Monday, May 21, 2012

Skipping the Daily Blood Draw






The following anecdote is from Ioana Baiu, a joint degree candidate in medicine and public health at Harvard University





One of the most memorable discussions regarding the cost of care was at 4:45AM during surgical morning rounds.  As usual, the interns would present the overnight events of their patients to the chief resident and a plan for the day would be agreed upon.  These morning rounds were particularly intense: in addition to the 30 patients that an intern had to manage solo over night, the brutal hours that the surgical oncology service demanded, our chief resident, Dr. W., was a former army officer and his team was therefore ran in the most organized fashion that one could hope for.  On the first morning, as the interns were plowing through test results from laboratory data, Dr. W. asked them to justify some of the lab tests.  “Why did we order a Calcium on Mr. Z.? “, “Why do are we getting daily coagulation studies on Ms. S.?”.  Everyone seemed puzzled, as this was the first time when they were confronted with this issue.  Doing daily blood draws is considered as much of a routine as feeding patients and it seemed inconceivable that a blood test would be skipped. Indeed, this practice has become such a habit that nobody questioning anymore.

Dr. W., with the firmness of a longtime army veteran and the boldness of a surgeon, looked his interns in the eye, slowly, one by one.  And as everybody’s heart was racing, he referenced a study done at the Harvard School of Public Health a few years prior, illustrating the lack of utility of most blood tests for hospitalized patients.  Indeed, not only was drawing five tubes of blood on a daily basis a physiologically unnecessary stress on a post-surgical patient, but the costs associated with these tests or their results were not justifiable.  Quite the contrary, many of these results would lead to unwarranted attempts to correct an imbalance that did not affect the patient’s outcome. One famous phrase in Intensive Care Units is that patients die with perfectly normal levels of electrolytes; in other words, our fervent desire to measure everything and balance every electrolyte is often futile.

The following morning, Dr. W. was surprised to see that once again, every patient had a complete panel of blood test.  To their despair, the interns impatiently searched their orders just to realize that the blood tests had been performed in the absence of physician’s orders.  So deep was the custom of collecting blood and doing daily tests, that everyone assumed it to be a routine.  As we continued to round, Dr. W. would occasionally point to the cost of a blood test, painfully emphasizing the excessive and worthless money spending of our team.  Perhaps it was the fear of missing a small detail, or the need to be perfectionists and thorough to unreasonable limits; or perhaps it was just our naïveté as medical students and interns to the culture of medicine and the assumptions that we automatically accept as part of the “usual practice.”

It took more than a week for the interns to talk to each nurse, phlebotomist or lab assistant about not performing the blood draws without explicit orders  It was not an easy battle, and the interns had to take over the responsibility of convincing the staff one by one that while the harm of a simple blood draw is fairly minimal, the impact that extra 30 blood draws have each day on each team’s patients in the entire hospital is immense.  Empowered by the knowledge and the passion that Dr. W. inspired into all of them, the interns began a slow but effective fight against unnecessary blood draws.  And as a domino effect, only a few days later, other residents had engaged in the argument and convinced their fellow surgeons of their cause.

While Dr. W.’s fight was against a simple blood draw, his emotional determination to make a change in the cost of health care, and more importantly in the education of brand new residents, made him a champion.  He proved that big changes can be made on a small scale and that it is not always the $5,000 MRI test that will crush our budget, but the trivial daily tests that add up to hundreds of MRI costs.  He showed us how one person can change a team, a mentality, a culture.  And that it is through small acts that great deeds can indeed be accomplished.

3 comments:

  1. Dr. W should be commended for changing a situation that is unnecessary and costly.

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  2. Unnecessary blood draws....I've always wondered about this....when my dad was in hospital it used to really upset him, and me, it just 'felt' unreasonable and excessive...I did not know enough then to query the practice...now I do, and will. Really excellent post...thank you.

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  3. I used to work in a hospital lab. Every morning from 4-6 am an avalanche of samples would stream down from every floor/every patient. Each patients tests cost well over $100 and up. I thought it was to generate money for the hospital, or as defense against malpractice lawsuits. Seems like a massive waste of resources and an increase on the cost of care.

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