SummaryThe two main campuses of Emory Healthcare—Emory University Hospital and Emory University Hospital Midtown—dedicate onsite phlebotomists to the emergency department during peak census hours. The phlebotomists collect blood specimens from patients and mark them for priority analysis with a yellow label, indicating to laboratory staff that they should prioritize these specimens for processing and analysis. The phlebotomists also provide additional support to emergency department clinicians by tracking and following up on the laboratory results. At Emory University Hospital Midtown, the program reduced laboratory turnaround time, the time to physician evaluation, and blood culture contamination rates, resulting in estimated annual cost savings of more than $400,000. In addition, patient satisfaction has increased since implementation of the program.Moderate: The evidence consists of before-and-after comparisons of key outcomes measures, including laboratory turnaround time, blood culture contamination rates, time from patient arrival until physician examination, and patient satisfaction, along with estimates of the cost savings due to lower contamination rates.
Developing OrganizationsEmory Healthcare
Date First Implemented2007
Problem AddressedBlood specimen quality and laboratory turnaround time (the time from sample collection to reporting of results) can affect the quality and safety of patient care.1 However, in the interest of cost savings, many hospitals have decentralized phlebotomy services, allowing blood specimens to be collected by nurses or other nonlaboratory personnel. The absence of hospital phlebotomists, especially in the emergency department (ED), has led to higher specimen contamination rates, longer laboratory turnaround times and ED length of stay (LOS), and increased use of antibiotics and other health care resources.1
- Elimination of phlebotomist positions: To reduce labor costs, hospitals often eliminate positions with duplicate skill sets. In many cases, hospitals have eliminated phlebotomy teams, instead allowing nurses and physicians to draw blood specimens.1
- More specimen contamination: Despite hospitals’ efforts to educate nonlaboratory staff on proper phlebotomy techniques,1 contamination rates are higher when clinicians other than phlebotomists collect the specimens. A study of 356 U.S.-based clinical laboratories found significantly higher blood culture contamination rates in institutions that use nonlaboratory personnel to collect specimens than in facilities using dedicated phlebotomists.2
- Longer turnaround time, higher resource utilization: The elimination of phlebotomy teams can lead to higher turnaround time for laboratory test results, thereby contributing to ED congestion and lengthier ED stays.1 In addition, the higher specimen contamination rates that often result from the elimination of phlebotomy teams can lead to longer ED and hospital LOS,1,3 and to increased use of antibiotics and other resources.3
- Special concerns in the ED: Quality, safety, and service concerns can be especially problematic for ED patients, who account for a high proportion of total specimens; at Emory University Hospital Midtown, between 25 and 33 percent of all blood culture specimens are collected in the ED.1
Description of the Innovative ActivityThe two main campuses of Emory Healthcare—Emory University Hospital and Emory University Hospital Midtown—dedicate onsite or on-call phlebotomists to the ED during peak census hours. The phlebotomists promptly collect blood specimens from patients and mark them for priority processing and analysis by laboratory staff. The phlebotomists also provide additional support to ED clinicians by tracking and following up on laboratory results. Key elements of the program include the following:
- Onsite or on-call ED phlebotomists during peak hours: At Emory University Hospital Midtown, the laboratory assigns a phlebotomist to work in the ED during the morning and evening shifts every day of the week. At Emory University Hospital, ED staff can call the laboratory to request an onsite phlebotomist whenever ED patient volumes are high, with the phlebotomist remaining in the ED as long as necessary to assist ED staff in assessing patients quickly.
- Quick specimen collection by phlebotomists: Phlebotomists frequently check the hospitals' health information system for newly entered orders for blood specimen collection. A notification appears in the system whenever an order is entered, and the onsite phlebotomist quickly completes the specific request. This process allows ED nurses and physicians to focus on other aspects of patient care.
- Colored labels indicating need for priority processing: All ED blood specimens are marked with a bright yellow label, which signals to laboratory staff the need for rapid processing and analysis. (By contrast, specimens from inpatient units or outside clinics have white labels). When the ED specimens arrive via pneumatic tube in the laboratory’s central processing area, staff recognize the yellow label, place the specimen in a centrifuge, and run the centrifuge manually. (In contrast, all other specimens are placed on an automation line, which runs batches of specimens through a high-volume automated centrifuge.) Once the ED specimen has been manually processed, laboratory staff bring the specimen to a designated spot in the medical technologists’ work area near the chemistry analyzers, and turn on a flashing light to indicate that an ED specimen awaits analysis.
- Priority analysis: Medical technologists see the flashing light and retrieve the ED specimen as soon as they come to a stopping point in their work, thereby prioritizing analysis of these specimens.
