Improving Quality of Patient Care in an Emergency Department

Abstract

The purpose of our study was to improve the quality of care in an emergency department (ED) as measured by length of stay (LOS), total turnaround time (TAT) for laboratory result reporting, and the blood culture contamination rate. Data were included for patients who had at least 1 of 5 laboratory tests performed as part of their care. The study was conducted in 2 phases. First, phlebotomy was performed by a dedicated phlebotomist or nonlaboratory personnel. The second phase added a dedicated laboratory technologist. There was a significant reduction in total TAT for all tests (at least 46 and 75 minutes in the respective interventions), and blood culture contamination rates dropped from 5.0% to 1.1%, although the overall LOS did not change. Estimated cost avoidance is more than $400,000 annually. Quality of care in an ED is improved when samples are collected by a dedicated phlebotomist, but overall LOS does not change.

Effectiveness of practices to reduce blood culture contamination: A Laboratory Medicine Best Practices systematic review and meta-analysis

“…Of the five studies included in the body of evidence for phlebotomy team practice effectiveness (Table 2), all were conducted in large U.S. hospitals, two in emergency departments only (Gander [41], Sheppard [13]). One of the studies is unpublished (Geisinger Wyoming Valley, 2009, Appendix B) and four are rated “Good” study quality and one is rated “Fair.” Of the included studies, three had phlebotomy team comparison groups using only venipuncture for blood draws (Gander [41], Surdulescu [16], Weinbaum [19]) which provide more reliable evidence for estimating phlebotomy team practice effectiveness than the two studies which include both venipuncture and catheter draws in their comparison groups.…”

“…Phlebotomy teams are applicable to a variety of hospital environments such as tertiary care, community and academic medical centers, emergency departments, adult general medical and surgical care settings [13,16,19,41]. Based on the included studies, phlebotomy team results are highly applicable across several patient groups in hospital settings, but less so in special cases where venipuncture may be less applicable such as neonatal intensive care units and critically ill patients in long term care.…”

“…These benefits include decreased turnaround time for laboratory test results on specimens other than blood cultures [13]; reduced frequency of misidentified and mislabeled specimens [43,44]; decrease in patient needle-stick bruises; improved quality of specimens; improved working relationships between phlebotomists and nurses; and higher levels of patient satisfaction [42,45]. …”

“…Although no definitive estimate is available, of all positive cultures, 20% to 50% are likely false positives [10–12]. According to the American Society for Microbiology (ASM) and the Clinical Laboratory Standards Institute (CLSI) overall blood culture contamination rates should not exceed 3% [1,2], however reported contamination rates in hospitals vary widely ranging from 0.6% to 12.5%, with the highest rates associated with emergency department settings [3,6–9,11,13–20]. One study reported a 26% contamination rate in pediatric outpatients [21].…”

No Preanalytical Errors in Laboratory Testing: A Beneficial Aspect for Patients

“…For example, differences in preanalytical procedures can explain up to 41 % of the variation of prevalence of hypercholesterolemia [8]. [10] reported that when the phlebotomy was performed in an emergency department by dedicated laboratory technologists, there was a reduction in overall turnaround time, and blood culture contamination rates dropped from 5.0 to 1.1 %.In addition, blood draws from indwelling catheters or during IV starts are more prone to hemolysis compared to venipuncture draws [11]. 3.…”