Reducing Phlebotomy in Hemodialysis Patients: A Quality Improvement Study

Abstract

Rationale & Objective Hospitalized patients receiving hemodialysis frequently have routine, daily laboratory studies drawn by peripheral venipuncture-a painful process that damages peripheral veins that may be needed for future dialysis access. Some of these peripheral venipunctures are likely preventable by drawing blood samples off the hemodialysis machine circuit. We describe an initiative to allow and encourage blood to be drawn “with dialysis.” Study Design Quality improvement study. Setting & Participants Non–critically ill adult patients treated with hemodialysis at Stanford Health Care between September 2018 and September 2019. Quality Improvement Activities We modified the electronic health record to allow providers to order laboratory studies with the frequency “with dialysis.” Use of the “with dialysis” frequency was promoted through educational efforts aimed at primary medical teams, nephrology consult staff, and nephrology advanced practice providers. Outcomes We tracked the number of “with dialysis” blood draws and the number of eligible patients per week during the first year of implementation. Analytical Approach The number of “with dialysis” blood draws and eligible patients per week were measured over time. Cost savings were estimated by multiplying the difference in cost between peripheral venipuncture and “with dialysis” blood draw by the number of “with dialysis” blood draws performed. Results Uptake during the first year of implementation was an average of 6.3 “with dialysis” draws per 100 eligible patients per week. Estimated savings exceeded $7,000 in the first year of the program. Limitations Our single-center study may not be generalizable to other institutions, especially those without dialysis ordering and laboratory ordering housed within the same electronic system. We were unable to track additional outcomes, including the number of peripheral venipunctures and delays in laboratory results. Conclusions The prevention of unnecessary peripheral venipuncture in hospitalized patients receiving hemodialysis is a promising and valuable quality improvement target, which may be aided by the electronic health record. Future work is needed to increase recognition and use of “with dialysis”blood work options.

Antecubital perforating vein stent‐grafting for radiocephalic arteriovenous fistula recovery: A case report

“…However, stenosis can develop in the APV, causing vascular access dysfunction. Avoiding venipuncture of the upper‐arm veins in patients with chronic kidney disease is crucial to prevent damage to the elbow veins 4 …”

“…3 Although not well-documented in the literature, venous scarring and fibrosis commonly occur in elbow veins associated with distal AVFs since median basilic, median cubital and cephalic veins are often used for peripheral venous catheter placement, leading to vein stenosis. 4 Single lesions of these veins may not have significant clinical implications, given the redundancy of venous drainage in the elbow region. 5 The antecubital perforating vein (APV) is usually spared and often serves as the last drainage path of the forearm AVF.…”

HoloVein—Mixed-Reality Venipuncture Aid via Convolutional Neural Networks and Semi-Supervised Learning

“…The regions covered include common venipuncture sites (e.g., antecubital fossa, forearm, foot). Common factors that increase the difficulty of venipuncture, such as age, skin tone, and kidney, liver, or heart disease, are well captured in the sample group (see Appendix A for detailed breakdown) [40].…”

Evaluation of trough-based vancomycin therapy in achieving targeted area under the curve in haemodialysis cases.

“…Practically, this may not suffice, as it would require for a subsequent sampling (post dose), increased waiting time for each patient, and increased use of laboratory facilities which ultimately increases the cost borne by the healthcare facility (Surendra et al, 2018). Additionally, reducing phlebotomy in haemodialysis preserves vascular access of the peripheral veins that may serve needful for future dialysis purposes in HD patients (McCoy et al, 2020). Thus, AUC quantification via manual calculation may not prove a viable option.…”