- Assistance with tracking and communicating results: When time permits, the phlebotomist checks on the status of pending laboratory specimens, follows up with laboratory staff if necessary, and communicates updates to the ED staff involved in the patient's care.
Context of the InnovationEmory Healthcare, with 1,184 licensed beds, includes Emory University Hospital, Emory University Hospital Midtown, and other specialty hospitals and clinics in the Atlanta area. Each year, Emory University Hospital Midtown's ED treats approximately 56,000 patients, while Emory University Hospital's ED handles nearly 33,000 patients. Emory Healthcare’s EDs had onsite laboratories until 1998, when laboratory testing was consolidated at Emory University Hospital in an effort to standardize testing practices and better utilize the shrinking laboratory labor force. By 2006, ED administrators became concerned about long ED LOS (which averaged roughly 6 hours) and the significant amount of time spent on diversion (which averaged 12.4 percent at Emory University Hospital Midtown). As a result, they began investigating programs that could improve these measures. ED and laboratory administrators met on an ongoing basis to discuss laboratory turnaround times and determine how to get results to the ED clinicians more quickly. These administrators suspected that onsite phlebotomists might improve turnaround time and reduce blood contamination rates.
ResultsThe program has reduced laboratory turnaround time, the time to physician evaluation, blood culture contamination rates, and ED LOS, resulting in estimated annual cost savings of more than $400,000. In addition, patient satisfaction has increased since implementation of the program.
Moderate: The evidence consists of before-and-after comparisons of key outcomes measures, including laboratory turnaround time, blood culture contamination rates, time from patient arrival until physician examination, and patient satisfaction, along with estimates of the cost savings due to lower contamination rates.
- Faster turnaround time: A pilot study conducted at Emory University Hospital Midtown found that average turnaround time for specimens of ED patients who had at least one of five tests (complete blood count, chemistry panel, prothrombin time, troponin, or blood culture) decreased by 46 minutes (from 165 minutes to 119 minutes) after dedicated phlebotomy staff were placed in the ED. Permanent adoption of the program at both sites has led to a significant reduction in overall turnaround time for blood specimens, from between 2 and 3 hours to less than 60 minutes.
- Shorter waits for patients to see physician: The pilot study found that the average amount of time ED patients waited after arrival to see a physician decreased by 24 minutes.
- Lower contamination rates: Blood culture contamination rates in the pilot study decreased from 5 percent before program implementation (when nonlaboratory staff collected specimens) to 1.5 percent after phlebotomists began collecting them, well below the 3 percent benchmark set by the Clinical and Laboratory Standards Institute.2 These rates are consistent with current (September to November 2009) contamination rates throughout the hospital, which run 1.5 percent for phlebotomist collections and 5 percent for nonphlebotomist collections.
- Cost savings: Given that nearly 60,000 ED blood cultures are collected each year at Emory University Hospital Midtown, program leaders estimate that the onsite phlebotomist saves the hospital more than $400,000 a year, as lower contamination rates reduce the need for repeat blood draws and test processing.
- Higher patient satisfaction: Before the implementation of the program, patient satisfaction scores (as measured by Press Ganey surveys) were equal across all shifts in the Emory University Hospital Midtown ED. At present, scores are significantly higher on the evening shift when onsite phlebotomists are usually present. ED administrators attribute these higher scores to the presence of the phlebotomist because no other significant differences exist between the evening and other shifts.
- Reduction in ED LOS: Information provided in July 2011 indicates that the program reduced ED LOS by several hours from its original level of approximately 6 hours.
- No change time on diversion: The program did not have a measurable impact on time on diversion at Emory University Hospital Midtown (which remained at approximately 12.4 percent).
Planning and Development ProcessKey steps in the planning and development process included the following:
- Identifying ED shift most in need of help: Given that limited laboratory resources would not allow placement of a phlebotomist in the ED during all shifts, laboratory and ED representatives met to determine which ED shift could most benefit from an onsite phlebotomist.
- Allocating onsite phlebotomist: The laboratory administrative director, who oversees the laboratory budget, determined how to allocate a dedicated phlebotomist to one high-volume shift at Emory University Hospital Midtown.
- Soliciting interest: The laboratory department put out a notice to all staff phlebotomists soliciting interest in an ED-based position.
- Pilot testing: The laboratory representatives determined the parameters to be monitored (e.g., turnaround time, blood contamination rate) and piloted the initiative on the evening shift in Emory University Hospital Midtown’s ED.
- Making program permanent: Based on positive pilot test results, the onsite phlebotomist has been retained on the evening shift; laboratory resources cannot support a similar assignment at Emory University Hospital, so laboratory and ED representatives agreed to accommodate ED needs by allowing the laboratory to dispatch an on-call phlebotomist to the ED as needed during peak census hours.
