D226 Task 1 PDSA Capstone Paper Example

Fewer Redraws in the Emergency Department: A Plan-Do-Study-Act Cycle to Reduce Hemolyzed Blood Samples Drawn by Nurses

Student Name

Leavitt School of Health, Western Governors University

D226: BSNU Capstone, Task 1

Course Instructor

Month Day, Year

Fewer Redraws in the Emergency Department: A Plan-Do-Study-Act Cycle to Reduce Hemolyzed Blood Samples Drawn by Nurses

The Practice Problem

A hemolyzed blood sample is one in which red cells have ruptured during collection or handling, releasing potassium, lactate dehydrogenase and hemoglobin into the serum. The laboratory cannot report many chemistry results from such a sample, so the patient must be stuck again, results are delayed and decisions wait. Falsely high potassium from a hemolyzed sample can also prompt unnecessary treatment or repeat testing. In emergency departments, where nurses draw most blood through intravenous catheters as they place them, hemolysis rates are much higher than in samples drawn by phlebotomists. In a study of more than 141,000 encounters across three EDs between 2021 and 2022, 17.2% of samples from patients with an ED-placed catheter were hemolyzed (Calleja et al., 2023), and in another ED, patients whose samples hemolyzed stayed an average of 62 minutes longer than patients whose samples did not (Phelan et al., 2020).

The setting for this capstone is a composite 36-bed emergency department (ED) in a 300-bed community hospital with about 52,000 visits a year. Nurses collect nearly all ED blood samples, usually through a new 20-gauge or 22-gauge catheter at the time of insertion, using vacuum tubes attached directly to the catheter hub. The laboratory's quality report for the last three months showed that 14.2% of 9,840 ED chemistry samples were rejected or flagged for hemolysis, compared with 2.1% for inpatient samples drawn by phlebotomy. Each rejected sample meant a second stick and, by the ED's own tracking, a median delay of 48 minutes to the result. Nurses described redraws as one of the most frustrating parts of the job, and patients described them as a sign that staff did not know what they were doing.

Evidence for the Intervention

The strongest evidence is a meta-analysis carried out for the Centers for Disease Control and Prevention's laboratory medicine best practices initiative. All 11 studies comparing new straight needle venipuncture with drawing through a newly placed intravenous catheter found lower hemolysis rates with venipuncture, with an average risk ratio of 0.16, and four studies found that when catheters had to be used, placing them at the antecubital site reduced hemolysis by more than half (Heyer et al., 2012). The review rated the overall strength of evidence as high and recommended straight needle venipuncture as a best practice.

A single-site study in an urban ED illustrates the effect in practice: requiring separate venipunctures for laboratory samples reduced the hemolysis rate from 23.0% to 6.6% in the following month (Straszewski et al., 2011). Where drawing through a catheter cannot be avoided, the force of collection matters. In a randomized comparison of samples drawn through catheters, gentle manual aspiration produced hemolyzed samples about 2% of the time, while vacuum collection produced them about 30% of the time (Lippi et al., 2013). Recent data point the same way: in the three-ED cohort, 22-gauge catheters carried higher odds of hemolysis than 20-gauge catheters (odds ratio 1.78), and hand or wrist placement roughly doubled the odds compared with the antecubital site (Calleja et al., 2023).

Together these studies support a two-part intervention: a separate straight needle venipuncture for laboratory samples in stable patients who need a catheter only for later use, and, when a catheter draw is necessary, a 20-gauge or larger catheter at the antecubital site with gentle manual aspiration rather than direct vacuum.

Aim and Measures

Aim: reduce the hemolysis rate of ED chemistry samples from 14.2% to below 8% within four weeks on the unit where the change is tested, and to below 6% department-wide within six months.

Outcome measure: the percentage of ED chemistry samples flagged for hemolysis by the laboratory's automated index, taken from the laboratory's daily quality report. Process measure: the percentage of audited collections that followed the new practice, checked on ten random collections per shift by the charge nurse. Balancing measures: the average number of needle sticks per patient who had blood drawn, and patient complaints related to blood draws.

Plan

The first cycle will be tested on the night shift, when volume is lower and the same group of about twelve nurses works most shifts. The prediction is that hemolysis on night shift samples will fall below 8% in four weeks and that sticks per patient will rise by no more than 0.3.

Stakeholders and roles: the ED nurse manager approves the test; I lead it as a night shift staff nurse; the laboratory quality coordinator provides daily hemolysis data by shift; two night charge nurses complete audits; a nurse educator reviews the technique with each night nurse in a ten-minute session at the start of a shift; and the materials coordinator stocks syringe transfer devices and butterfly needles in each treatment room. Resources are modest: education time of about two hours in total, audit time of about ten minutes per shift and supplies already on the hospital's contract.

