New Phlebotomist Policy Achieves Zero Error Rate

For more than a year, Nevada medical center cuts contaminants in blood cultures to zero

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CEO SUMMARY: It’s not often when a hospital laboratory can use a patient safety project to achieve zero defects for more than one year. But that’s what happened at Desert View Hospital in Las Vegas, Nevada, when it went an entire year with no contaminants in draws for blood culture. DVH has 25 beds and does 110 blood culture draws each month. Nationally, the average rate of blood culture contamination is 3% to 5%. The financial benefits to the hospital supported the cost of adding more phlebotomy staff to achieve this goal.

ACHIEVING A ZERO RATE of contaminated blood cultures for more than a year by taking simple management steps is the lesson to be drawn from the experience of the laboratory at Desert View Hospital (DVH) in Pahrump Valley, Nevada.

This achievement saved the hospital $252,000 in the first year alone, based on savings calculated from the national average of contaminated blood cultures. It came about because of a management emphasis on how phlebotomy duties were performed.

“During 2007, our hospital had a rash of contaminants in blood cultures that caused us to exceed the national average of 3% to 5%,” recalled Henry Pfiester, Laboratory Manager at DVH. “The majority came from nurse draws and others were from phlebotomist collections.

“To address this problem, in January 2008, we retrained all phlebotomists in the proper methods of collecting blood cultures,” he explained. “A policy was then implemented that only phlebotomists could draw blood culture samples. In the first few months, we had a few contaminated cultures. But then the number fell to zero and our blood cultures have been contamination-free since April 1, 2008. It was as simple as that!

Cost-Benefit Analysis

“In other places where I’ve worked, I’ve seen the same thing: high rates of contaminated blood cultures,” Pfiester commented. “But unfortunately, in some facilities, hospital administrators are reluctant to do anything about it because it would cost money to hire phlebotomists.

“But that is false economy. When you consider that one contaminated blood sample can cost a hospital $3,000 or more per contaminant, some hospital administrators are often penny wise and pound foolish when they decline to spend the money to hire phlebotomists to collect samples the proper way.

“In doing a blood culture, for example, if the person drawing the sample coughs or sneezes when drawing the collection, then normal flora from the throat have been introduced into that culture,” noted Pfiester. “When these blood cultures are incubated, they come up positive or negative. If positive, the lab doesn’t know what caused that positivity. Thus, the patient cannot be released from the hospital until that positive result is identified. If it’s a pathogenic organism, the patient needs to be treated immediately with an antibiotic.

Hospital Bears Cost of Errors

“But if it’s a contaminant, which is often a normal skin flora or normal throat flora, then the patient cannot be charged for their extra stay,” he added. “They can’t be released and so the hospital bears the cost of keeping them for an extra day until that contaminant is identified. The national average for a day in a hospital is $3,000— and that’s just for a normal hospital day! It can be three or four times more for a specialized hospital day.

“Ten cases at $3,000 each adds up to enough to hire a phlebotomist at $11 per hour for 40 hours a week,” observed Pfiester. “In our hospital, we have only 25 beds and do only 100 to 150 blood cultures a month. If we have even the national average of contaminants of 3% to 5%, that would be 3 to 7 patients a month. That’s $9,000 to $21,000 in extra costs each month. Yet, the cost of an extra phlebotomist is much less than that. Depending on experience, a phlebotomist will get paid $11 to $15 per hour.

“In our first efforts to lower rates of contaminated blood cultures, we tried training the nurses to do the blood culture draws properly,” he said. “That didn’t work because, like everyone else in the hospital, nurses are short staffed. When lots of patients present in the emergency room, nurses don’t have time for the niceties.

Phlebotomists Draw Blood

“So our next step was to hire an extra phlebotomist to do blood culture draws during the day, the time when most cultures are drawn,” Pfiester explained. “If a blood culture needs to be done at night, then it is our policy to have a phlebotomist draw that sample. That change in policy costs nothing, while the additional day phlebotomist increases our staff costs by $11 to $15 an hour for eight hours five days a week.

“We considered this to be a no-brainer investment,” he said. “Of course, there is always the hospital administrator who, upon hearing this type of proposal, may give it a thumbs down because it means the hospital will be hiring another phlebotomist. They want to avoid adding to the number of staff.

Focusing on Cost Control

“Our success in this regard came because we presented a cost-benefit analysis and it made sense to our administration,” noted Pfiester said. “At other hospitals, administrators might simply want to keep head count down or it could be that the financial incentives are not aligned properly. In some cases, there may be outside managers or contractors involved and who veto the proposal.

“At our hospital, everyone shares in the cost of hiring the phlebotomist because the lab at DVH is run by the hospital and not by an outside agency,” he added.

“Even though we have a small hospital, the costs of a contaminated blood culture can add up quickly at $3,000 per case,” Pfiester explained. “Last year we did about 250,000 billed tests. We have six full-time technologists, two per-diem technologists, six full-time phlebotomists, and two per-diem phlebotomists. For pathology services, we hire a pathologist from Quest Diagnostics Incorporated and he serves as our medical director.”

THE DARK REPORT observes that health care policy experts have a significant challenge in uncovering all of the examples where misaligned financial incentives can thwart the best efforts to control spending. Fortunately for DVH, the financial incentives are aligned properly so that the medical center can cut costs effectively.

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