Resources Used and Skills Needed
- Staffing: The program requires no new staff, as existing staff incorporate it into their daily routines; information provided in July 2011 indicates that two phlebotomists are assigned to cover a morning and an evening shift each day. The Emory Medical Laboratory, which covers Emory University Hospital, Emory University Hospital Midtown, and the specialty hospitals and clinics employs 81.25 full-time employees as phlebotomists. The core laboratory at Emory University Hospital Midtown employs 19 medical technologists, while 23 medical technologists are employed at Emory University Hospital.
- Costs: This program required no incremental costs for planning or ongoing operations.
Funding SourcesEmory Healthcare
Getting Started with This Innovation
- Take multidepartmental approach: Discussing and developing this type of program should involve laboratory, ED, and hospital administrators. Each group views the patient care process through a different lens, and hence can contribute unique suggestions for improvements. In addition, including different stakeholder groups ensures that the process reflects each group’s needs, that all relevant improvement measures are tracked, and that workflow changes have broad support.
- Dedicate a phlebotomist, but not a medical technologist: In addition to assessing the effect of an onsite phlebotomist during the initial pilot at Emory University Hospital Midtown, researchers also tested the impact of having one medical technologist in the laboratory only receive and analyze ED specimens. Though this intervention did improve turnaround time, the researchers determined that it would be more efficient to have multiple medical technologists prioritize the ED specimens concurrently, as they feared that a dedicated ED medical technologist could experience work backlogs during peak census times in the ED. This conclusion led to the development of the workflow process currently used at Emory University Hospital and Emory University Hospital Midtown.
- Choose the right phlebotomists: The ED environment can be very fast paced and tense, and hence much different than an inpatient unit. Select a phlebotomist who is engaged by and can thrive in such an environment. The phlebotomists should also be prepared to do more than just draw blood by acting as a laboratory liaison who helps smooth the work process.
- Plan and explain workflow to phlebotomist: Time-pressed ED staff cannot be expected to orient the phlebotomist to the ED setting and workflow. Plan the workflow with the ED administrator, and then prepare the phlebotomist accordingly so that he/she understands where to check for orders and what tasks need to be performed.
Sustaining This Innovation
- Track data and share results: Tracking and sharing data related to turnaround time, blood contamination rates, and estimated cost savings due to reductions in these contamination rates, can convince hospital administrators to maintain and/or expand the program.
- Recognize the importance of job "fit": Information provided in July 2011 indicates that phlebotomists may be used to working in a hospital environment, not in a busy ED. Program developers report that traditional hospital phlebotomists have had trouble fitting into their new role.
- Consider different workflows when attempting to spread the innovation to other EDs: Information provided in July 2011 indicates that program developers have spread this innovation to the Emory University Hospital campus, but had to incorporate a different design to accommodate that ED's work flow. At Emory University Hospital, ambulatory patients entering the ED are first seen in triage where a decision is made to fast track them for release or send them to the midlevel ED for additional testing or protocol activation. Program developers arranged for the phlebotomist to collect specimens when the midlevel ED placed the orders. However, although the order-to-verified turnaround times were on average 1 hour faster when collected by the phlebotomist rather than nonphlebotomists, a single phlebotomist was unable to collect specimens on enough patients to impact the turn around time for all ED patients.
Contact the InnovatorNicole Franks, MD, FACEP
Chief Quality Officer
Emory University Hospital Midtown
Associate Professor Emergency Medicine
Co-Director: Emergency Medicine Administration Fellowship
Emory University School of Medicine
550 Peachtree Street
Atlanta, GA 30308
Phone: (404) 686-4536
Innovator DisclosuresDr. Franks has not indicated whether she has financial interests or business/professional affiliations relevant to the work described in this profile.
References/Related ArticlesSheppard C, Franks N, Nolte F, et al. Improving quality of patient care in an emergency department: a laboratory perspective. Am J Clin Pathol 2008;130:573-7. [PubMed]
Sheppard C, Franks N, Nolte F, et al. Improving quality of patient care in an emergency department: a laboratory perspective. Am J Clin Pathol 2008;130:573-7. [PubMed]
Bekeris LG, Tworek JA, Walsk MK, et al. Trends in blood culture contamination: a College of American Pathologists Q-Tracks study of 356 institutions. Arch Pathol Lab Med 2005;129:1222-5. [PubMed]
Surdulescu S, Utamsingh D, Shekar R. Phlebotomy teams reduce blood-culture contamination rate and save money. Clin Perform Qual Health Care 1998;6:60-2. [PubMed]
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Original publication: July 21, 2010.
Original publication indicates the date the profile was first posted to the Innovations Exchange.
Last updated: July 30, 2014.
Last updated indicates the date the most recent changes to the profile were posted to the Innovations Exchange.
Date verified by innovator: June 02, 2013.
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