We’ve all experienced it: Waiting in the doctor’s office, hospital room or ER, perhaps in a flimsy, colorfully printed gown with your backside hanging out, for the friendly phlebotomist or nurse to come in with a rubber strap, a needle and a rack of tubes, each perhaps the size of your little finger.
The usual procedure, deftly performed in an efficient ballet: wrap the band around a bicep, have the patient flex until the vein bulges, swab the area and put in the needle.
If you’re lucky, the phlebotomist will stop at filling one tube. But often they suck out a second, a third, or more, until you’re sure you’ll be drained dry. Each tube has its own colored cap, designating the laboratory test for which it’s destined.
Unpleasant, but necessary, right? It’s all about finding out what’s wrong and how to fix it. Those extra tubes could provide the vital clues to a cure.
But what if they don’t? A study out last week from University of Iowa Hospitals and Clinics (UIHC) had surprising findings about the fate of those blood-filled tubes.I should say the results surprised me and I suspect they’ll surprise the average reader. But they confirmed a hunch long held by UI pathology professor Matthew Krasowski, an author of the study published November 7 in the journal JAMA Internal Medicine.
The paper analyzed the practice of drawing extra blood specimens – ones taken when a medical practitioner wasn’t sure if they’d be used or hadn’t ordered them. Take enough specimens and it’s a “rainbow draw” of blood-filled tubes sealed with caps in multiple colors.
It’s a widespread procedure, say Krasowski and his coauthors, UI medical student Robert Humble and Herman Hounkponou of the UIHC information systems department.
Yet, when the collaborators looked at UIHC electronic medical records from May 2009 to June 2015, they found only a tiny number of those extra blood samples actually were tested.
Of the 370,601 extra blood tubes technicians drew during this six-year span, only 7 percent were used for add-on testing, the study found. In-patient units, like hospitals, actually tested the most extra tubes at 11.5 percent, while extra tubes drawn in emergency rooms were tested only 2.8 percent of the time. In some cases, extra tubes were used for the intended test only four times out of every thousand.
Each tube typically holds about 5 cubic centimeters, or about a teaspoon, so the extra blood loss patients suffered was small. But the study found one patient had 165 extra tubes drawn – the highest for an individual. Each of another 572 patients had 50 or more extra blood tubes taken.
In a UIHC story on the study, Krasowski says several misconceptions lead to extra blood draws: doctors aren’t sure what tests they will need and want to cover their bases, or medical workers want to save patients trouble and pain by taking extra tubes rather than poking them a second, third or fourth time.
But the extra samples carry extra risks, the authors say. The specimens present a biohazard to healthcare workers, increasing their chance of exposure to blood-borne diseases. There’s a small possibility extra draws could contribute to anemia, especially in someone who’s severely ill. And despite healthcare workers’ belief that drawing extra tubes will be better for patients in the long run, unused samples actually mean they suffer discomfort for no good reason. Anyone who had a needle in their arm for more than a few seconds gets that.
And of course, there’s the waste and expense. Krasowski notes that the extra tubes consume time and money to collect, process and destroy.
Humble, in an email, said the spare specimens are incinerated as biohazard waste. “This is considerably more expensive than regular waste disposal and also contributes to pollution,” he wrote.
What I wondered after reading this is whether the study’s results could be extrapolated to the medical industry as a whole. UIHC is a research and teaching institution, one that presumably studies and implements best practices. If their experts have taken tons of unnecessary specimens, how bad could it be elsewhere?
There’s little scholarly research on the issue, Humble wrote, but the practice of taking extra blood specimens probably is widespread. Krasowski has seen it happening at other academic medical centers.
“Our suspicion is that the findings at UIHC are not unique,” Humble wrote, although it’s hard to say unless other medical centers do similar research. “The problem could be worse elsewhere. On the other hand, there are likely institutions that have dealt with this issue and who simply haven’t published their experience.”
In editor’s note accompanying the study in JAMA Internal Medicine, Dr. Deborah Grady wrote: “As a routine practice, we believe collecting extra blood for possible future testing is not patient-centered and is inefficient and potentially harmful.” Most medical centers have taken steps to cut down, Grady added.
That’s the case at UIHC, as Humble suggested. The study found policy and practice changes produced steep drops in the number of extra blood specimens.
First, the entire UIHC system switched to paperless specimen labeling. Getting an extra blood sample now means creating an additional electronic order to produce a label. Without a label for a specific tube, medical workers drew fewer extra samples.
Second, medical staff at two clinics collaborated to cut down after data analysis found the locations drew extraordinarily more samples than other facilities. The resulting drop almost entirely accounted for the overall decrease in outpatient extra tube use from 2013 to 2015, the paper says – even as the number of patients treated remained steady or grew slightly.
This bodes well for efforts to wring efficiency from a health-care system plagued by rising costs. As Humble noted, “We’ve used data analytics to inform best practices regarding specimen collection throughout the institution,” and the study shows that intervention can effectively reduce blood specimen waste. “There’s always room to improve on existing practices, and data analytics is one of the increasingly important tools … to carry out that work.”