Anticipated barriers include nurses' reluctance to add a second stick for patients who will need a catheter anyway, time pressure during surges and habit. The education session will present the department's own redraw data, since each redraw is also a second stick, and the charge nurses will model the practice on their own patients.

Do

The test ran for four weeks on the night shift. Nurses drew samples by straight needle venipuncture for stable patients, used the antecubital site and a syringe with gentle manual aspiration when a catheter draw was necessary, and continued usual practice for critically ill patients when speed required it. The charge nurses completed 224 audits, and the laboratory reported hemolysis for every night shift chemistry sample. Two problems appeared in the first week: syringe transfer devices ran out on two nights, and three nurses said they did not know when a patient counted as unstable. The materials coordinator doubled the par level, and the educator added a one-line rule to the education card: if the physician wants results before a catheter would otherwise be placed, draw separately.

Study

Over the four weeks, 7.9% of 812 night shift chemistry samples were flagged for hemolysis, compared with 14.6% on the night shift during the baseline period, meeting the prediction of below 8%. Day and evening shift samples, where practice had not changed, stayed at 14.0% over the same period, which makes it unlikely that the improvement came from a change in the laboratory or the analyzer. Audits showed that 81% of collections followed the new practice, rising from 68% in the first week to 90% in the fourth. Sticks per patient rose from 1.3 to 1.5, within the predicted limit, and no complaints about blood draws were recorded. Samples from critically ill patients drawn through catheters under time pressure accounted for a large share of the remaining hemolysis.

Act

The decision is to adapt and expand. The practice will be extended to the day and evening shifts in a second cycle, with the education session delivered at each shift huddle and the audit continued for eight weeks. The second cycle will add one change aimed at the remaining hemolysis: stocking syringe draw kits at the resuscitation bays so that even urgent catheter draws use gentle aspiration. If the department-wide rate falls below 6% and holds for three months, the practice will be written into the ED's specimen collection policy and the checklist new ED nurses complete during orientation, and the laboratory will add hemolysis by shift to the ED's monthly quality dashboard so the result stays visible. The cycle method itself is the reason for starting small: it allowed the team to fix supply and definition problems on one shift before asking the whole department to change (Langley et al., 2009).

Leadership Reflection

I did not need a title to lead this change, but I did need data the nurse manager trusted and colleagues who saw the problem the same way I did. The most persuasive moment was not the evidence review but showing the night staff that every redraw is also an extra stick, which answered their main objection directly. If I repeated the project, I would involve the laboratory quality coordinator earlier, since her daily report by shift made the study stage possible and she had ideas about specimen transport that we have not yet used.

References

Calleja, R., Mielke, N., Lee, R., Johnson, S., & Bahl, A. (2023). Hemolyzed laboratory specimens in the emergency department: An underappreciated, but frequent problem. Journal of Emergency Nursing, 49(5), 744-754. https://doi.org/10.1016/j.jen.2023.06.001

Heyer, N. J., Derzon, J. H., Winges, L., Shaw, C., Mass, D., Snyder, S. R., Epner, P., Nichols, J. H., Gayken, J. A., Ernst, D., & Liebow, E. B. (2012). Effectiveness of practices to reduce blood sample hemolysis in EDs: A laboratory medicine best practices systematic review and meta-analysis. Clinical Biochemistry, 45(13-14), 1012-1032. https://doi.org/10.1016/j.clinbiochem.2012.08.002

Langley, G. J., Moen, R. D., Nolan, K. M., Nolan, T. W., Norman, C. L., & Provost, L. P. (2009). The improvement guide: A practical approach to enhancing organizational performance (2nd ed.). Jossey-Bass.

Lippi, G., Avanzini, P., & Cervellin, G. (2013). Prevention of hemolysis in blood samples collected from intravenous catheters. Clinical Biochemistry, 46(7-8), 561-564. https://doi.org/10.1016/j.clinbiochem.2013.01.021

Phelan, M. P., Hustey, F. M., Good, D. M., & Reineks, E. Z. (2020). Seeing red: Blood sample hemolysis is associated with prolonged emergency department throughput. The Journal of Applied Laboratory Medicine, 5(4), 732-737. https://doi.org/10.1093/jalm/jfaa073

Straszewski, S. M., Sanchez, L., McGillicuddy, D., Boyd, K., DuFresne, J., Joyce, N., Wolfe, R., Lee, A. W., Fisher, J., & Mottley, J. L. (2011). Use of separate venipunctures for IV access and laboratory studies decreases hemolysis rates. Internal and Emergency Medicine, 6(4), 357-359. https://doi.org/10.1007/s11739-011-0568-9