Open Forum

Subject: Specimens without orders

1.  Specimens without orders

Posted 03-14-2017 08:13
I am wondering if any of you have measured the number of specimens received in the lab without orders.  I am currently working on a PI project for this and need benchmarking data.  I would appreciate any information members are willing to share.

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Stephanie Codina
Hospital System Laboratory Manager
Adventist Healthcare, Maryland
240-826-6689
stephanie.l.codina@questdiagnostics.com
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2.  RE: Specimens without orders

Posted 03-17-2017 14:06
There was a very good article in MLO a while back that might provide you with some useful information and an overview of the problem. The facility the article focused on found only 4 percent of the extra tubes drawn were actually uses, costing the facility over $200K.  Here's the link: Drawing extra blood tubes in the ED. Hope this helps.

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Dennis Ernst
Director
Center for Phlebotomy Education
Corydon IN
(812) 738-5700
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3.  RE: Specimens without orders

Posted 03-18-2017 00:53
I never liked the practice of drawing extra. Unfortunately cannot get rid of it from the lab. I cannot convince the lab leaders about it. 

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Drona Pandeya, MS. MLS(ASCP)
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4.  RE: Specimens without orders

Posted 03-19-2017 09:11
This is a frequent management project for students, so I can't point to anything in print, BUT every occasion I have seen (at least 4 and different institutions), the results of the students' projects point to the practice of "drawing a rainbow", as expensive.  The challenge in studying this practice, I think, is to weigh the value of the practice in those infrequent instances where it makes a critical difference in response to patient needs, against the cost overall.  One might expect that it could be important for patients in critical care areas (e.g ED) AND with critical diagnoses.  That means that the time it would take to get a second sample could  contribute to a life threatening delay.  Most patients, even in the ED, would not fall into that category.  But for a trauma victim, likely on the way to OR, having that extra tube on hand could be significant. 

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[Kathy] [Doig]
[Professor Emeritus]
[Michigan State University]
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5.  RE: Specimens without orders

Posted 03-20-2017 02:09
This practice was adopted many years ago as part of the doctors doing "Defensive Medicine" to prevent their exposure to certain liabilities. Even though it leads to increased costs related to these extra tubes, that often go unused, the need for physicians to cover themselves drives this practice more so than any potential benefit to the patient.

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Florence Morris-Turcotte
--
Tunapuna
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6.  RE: Specimens without orders

Posted 03-20-2017 14:57
Hi everyone,

I am a strong proponent for drawing a rainbow on ED patients if it helps with ED throughput in a busy ED.  If ED throughput isn't good then the waiting room backs up and the less urgent patients walk out the door (leave without being seen, or LWOBS).  This results in loss of revenue for both ED docs and the hospital. 

I was curious about the cost of the waste.  I had my students perform a project for the ED rainbow specimens in 2016 and calculate the cost of the wastage. 

They determined that:

80.2% of blue tubes were wasted  

49.5% of red tubes were wasted  

9.8% of mint green tubes were wasted  

86.9% of dark green tubes were wasted  

12.4% of purple tubes were wasted    

The total annual cost of the tubes and the cost to dispose these tubes as a biohazard was around  $8.1K.

If you weigh this cost against the pros of utilizing the rainbow the cost was actually pretty small.  The average cost of LWOBS is estimated to be around $2,000 per patient. 

Jenney Mead



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Jennifer Mead
Pueblo CO
(719) 253-7720
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7.  RE: Specimens without orders

Posted 03-21-2017 14:29
One study found when a redraw is needed due to a hemolyzed sample, it delays stat results by 54 minutes, and routine results by 90. I think it's reasonable to extrapolate the same would hold true when an add-on order is placed, but the proper tube wasn't collected for the add-on. Still, I refer back to the study that found only 4% of one facility's extra tubes were ever used. I'm not sure what the answer is, but every facility has to wrestle with finding the balance. Here's the link to the delayed TAT study: Haemolysis: an overview of the leading cause of unsuitable specimens in clinical laboratories. - PubMed - NCBI.

Cheers!

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Dennis Ernst
Director
Center for Phlebotomy Education
Corydon IN
(812) 738-5700
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8.  RE: Specimens without orders

Posted 03-21-2017 14:46
Dennis and others on this discussion, please contact Prof. Michelle Brown, michellebrown@uab.edu for a discussion of hospital-acquired anemia secondary to excessive inpatient blood collection. Michelle is collecting information on this subject as part of a doctoral dissertation. Tell her that George sent you.

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George Fritsma
Proprietor
The Fritsma Factor
Trussville AL
(205) 821-5641
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9.  RE: Specimens without orders

Posted 03-23-2017 16:15
Dennis,
I totally agree on your point on increased TAT for redraw for hemolyzed specimens. I think if multiple tubes are drawn by the same phlebotomomist and with exactly similar technique, chances of other tubes getting hemolyzed are high unless phlebotomist did not use the vacutainer and squeezed too hard to dispense the blood in tube than the other. I also want to add that most facilities use either Li Heparin tube or Gold tube as their primary tube which can be used for majority of the tests so we technically do not need extra tube to add on the test all the time unless those draws were short draws and/or need special containers. 

Great discussions.

Thanks 

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Drona Pandeya
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Lawton OK
(405) 535-4487
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10.  RE: Specimens without orders

Posted 04-14-2017 02:35

Regarding the collection of extra samples, the only problem I have with it is that the specimens are sometimes left at the bedside, and sometimes without any type of labeling, date/time of collection, etc. (I know...this NEVER happens at your institution) This is a problem on so many levels, e.g. sample mix-ups, improper storage, etc.

Just my two cents...



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Lauro E. Guerra, Jr., MLS(ASCP)cmSBBcm

If only they had an SOP for common sense...
--Musing of a former colleague
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11.  RE: Specimens without orders

Posted 03-23-2017 11:42
We had a similar issue at our institution.  One of our med students worked with our Medical Director to do a study on extra tubes...and the results were published last November.  I think you would be interested in the results and you may be able to use it to convince your providers that more is not necessarily good.
  "A total of 370,601 extra tubes of blood were collected between May 2009 and June 2015. The majority came from inpatient units (46 percent), while outpatient units accounted for 30 percent, and the emergency department (ED) for 24 percent. Overall, only 7 percent of these extra tubes were used for add-on tests, and some tube types were used less than four times out of 1,000. The findings were published Nov. 7 in the journal JAMA Internal Medicine."

JAMA Internal MedicineResearch LetterJanuary 1, 2017

The “Rainbow” of Extra Blood Tubes—Useful or Wasteful Practice?

Abstract Full Text
JAMA Intern Med. 2017; 177(1):128-129. doi: 10.1001/jamainternmed.2016.6834

This study analyzes extra blood tube usage over 6 years at the University of Iowa Hospitals and Clinics to examine how often extra tubes were used for add-on orders.



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[Rebecca] [Dill-Devor]
[MLS Supervisor]
[UIHealthcare Iowa River Landing][Coralville] [IA]
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12.  RE: Specimens without orders

Posted 03-23-2017 16:22
Thank you for posting this research article Rebecca. I was amazed to see that only 7% of the extra tubes are utilized for testing and as many as 165 extra tubes were drawn on a patient which could have been a case of ( if there was) iatrogenic anemia on that patient. This arises a question that are extra/rainbow draws really necessary ? 

Drona 

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Drona Pandeya
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Lawton OK
(405) 535-4487
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