Client Profile
Memorial Healthcare System
Location: Florida
- • 6 Hospitals
- • 2,000+ Staffed Beds
Accumen Products
- • Lab Operations Management
Background
A vacutainer is a blood collection tube that is sterile, glass or plastic, with a colored rubber stopper creating a vacuum seal inside the tube to facilitate drawing a predetermined volume of liquid. Tubes for different types of laboratory tests have different colors of rubber stoppers. Thus, “drawing a rainbow” refers to the practice of collecting multiple types of tubes—typically gold, blue, green, lavender, red, and gray are the colors. Each tube type/color has a different cost per tube. In outpatient draw sites, inpatient hospital stays, and emergency room visits, nurses and phlebotomists (someone trained to draw blood from a patient for clinical or medical testing) may frequently choose to collect one or more extra tubes of blood from patients, in addition to those drawn for a specific laboratory test that has been ordered by a physician or other healthcare provider. Collectors may draw more than the required number of tubes for a color, draw tubes of colors not associated with tests ordered, or both. Collectors’ perception is likely that these tubes will later be used for testing, thus saving patients from a second needlestick. However, often these extra tubes do not really get used, and many resources are wasted in time, supplies, money, and patient blood. (1)
In addition to that waste, perhaps most important is the patient impact of this practice. More time with the needle in the arm drawing blood prolongs patient discomfort. More significantly, hospital-acquired anemia (decreased red blood cells or hemoglobin upon hospitalization) as a result of phlebotomy blood loss is associated with poorer patient outcomes. (2)
Assessment
In August 2021, Accumen completed an extra tubes assessment for the emergency departments of Memorial Healthcare System. Since its inception in 1953, Memorial Healthcare System has been a leader in providing high quality healthcare services to South Florida residents. It’s one of the largest public healthcare systems in the nation. Memorial Regional Hospital is the flagship facility of the healthcare system and is one of the largest hospitals in Florida. (3)
Katie Benyo, MHA, ASQ CSSBB, leading Accumen’s laboratory operations excellence work at Memorial, performed the assessment. Data collection used an Epic Beaker extra tubes report; settings provided by Accumen. This not only quantifies the number of extra tubes collected, but also notes whether or not a test was performed on that tube. The team used a one-month baseline of data from July 2021. In that baseline, total extra tubes collected (both used for testing as well as not used) averaged 1,619 per day across the in-scope emergency departments.
These included Memorial Regional Hospital, Joe DiMaggio Children’s Hospital, Memorial Hospital West, Memorial Hospital Miramar, Memorial Hospital Pembroke, and Memorial Regional Hospital South. Joe DiMaggio Children’s Hospital emergency department was initially assessed but later removed from project scope due to differences between pediatric care and adult facilities.
Findings
72% of the extra tubes collected were not used for any laboratory testing – this is considered waste (36,267 not used versus 13,916 used). Quantity collected and usage for testing varied by tube type/color, and gold top, pink top, and blue top tubes presented the greatest opportunity for reduction in collection. The annual financial opportunity was $42,788+ in supplies (tubes) discarded, based on the cost per tube provided by Memorial’s Supply Chain team. This considered each tube type/color’s unique price. Urine tubes and blood culture bottles were initially excluded from the financial calculation, which would present additional savings if reduced. Reduced biohazard waste disposal is another undocumented factor that would present additional savings.
The annual time/capacity opportunity was 3.5 laboratory full-time equivalents (FTEs) and 1.7 emergency department FTEs spent on this process. Laboratory time spent includes receiving, processing, storing, and discarding the extra tubes (using the current Specimen Processing productivity of 1 minute per tube), and nursing time spent included drawing the extra tubes (using an estimate of 30 additional seconds per tube during a collection). The annual financial and time/capacity opportunities were also broken out by site. Lastly, based on the required mL/tube, the tubes discarded annually equated to about 3,790 pints of blood. While the average-sized adult man has 12 pints of blood in his body, this equates to over 315 “bodies’ worth” of blood discarded per year as waste!
Further investigation identified that 74% of emergency department testing at the adult facilities could be captured by a light green and a lavender top tube.
Initial Implementation and Improvement
Implementation:
A project was initiated with the goal of reducing the number of extra tubes collected and not used for testing. Laboratory leadership would work with emergency department leadership, providers, and nursing to reduce the collection of extra tubes. Education would be provided regarding the opportunity to reduce wasted supplies, money, and time – as well as the opportunity to draw less blood unnecessarily from patients, contributing to their health. Emergency departments would implement new workflows, and Accumen would provide monthly monitoring of post-improvement data to ensure sustainment. The opportunity to analyze data for collection departments outside of emergency was not pursued at that time.
A kick-off meeting was held and led by Ed Peterson, MBA, MT(ASCP), Vice President of Laboratories for Memorial Healthcare System. Laboratory leadership as well as emergency physicians were in attendance to identify the parameters (e.g. patient types – exclude trauma, etc.) of the initiative. The team would communicate to staff via huddles, and data would be evaluated to determine effectiveness. The sites of Memorial Regional Hospital, Memorial Hospital Pembroke, and Memorial Regional Hospital South were the first to participate.
Improvement:
Memorial Regional Hospital saw significant improvement in mid-August 2021 and further improvement in early October 2021. Total extra tubes collected decreased by 77% over time, from average 498 per day to 114 per day.
