Impact of Phlebotomy Volume Knowledge on Provider Laboratory Ordering and Transfusion Practices in the Pediatric Cardiac ICU

Objectives: Phlebotomy can account for significant blood loss in post-surgical pediatric cardiac patients. We investigated the effectiveness of a phlebotomy volume display in the electronic medical record (EMR) to decrease laboratory sampling and blood transfusions. Cost analysis was performed. Design: This is a prospective interrupted time series quality improvement study. Cross-sectional surveys were administered to medical personnel pre- and post-intervention. Setting: The study was conducted in a 19-bed cardiac ICU (CICU) at a Children's hospital. Patients: One hundred nine post-surgical pediatric cardiac patients weighing 10 kg or less with an ICU stay of 30 days or less were included. Interventions: We implemented a phlebotomy volume display in the intake and output section of the EMR along with a calculated maximal phlebotomy volume display based on 3% of patient total blood volume as a reference. Measurements and Main Results: Providers poorly estimated phlebotomy volume regardless of role, practice setting, or years in practice. Only 12% of providers reported the availability of laboratory sampling volume. After implementation of the phlebotomy display, there was a reduction in mean laboratories drawn per patient per day from 9.5 to 2.5 (p = 0.005) and single electrolytes draw per patient over the CICU stay from 6.1 to 1.6 (p = 0.016). After implementation of the reference display, mean phlebotomy volume per patient over the CICU stay decreased from 30.9 to 14.4 mL (p = 0.038). Blood transfusion volume did not decrease. CICU length of stay, intubation time, number of reintubations, and infections rates did not increase. Nearly all CICU personnel supported the use of the display. The financial cost of laboratory studies per patient has a downward trend and decreased for hemoglobin studies and electrolytes per patient after the intervention. Conclusions: Providers may not readily have access to phlebotomy volume requirements for laboratories, and most estimate phlebotomy volumes inaccurately. A well-designed phlebotomy display in the EMR can reduce laboratory sampling and associated costs in the pediatric CICU without an increase in adverse patient outcomes.