Anesth Analg 2003;97:1479-1482
© 2003 International Anesthesia Research Society
ECONOMICS, EDUCATION, AND HEALTH SYSTEMS RESEARCH
Educational or Organizational Approach: Which Is More Effective in Changing Blood-Sampling Habits?
Christopher Gonano, MD*,
,
Christian Sitzwohl, MD*,
Franz Pusch, MD*,
Stephan C. Kettner, MD*,,
Christian Weinstabl, MD*, and
Michael Zimpfer, MD MBA*,
*Department of Anesthesiology and General Intensive Care, University of Vienna, Vienna, Austria; and
Ludwig Boltzmann Institute of Clinical Anesthesiology and Intensive Care, Vienna, Austria
Address correspondence and reprint requests to Christopher Gonano, MD, Department of Anesthesiology and General Intensive Care, General Hospital of Vienna, A-1090 Vienna, Waehringer Guertel 18-20. Address e-mail to christopher.gonano{at}univie.ac.at
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Abstract
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Diagnostic blood loss is a recognized issue during the delivery of intensive care services. We designed this study to compare the effects of educational versus organizational approaches to reduce daily diagnostic blood loss in intensive care patients. First, as an educational approach, physicians on two wards were repeatedly informed about the importance of diagnostic blood loss and that 1.0–1.5 mL is sufficient for blood gas analysis. Second, as an organizational approach, 3-mL syringes were replaced by 2-mL syringes. Measurements after both periods were compared with a control group. The amount of drawn/discarded blood of 320 samples was measured in each group after the 2 interventions. Compared with the control group, the educational program reduced the amount of drawn/discarded blood in one ward, but not the other. After the organizational change, the amount of drawn/discarded blood was reduced in both wards. Additionally, because of the smaller costs of 2-mL syringes, implementation of 2-mL syringes saved US$30,800/yr in our hospital. In conclusion, our study shows that an educational program seems less effective in influencing physician behavior than organizational changes. Therefore, organizational changes should be favored over educational approaches whenever possible.
IMPLICATIONS: Organizational change is more effective than educational programs to reduce diagnostic blood loss. Organizational implementation of smaller syringes reduces the amount of discarded blood and can save money.
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Introduction
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Treatment of intensive care patients requires frequent blood analyses to monitor their respiratory and metabolic status. Daily blood samples required for diagnosis and monitoring of intensive care unit (ICU) patients range from 60 to 75 mL (1), which can worsen ICU-related anemia (2–4). Usually more blood than needed is collected for specific determinations, resulting in large amounts of discarded blood (5). Because blood gas analyses are performed more often than other laboratory investigations, they contribute significantly to daily diagnostic blood loss.
Many attempts to decrease the amount of drawn and discarded blood are reported. In an attempt to influence physician behavior, amounts of diagnostic blood loss were recorded and smaller specimens used. This led to a reduction in the number of ordered tests, thereby resulting in less drawn and discarded blood (6). Another approach to reduce daily diagnostic blood loss is the use of smaller sample tubes, which reduces the blood sample volume to approximately 40% without worsening the quality of laboratory tests (7). However, this approach is used in <10% of adult ICUs (8). All these studies chose organizational approaches to reduce daily diagnostic blood loss.
Another approach to reduce daily diagnostic blood loss is educational programs. These educational programs are very popular; nevertheless, their effectiveness is debated. However, no study has compared organizational changes versus educational programs in their effectiveness to reduce the amount of drawn and discarded blood.
Therefore, we investigated the effect of educational programs versus organizational changes on the amount of drawn and discarded blood for routine blood analysis in ICU patients. We hypothesized that the organizational approach is more effective than the educational program in influencing physician blood-sampling habits.
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Methods
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According to Austrian regulations and the GCP, an ethics committee approval was not necessary. This study was performed at three ICU wards for surgical and trauma patients at the University of Vienna. Two wards (A and B) underwent two 1-mo study periods, whereas Ward C served as a control group. Each ward was staffed with four residents in their fourth and fifth year of residency in anesthesia and intensive care with 6 mo to 1 yr of experience in critical care. Blood samples were drawn by using a closed arterial sampling system. This device allows the complete return of the initial volume of blood taken to clear the arterial line before sampling to the patient and thereby decreases the amount of discarded blood (9).
