Advocacy and Excessive Blood Draws

Blood loss from phlebotomy is substantial in patients with AMI, varies across hospitals, and is independently associated with the development of hospital acquired anemia.

Many moons ago as a critical care nurse I encountered my first report of hospital acquired anemia. I thought it was a rare occurence but that notion was dispelled as I accumulated more years of experience.  In fact, the first research I encountered on the topic was published in 1973 and referred to the phenomenon as nosocomial anemia. More recently, research into hospital acquired anemia found that as many as 20% of MI patients developed the condition, which researchers liniked to excessive blood draws for lab tests.

A study done about 6 years ago analyzed data for nearly 17,700 patients in 57 US hospitals between 2000 and 2008. None of these patients had an admitting diagnosis of anemia, but one in five developed moderate to severe anemia with hemoglobin levels of less than11 g/dL.  The authors found that the mean phlebotomy volume for patients who developed hospital acquired anemia was 173.8 mL vs 83.5 mL for other MI patients.  According to the study, which I found online in the Achives of Internal Medicine, every 50 mL of blood drawn was associated with an 18% increase in patients' risk for moderate to severe hospital acquired anemia.  

The authors conclude that many cases of hospital-acquired anemia are preventable and that hospital leaders should introduce tactics to decrease the number of disgnostic blood draws. I would argue that a patient-centered care manager would be attuned to these risks and take action to avoid them if at all possible. Yes, there are other tools that can be considered to address this issue such as the use of evidence based protocols, physician practice profiles, and internal laboratory quality improvement projects, but the bottom line is that together with the patient's nurse, the care manager must speak up to protect the patient against avoidable iatrogenic risk.  

A related study published in the August, 2016 issue of Journal of Hospital Medicine found that, according to self-reporting by medical residents, 88% of internal medicine residents and 68% of general surgery residents admitted ordering unnecessary labs. Across both specialties, the residents cited the following reasons:  A culture that ignored costs; a lack of transparency around costs; and a lack of faculty role models advocating for ordering constraints.  

Advocacy is job one for the hospital care manager and if the care managers are diverted from this obligation because of discharge planning responsibilities for an entire patient population, then care management leaders and hospital executives are squandering valuable resources at the expense of patient safety.