From the 2018 HVPAA National Conference
Rebecca Levin (University of Chicago), Shwetha Devanagondi (University of Chicago), Daphne Vander Roest (University of Chicago), Namrata Patel (University of Chicago), Allison Bartlett (University of Chicago)
Premature infants are susceptible to anemia, often requiring transfusion, as a result of repeated blood draws. Transfusions are associated with morbidity and mortality in the neonatal intensive care unit (NICU) setting. Other sequelae of blood draws include infection, painful stimuli, increased cost, and unnecessary use of resources.
Pediatric residents identified significant lab test schedule variability among NICU providers and devised a project to decrease labs in their 70-bed, level-IV NICU. The aim was to decrease lab orders during the first 30 days of life in NICU infants born less than 1500 grams (g) by 10% within 1 year of August 2017. Secondary aims included implementing a standardized lab schedule for low birth-weight infants, decreasing transfusions, and decreasing the number of blood draws.
This project followed Plan-Do-Study-Act cycles in the IHI Model for Improvement. Initial interventions were focused on influencing resident practice and workflow. Routine lab schedules for neonates < 750g, 750-1000g, and 1000-1500g were developed with neonatal nurse practitioner and attending input and displayed prominently in the resident workroom. Resident rounding templates were modified to include scheduled labs. Project rationale and new rounding expectations were shared with the entire residency program as a Morning Report and via email and face-to-face communications with each new team to rotate through the NICU.
Compared with the 12 months prior to implementation, lab orders have decreased by 35% and 18% in the <750g and >1000-1500g birthweight categories and increased by 3% in the 750-1000g category, representing a $60,000 cost savings. Transfusion rates decreased between 35-48% in all weight classes and we have avoided 68 transfusions since implementation.
We surpassed our initial aim to decrease lab orders by 10% within 1 year, and we are on track to avoid 135 transfusions and over $100,000 in laboratory costs. Current and future interventions are aimed at encouraging more active participation from fellows, nurse practitioners, and nursing staff, as well as ensuring the project’s sustainability in the NICU. We are also working with our colleagues in the Pediatric Intensive Care Unit to spread this initiative.
Implications for the Patient
We have shown that simplistic interventions with minimal changes to workflow can decrease unnecessary testing and hopefully its many negative sequelae. We demonstrated that residents can strongly impact quality of care in a busy facility with many levels of providers by taking initiative in patient management on a system level.