best practice presentation. The Thin Red Line

research proposal presentation for RCH best practice 2019.

Transcript

1. The Thin Red Line Characteristics of blood sampling practice. 10 Oct 2019 Matthew Van de Velde.
2. Best Practice 2019-2020. • To Understand the Characteristics of blood sampling practice of the Royal Children’s Hospital intensive care unit and the key influences that drive variation in nursing practice.
3. • National Standards. • Recommendations and findings. • Current RCH guidance, with Comparison to other centres. • Research proposal. Today’s Presentation.
4. • Neonate A. • 3.0kg (85-105mls/kg apx 255mls circulating volume). • Blood gases QID and daily bloods. • Nurse A draws 1ml for ABG and 4mls for daily tests. • Over 3 days 30mls or 11% circulating volumed is sampled. • Neonate B. • 3.0kg (85-105mls/kg apx 255mls circulating volume). • Blood gases QID and daily bloods. • Nurse B draws .5mls for ABG and 2.5mls for daily tests. • Over 3 days 16.5mls or 6.5% circulating volume is sampled. What if ?
5. • Blood Management Standard. (ASQHC, 2019) National Safety and Quality Health Services
6. • Avoiding excess sampling Volumes.4.3.3 • Early removal of sampling lines.4.3.2 • As needed sampling.4.3.4 • Return of discard/void volumes in sampling lines.4.3.5 (National Blood Authority, 2016).
7. • 2017 Audit to explore current practice. • 78 sites. • The largest explanation of lack of policy “practice has not been considered” (Blood Matters, 2017) Blood Matters Audit:
8. • Stacey and Bateman (2012). • Prospective observational study. • 63 patients. • Overdrawing of volume required. • 110% on arterial samples. • 254% on venous samples. Existing evidence:
9. • Ullman, et al (2016). • Study across 3 centres. • 940 samples observed. • 80% of samples arterial blood gases. • 50% had no data given for reason for testing. Existing evidence:
10. • Whitehead, et al (2019). • Review of inpatient studies on prevention of Iatrogenic anaemia. • 2564 studies reviewed. 21 included. • Moderate evidence for the use of inline sampling devices. Existing evidence:
11. • Watts, et al (2018) • Prospective observational study. Adult ICU. • Peak sampling time 0400-0700. • Peak POCT testing ICU, Avg costing $51 au. • No Clinical Practice Guideline for POCT. Existing evidence:
12. • Eaton, et al (2017). • Interventions to reduce unnecessary testing. • Education, EMR restrictions, Audit and feedback. • 12-21% reduction in testing. Existing evidence:
13. • Jones, et al (2019). • Impact of Nursing education on phlebotomy blood loss. • No change in Hb. • 27% of nurses reporting no previous education on Blood conservation strategies. Existing evidence:
14. • Goobie, et al (2016). • Pre-op anaemia association to post-op mortality. • Retrospective analysis • 2764 cases included. • Anaemia independently correlated to increased mortality. Existing evidence:
15. • Zhou, et al (2018) • Effect of diagnostic blood loss (Congenital cardiac disease). • 210 patients. • Mean sample volume Total 33mls +-25mls. • Mean daily sample volume 5.4mls +-1.94mls. Existing evidence:
16. • Anaemia is directly associated to higher mortality rate. • Limited Guidance existing in Literature. • ICU highest area of independent sampling. • Over sampling and inefficient practice remains a significant burden to patient mortality and hospital costing. Key points:
17. • Safe Care Vic, (2019). NICU, (2019). Interatrial access of the neonate. • PICU, (2015). Invasive Haemodynamic monitoring lines. • “2mls dead space”. • Return the discard / void volume. • “2mls dead space or 5mls or 10mls” (if checking coagulation) • Return the discard. Current guidelines:
18. • RCH, (2018). CVAD Policy. • The Sydney Children's Hospital Network, (2017) CVAD Guideline. • Discard 5mls • Do not return the Discard. (except neonate). • Discard 5mls. • Only access twice daily. • Do not return the discarded volume. Current guidelines:
19. • Westmead Children’s Hospital (2017). Arterial catheter management in neonates. • Westmead Children’s Hospital (2017). Neonatal Blood collection. • Use of “safe set” closed circuit system. • .3mls required for arterial gas. • 1.5mls discard required from a CVC. • Do Not return the Discard. Current guidelines:
20. • RCH, (2019). Patient blood management in the surgical setting State wide. • Nomothetic. • Balanced ph. Optimised Ca+. • Restrictive transfusion levels. • Minimise sampling. • Early removal of lines. • Clinical pathway for testing. Current guidelines:
21. • We don’t document blood sampling volume. • We routinely return discard volume from CVAD. • Sampling timing is not guided. • We don’t know the effects of our current practice. • What happens at the bedside currently.
22. • Part one. • Prospective self reported Audit. • Open to both sides of PICU. • Based on Blood matters audit tool (2019). • Part two. • Focus groups. • Elaboration of independent influences in nursing practice. Best Practice proposal:
23. Prospective Data collection:
24. • Voluntary. • Even mix of skill • Separate group for educators / Quality teams. • Independently facilitated. • 30 minutes in maximum length. • <10 focused questions directly relating to practice. Focus Groups:
