab draws blood, and second, you’re always going to have that—it’s something you cannot improve. So we wanted other labs to know we’ve broken the feeling that this is impossible. Laboratories can significantly improve their hemolysis rates, and they can even get their hemolysis rates down to unheard-of levels.”

Sarasota’s success can be duplicated anywhere, Ernst believes. “They have a method, they have a strategy, and they have a proven success with their strategy.” If every facility worked to educate staff on how hemolysis occurs and the cost to the patient and hospital of doing nothing, “then there would be more cooperation across the spectrum of health care professionals to reduce hemolysis. I think if people know, then they will make the adjustments in their technique.” Proper and comprehensive training is the key, he adds.

But process improvement in blood collection is not something that can be done on a one-time basis, Dr. Kiechle warns. “The minute you stop doing a really good job of training hospital staff in correct blood collection practices, you’re going to find hemolysis increase. Any time you find phlebotomy being done in a really high-pressure area where nurses are extremely busy and they may not have the time to devote to take care to do things correctly, there are going to be problems. And somebody has to raise the red flag.”

“Everybody and anybody with success stories in reducing hemolysis needs to talk about them to get their story heard,” he adds. “Hemolysis is an ongoing problem and it needs continuous vigilance.” 

Anne Paxton is a writer in Seattle.