The amount of drawn and discarded arterial blood was recorded by two independent observers. The amount of blood was registered before and after complete routine blood analysis, including blood gas analysis and analyses of sodium, potassium, calcium, chloride, glucose, creatinine, blood urea nitrogen, lactate, total proteins, osmolarity, and colloid osmotic pressure, with our standard laboratory machines. Only samples drawn in the morning by the physician in charge were registered for study evaluation by the medical laboratory staff, because during the day blood samplings could not be attributed to a single physician. Because of legal reasons in Austria, blood from arterial lines has to be sampled by a physician. Therefore, nurses could not take part in this study. In Wards A and B, each of the 4 residents provided 20 blood samples after the educational program and after the change to 2-mL syringes. In Ward C, each resident provided 20 samples. To omit bias, the physicians were not informed about this study. During Period 1, repeated educational programs for all physicians of Wards A and B were held for 1 mo.
During this time, each resident was instructed, in informal individual sessions of 2 to 3 min duration held by a technical assistant, to draw between 1.0 and 1.5 mL, which is the optimal volume to minimize the amount of discarded blood while still providing sufficient blood for sampling and analyzing. Furthermore, the residents were informed that all additional blood is wasted and that diagnostic blood loss is an important issue in ICU-related anemia. Additionally, a 1-h talk about the importance of daily diagnostic blood loss in ICUs was given to the involved physicians. Immediately after these educational programs, the amount of drawn and discarded blood was recorded for 80 samples each from Ward A and B. During this period, standard blood gas analysis syringes containing dry lithium heparin with a maximum sample volume up to 3.4 mL and a graduation up to 3.0 mL were used. Blood sample volumes were compared among Wards A, B, and C.
On the first day of Period 2, standard blood gas syringes were exchanged with smaller ones with a maximum sample volume up to 2.5 mL and a graduation up to 2.0 mL containing 80 IU of heparin. Four weeks after implementation of the smaller syringes, the amount of drawn and discarded blood was again recorded for 80 samples from each ward. The medical staff and the equipment used for arterial routine blood analysis, except for the syringes, remained unchanged during the entire study period.
All data are presented as median ± range. Normality of distribution was assessed by the Kolmogorov-Smirnov test. The Mann-Whitney U-test for nonparametric data and for comparison of continuous data was used. A P value <0.05 was considered significant.
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Results
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Eighty-two patients of 3 surgical ICU wards were included in the study, and 400 blood samples were analyzed. The control group on ward C drew 2.4 mL by using the 3-mL syringes without any education. After the educational program, median drawn blood sample volumes with 3-mL syringes at ICU A were equal to those from the control group but were larger than those on Ward B. Accordingly, volumes of discarded blood on Ward A were larger than on Ward B.
Compared with the control group during Period 2 using the 2-mL syringes, median blood sample volumes could be reduced on both wards, with Ward A still drawing more blood than Ward B. Accordingly, using the 2-mL syringes instead of the 3-mL syringes reduced the amount of drawn blood in Ward A from 2.7 to 1.7 mL. Thereby, the amount of discarded blood decreased from 2.0 to 1.0 mL. In Ward B, the median volumes of drawn blood after the educational program of 1.7 mL were not further reduced by the implementation of the 2-mL syringes instead of the 3-mL syringes. There were no blood samples of insufficient quantity (Table 1).
The organizational change to 2-mL syringes instead of 3-mL syringes also had positive economic effects. Our hospital (210 ICU beds and approximately 26,000 surgeries per year) uses 280,000 syringes for blood gas analysis per year. Because the actual price offered to our hospital for the 2-mL syringes (US$0.35) is smaller than that for the 3-mL syringes (US$0.46), US$30,800 could be saved per year by completely exchanging the syringes.