25. • No Patient identification to be collected. • No Nursing identification to be collected. • Only burden to staff will be time required to complete both activities. Ethical Considerations:
26. • Help to shape improved nursing practice. • Increased awareness. • EMR improvements. • Future studies. Findings:
27. • PICU has the highest population of regular POCTs. • Iatrogenic anaemia and unnecessary testing holds significant mortality and cost burden. • Variation in practice can be improved. Conclusion:
28. • Australian Commission on safety and quality in health care, (2019). Prescribing and Clinical use of blood and blood products, https://www.safetyandquality.gov.au/standards/nsqhs-standards/blood- management-standard/prescribing-and-clinical-use-blood-and-blood- products/action-74 accessed on 26/09/2019. • Australian Red Cross Blood Service. (2017). Blood matters: Snapshot Audit of minimal volume blood sampling to prevent iatrogenic anaemia, Melbourne, Victorian Government. • Eaton KP, Levy K, Soong C, Pahwa, A, Petrilli, C, Ziemba, J, Cho, H, Alban, R, Blanck, J and Parsons, A (2017). Evidence-Based Guidelines to Eliminate Repetitive Laboratory Testing. JAMA Intern Med.177(12):1833–1839. DOI:10.1001/jamainternmed.2017.5152 References:
29. • Goobie, S.M., Faraoni, D., Zurakowski, D., & Dinardo, J.A. (2016). Association of Preoperative Anemia With Postoperative Mortality in Neonates. JAMA pediatrics, 170(9), 855-62. DOI:10.1001/jamapediatrics.2016.1032. • Jones, S., Spangler, P., Keiser, M.S., & Turkelson, C.L. (2019). Impact of Nursing Education on Phlebotomy Blood Loss and Hospital-Acquired Anemia: A Quality Improvement Project. Dimensions of critical care nursing : DCCN, 38 (1), 13-19. DOI:10.1097/DCC.0000000000000333. • National Blood Authority. (2016). Patient Blood Management Guidelines: module 6 neonates and paediatrics, https://www.blood.gov.au/pubs/pbm/module6/#bookmark_1 accessed on 26/09/2019. References:
30. • Royal Children's Hospital, (2018). Central Venous Access Device, https://vpn.rch.org.au/+CSCO+dh75676763663A2F2F6A6A6A2E6570752E62 65742E6E68++/policy/policies/Central_Venous_Access_Device/. Accessed on 26/06/2019. • Royal Children's Hospital, (2015). Invasive Haemodynamic Monitoring. https://vpn.rch.org.au/+CSCO+dh75676763663A2F2F6A6A6A2E6570752E62 65742E6E68++/picu_intranet/guidelines/Invasive_Haemodynamic_Monitoring/. Accessed on 26/09/2019. • Royal Children's Hospital, (2019). Patient Blood management in the Surgical Setting.https://vpn.rch.org.au/+CSCO+dh75676763663A2F2F6A6A6A2E65707 52E6265742E6E68++/clinicalguide/guideline_index/Patient_Blood_Manageme nt_in_the_Surgical_Setting/. Accessed on 26/09/2019. References:
31. • Royal Chilkdren’s Hospital, (2013). Peripheral arterial access of the neonate. https://vpn.rch.org.au/+CSCO+dh75676763663A2F2F6A6A6A2E6570752E626 5742E6E68++/neonatal_rch/intranet_resources/Peripheral_arterial_access_of_ the_neonate/. Accessed on 26/09/2019. • Safe care Victoria, (2019). Peripheral arterial access in neonates requiring intensive care. https://www.bettersafercare.vic.gov.au/resources/clinical- guidance/maternity-and-newborn/peripheral-arterial-access-in-neonates- requiring-intensive-care. accessed on 26/09/2019. • Stacey, V And Bateman, S (2012). Identifying factors to minimise phlebotomy- induced blood loss in the paediatric intensive care unit, paediatric Critical care medicine, 13(1). 22-27. DOI: 10.1097/PCC.0b013e318219681d. References:
32. • The Sydney Children's Hospital Network, (2017). Central Venous Access Devices CVAD. https://www.schn.health.nsw.gov.au/_policies/pdf/2013- 9037.pdf. Accessed on 26/09/23019. • Ullman, A, Keogh, S, Coyer, F, Long, D, New, K and Rickard, C. (2016). True blood The critical care story: An Audit of blood sampling practice across three adult, paediatric and neonatal intensive care settings. Australian critical care, 29(2), 90-95. DOI: https://doi.org/10.1016/j.aucc.2015.06.002 • Watts, S, Dhanani, J, Keogh, S, Doubrovsky, A and Coyer, F. (2019). Intensive care point of care testing for arterial blood gas analyses: a prospective observational study, University of Queensland. References:
33. • Westmead Children’s Hospital, (2017). Arterial Catheter Management Practice Guideline. https://www.schn.health.nsw.gov.au/_policies/pdf/2012-0004.pdf. Accessed on 26/09/2019. • Westmead Children’s Hospital, (2017). Blood collection in Neonate Practice Guideline. https://www.schn.health.nsw.gov.au/_policies/pdf/2012-6006.pdf. Access on 26/09/2019. • Whitehead, N, O.williams, L, Meleth, S, Kennedy, S, Ubaka-Blackmore, N, Geaghan, S, Nichols, J, Carroll, P, T.Mcevory, M, Gayken, J, Ernst, D, Litwin, C, Epner, P, Taylor, J and Graber M. (2019). Interventions to prevent iatrogenic anemia: a laboratory medicine best practices systematic review, Crical care. 23(278), 1-11. DOI: 10.1186/s13054-019-2511-9. References:
34. • Zhou, D., Luo, Y., Luo, S., Feng, M., & Tang, M. (2018). The Effect of Diagnostic Blood Loss on Anemia and Transfusion Among Postoperative Patients With Congenital Heart Disease in a Pediatric Intensive Care Unit. Journal of pediatric nursing, 38, 62-67. DOI:10.1016/j.pedn.2017.09.007. References: