Reducing Phlebotomy in Hemodialysis Patients: A Quality Improvement Study

RATIONALE & OBJECTIVE: Hospitalized patients receiving hemodialysis frequently have routine, daily laboratory studies drawn by peripheral venipuncture-a painful process that damages peripheral veins that may be needed for future dialysis access. Some of these peripheral venipunctures are likely preventable by drawing blood samples off the hemodialysis machine circuit. We describe an initiative to allow and encourage blood to be drawn “with dialysis.” STUDY DESIGN: Quality improvement study. SETTING & PARTICIPANTS: Non–critically ill adult patients treated with hemodialysis at Stanford Health Care between September 2018 and September 2019. QUALITY IMPROVEMENT ACTIVITIES: We modified the electronic health record to allow providers to order laboratory studies with the frequency “with dialysis.” Use of the “with dialysis” frequency was promoted through educational efforts aimed at primary medical teams, nephrology consult staff, and nephrology advanced practice providers. OUTCOMES: We tracked the number of “with dialysis” blood draws and the number of eligible patients per week during the first year of implementation. ANALYTICAL APPROACH: The number of “with dialysis” blood draws and eligible patients per week were measured over time. Cost savings were estimated by multiplying the difference in cost between peripheral venipuncture and “with dialysis” blood draw by the number of “with dialysis” blood draws performed. RESULTS: Uptake during the first year of implementation was an average of 6.3 “with dialysis” draws per 100 eligible patients per week. Estimated savings exceeded $7,000 in the first year of the program. LIMITATIONS: Our single-center study may not be generalizable to other institutions, especially those without dialysis ordering and laboratory ordering housed within the same electronic system. We were unable to track additional outcomes, including the number of peripheral venipunctures and delays in laboratory results. CONCLUSIONS: The prevention of unnecessary peripheral venipuncture in hospitalized patients receiving hemodialysis is a promising and valuable quality improvement target, which may be aided by the electronic health record. Future work is needed to increase recognition and use of “with dialysis”blood work options.