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Discussion
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Our study shows that the organizational change to smaller syringes for blood gas analysis can reduce the volumes of drawn and discarded blood significantly in ICU patients, whereas educational programs for the treating physicians failed to do so. Diagnostic blood loss is a recognized problem in ICU patients. There have been many attempts to increase awareness of the volume of sampled blood (1,7,10). Measuring the amount of drawn blood and using of pediatric-sized tubes in adult patients decreases daily diagnostic blood loss in ICU patients by nearly half (4). Nevertheless, pediatric-sized tubes are used in only approximately 10% of adult ICUs. Another way to reduce the diagnostic blood loss is through the use of closed systems, by which the blood drawn to clear the arterial line is returned to the patient. Gleason et al. (9) found that mean volume of drawn blood per day can be reduced from 69 to 35 mL by using closed systems and smaller specimens. Despite this finding, only 18% of ICUs return the volume of blood withdrawn to clear the arterial line before sampling to the patient (8).
A reasonable approach to changing habits is through educational programs. As shown by Berman and Simon (11), educational programs to influence physician behavior have only short-term effects and may even show rebound effects. Wallace et al. (12) reported that although educative programs were very popular, they were ranked together with training in information management as the least effective strategies for influencing physician behavior. More effectively ranked were facilitation of best practice in clinical teams (79%), the use of pilot projects (73%), and protocols and guidelines (52%).
We started a 1-mo program in which the physicians working in two ICUs were repeatedly informed about diagnostic blood loss due to blood sampling and how this blood loss could be reduced. Physicians of both wards underwent the same repeated educational programs and had comparable clinical experience but were unaware of the present study. We further instructed them that for routine blood analysis, 1.5 mL of blood is needed. Compared with the control group, the educational method did not decrease the volume of discarded blood on Ward A, whereas physicians on Ward B withdrew significantly less blood after the educational program.
Because physicians in all wards had the same level of experience and underwent the same educational training, this finding might represent only normal variations of educational effects. This means that some respond better to education than others. Another feasible explanation for the difference in the success of the educational program might be that physicians on Ward B care for adult and pediatric patients. Because diagnostic blood loss is an even greater problem for children than it is for adults, physicians caring for pediatric patients might be more sensitive to the problem of diagnostic blood loss than physicians who care only for adults. However, even physicians on Ward B did not meet the recommendation to draw only 1–1.5 mL after the educational program.
In a second, organizational step, we replaced standard 3-mL syringes with 2-mL syringes in an attempt to prevent physicians from drawing too much blood. Compared with the control group and after Period 1, this organizational change reduced the amount of drawn and discarded blood on Ward A by approximately 25% and 40%, respectively. On Ward B, the low volumes drawn and discarded during Period 1 could not further be reduced during Period 2.
We think that procedures in hospitals should be designed to ensure the highest level of quality independent of the individuals involved. Exchanging syringes even helped to reduce the amount of drawn and discarded blood in the group of physicians who did not respond to the educational program. Therefore, the organizational change seems more reliable than the educational approach in influencing physician behavior.
The minor organizational change from 3- to 2-mL syringes had several implications. First, the amount of drawn and discarded blood was reduced, thereby reducing diagnostic blood loss, which could result in less ICU-associated anemia. Second, our study shows that an organizational change can be effective in reducing the amount of drawn and discarded blood, whereas the educational program failed. Third, the implementation of 2-mL syringes had positive economic effects, because the 2-mL syringes are less expensive than the 3-mL syringes, resulting in US$30,800 savings in our hospital alone per year. Fourth, reducing diagnostic blood loss could result in a reduction of transfusion requirements, thereby reducing costs and patient risk associated with red blood cell transfusions.
In conclusion, our study shows, in accordance with previous studies, that whenever possible, organizational changes should be favored over educational approaches, because they are more reliable in influencing outcome. This insight might be relevant for many clinical problems for which physician habits have to be influenced, e.g., choosing between two drugs or treatments.
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Acknowledgments
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We want to thank the team of medical laboratory personnel for their support in recording the blood volumes.
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Footnotes
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None of the authors has any potential conflict of interest for this investigation.
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References
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Accepted for publication June 26, 2003.
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Abstract
Introduction