Memorial Hospital Pembroke saw significant improvement in mid-August as well – a decrease of 58% over time, from average 196 per day to 83 per day.
Memorial Regional Hospital South saw significant improvement in early September – a decrease of 60% over time, from average 85 per day to 34 per day.
An additional question asked was whether ED census had decreased over the same time period. It was tracked for each site individually over July to October 2021 and remained stable over time.
Sustainment
After initial improvement, the three sites entered a 12-month monitoring period for sustainment (November 2021 to October 2022). Results were a 44% reduction/improvement in total extra tubes collected at Memorial Hospital Pembroke, 70% at Memorial Regional Hospital South, and a leading 74% at Memorial Regional Hospital. The majority of extra tubes collected continued to not be used for any testing (waste) – 64% at Memorial Hospital Pembroke, 62% at Memorial Regional Hospital South, and 71% at Memorial Regional Hospital. Each month, analysis also looked at waste by tube type/color, monthly time/capacity savings in laboratory and emergency department FTEs, and waste avoided in terms of pints and “bodies’ worth” of blood. Supplies (tubes) cost savings totaled $3,828 at Memorial Hospital Pembroke, $1,983 at Memorial Regional Hospital South, and $14,564 at Memorial Regional Hospital over the twelve months; a combined cost savings of $20,375.
Pandemic Impact
The United States experienced significant interruptions in the supply of several blood specimen collection tubes due to the increase in demand during the COVID-19 public health emergency as well as vendor supply challenges. In June 2021 the U.S. Food and Drug Administration (FDA) issued a letter to healthcare and laboratory personnel about a shortage of sodium citrate (light blue top) blood specimen collection tubes (Section 506J of the Federal Food, Drug, and Cosmetic Act requires the FDA to maintain a publicly-available, up-to-date list of the devices the FDA has determined to be in shortage), and in January 2022 it expanded the medical device shortage list to include all blood specimen collection tubes. The FDA recommended that healthcare providers, laboratory directors, phlebotomists, and other personnel consider a number of conservation strategies to minimize blood collection tube use while maintaining the quality and safety of patient care. These included only performing blood draws considered medically necessary, removing duplicate test orders to avoid unnecessary blood draws, avoiding testing too frequently or extending time intervals between tests whenever possible, reducing tests at routine wellness visits and allergy testing to only those that target specific disease states or where it will change patient treatment, considering add-on testing or sharing samples between laboratory departments if previously collected specimens are available, using tube types that have a greater quantity available at the facility when a discard tube is needed, and considering point of care testing that does not require using blood specimen collection tubes. (4,5)
The initiative to reduce collection of extra tubes not needed for a specific ordered lab test is in line with these recommendations to conserve supplies during times of shortage, and arguably at all times. Memorial Healthcare System benefitted from implementing changes prior to the height of the shortage.
System-wide Roll Out
In March 2022, a roll-out meeting was held and led by Ed Peterson with Memorial Hospital West and Memorial Hospital Miramar laboratory leaders, emergency department leaders, and emergency physicians. The group identified the parameters for roll-out – patient types, start dates, communication to staff, and Accumen monthly data monitoring. An additional question asked was regarding tests cancelled due to specimen integrity; these were excluded from data analysis. Another question was regarding redraw rates before versus after the implementation at the initial sites – this was analyzed and there was no increase in redraw rate over time.
The start time for both sites was March 2022, and a 12-month monitoring period was assessed for sustainment (through February 2023). Results were a 75% reduction/improvement in total extra tubes collected at Memorial Hospital West, and 65% at Memorial Hospital Miramar. The majority of extra tubes collected continued to not be used for any testing (waste) – 72% at Memorial Hospital West and 64% at Memorial Hospital Miramar. Each month, analysis continued to look at waste by tube type/color, monthly time/capacity savings in laboratory and emergency department FTEs, and waste avoided in terms of pints and “bodies’ worth” of blood. Supplies (tubes) cost savings totaled $9,546 at Memorial Hospital West and $12,372 at Memorial Hospital Miramar over the twelve months; combined cost savings of $21,918.
Conclusion
In summary, the practice of “drawing a rainbow” of multiple types of tubes in outpatient draw sites, inpatient hospital stays, and emergency room visits is likely due to nurses’ and phlebotomists’ perception that these tubes will later be used for testing, thus saving patients from a second needle stick. However, based on data collection and analysis performed by Accumen, the majority of these extra tubes do not truly get used for testing. Memorial Healthcare System was able to implement changes among five of their emergency departments to reduce this practice’s waste in terms of time, supplies, money, and patient blood – not to mention impact on patient health/healing.
References
1. “Stemming the Tide: One healthcare system drew from lean Six Sigma to reduce lab waste and save patients’ blood.” Castree, Katherine L. Lean & Six Sigma Review. Volume 20, Issue 3. May 2021.
2. Jaimie Noguez, “Tackling Hospital-Acquired Anemia: Lab-Based Interventions to Reduce Diagnostic Blood Loss,” Clinical Laboratory News, April 1, 2016.
3. Memorial Healthcare System – About Us. mhs.net/about
4. “Update: Blood Specimen Collection Tube Conservation Strategies – Letter to Health Care and Laboratory Personnel.” fda.gov January 19 2022.
5. “Lab Access to Blood Collection Tubes Threatened by Shortage.” Marcus Robertson. Becker’s Hospital Review. March 29 2022.
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