The feasibility and impact of midnight routine blood draws on laboratory orders and processing time

Evaluating Whether an Inpatient Initiative to Time Lab Draws in the Evening Reduces Anemia

BACKGROUND

Hospital acquired anemia is common during admission and can result in increased transfusion and length of stay. Recumbent posture is known to lead to lower hemoglobin measurements. We tested to see if an initiative promoting evening lab draws would lead to higher hemoglobin measurements due to more time in upright posture during the day and evening.

METHODS

We included patients hospitalized on 2 medical units, beginning March 26, 2020 and discharged prior to January 25, 2021. On one of the units, we implemented an initiative to have routine laboratory draws in the evening rather than the morning starting on August 26, 2020. There were 1217 patients on the control unit and 1265 on the intervention unit during the entire study period. First we used a linear mixed-effects model to see if timing of blood draw was associated with hemoglobin level in the pre-intervention period. We then compared levels of hemoglobin before and after the intervention using a difference-in-difference analysis.

RESULTS

In the pre-intervention period, evening blood draws were associated with higher hemoglobin compared to morning (0.28; 95% CI, 0.22-0.35). Evening blood draws increased with the intervention (10.3% vs 47.9%, P > 0.001). However, the intervention floor was not associated with hemoglobin levels in difference-in-difference analysis (coefficient of -0.15; 95% CI, -0.51-0.21).

CONCLUSIONS

While evening blood draws were associated with higher hemoglobin levels, an intervention that successfully changed timing of routine labs to the evening did not lead to an increase in hemoglobin levels.

Effectiveness of periodontal intervention on the levels of N-terminal pro-brain natriuretic peptide in chronic periodontitis patients

Background:

N-terminal-pro-brain natriuretic peptide (NT-proBNP) is an inactive hormone that is seen during inflammation and is a known biomarker of cardiovascular disease (CVD). Evidence suggests that periodontitis has a bidirectional relationship with CVD and NT-proBNP has a potential role in periodontal disease. However, there is no evidence on the impact of nonsurgical periodontal therapy (NSPT) on the levels of NT-proBNP in gingival crevicular fluid (GCF) and serum in patients with chronic periodontitis. Hence, the aim of this study was to compare the levels of NT-proBNP in GCF and serum in patients with chronic generalized periodontitis.

Materials and methods:

GCF and serum samples were collected in 19 patients with chronic periodontitis before and after NSPT after 6 weeks and the cumulative or reduction in values of NT-proBNP in GCF and serum was assessed. NT-proBNP levels in GCF and serum were determined by enzyme-linked immunosorbent assay.

Results:

The concentrations of NT-proBNP were significantly reduced in GCF and serum after NSPT. Statistically significant difference of NT-proBNP concentration between pre- and postgroups in GCF was apparent (p < 0.0001), whereas statistically nonsignificant results in NT-proBNP serum levels when compared at baseline to postoperative state with mean of 61.77 (22.6 standard deviation [SD]) preoperatively and 72.67 (51.86 SD) postoperatively (p = 0.0007) was observed.

Conclusion:

Significant reduction of NT-proBNP concentrations in GCF and serum in patients with chronic periodontitis subjected to NSPT was observed. This may account for a significant relation between periodontal disease, bacteremia, and CVD.

Improving the Timing of Laboratory Studies in Hospitalized Children: A Quality Improvement Study

OBJECTIVES

For hospitalized children and their families, laboratory study collection at night and in the early morning interrupts sleep and increases the stress of a hospitalization. To change this practice, our quality improvement (QI) study developed a rounding checklist aimed at increasing the percentage of routine laboratory studies ordered for and collected after 7 am.

METHODS

Our QI study was conducted on the pediatric hospital medicine service at a single-site urban children's hospital over 28 months. Medical records from 420 randomly selected pediatric inpatients were abstracted, and 5 plan-do-study-act cycles were implemented during the intervention. Outcome measures included the percentage of routine laboratory studies ordered for and collected after 7 am. The process measure was use of the rounding checklist. Run charts were used for analysis.

RESULTS

The percentage of laboratory studies ordered for after 7 am increased from a baseline median of 25.8% to a postintervention median of 75.0%, exceeding our goal of 50% and revealing special cause variation. In addition, the percentage of laboratory studies collected after 7 am increased from a baseline median of 37.1% to 76.4% post intervention, with special cause variation observed.

CONCLUSIONS

By implementing a rounding checklist, our QI study successfully increased the percentage of laboratory studies ordered for and collected after 7 am and could serve as a model for other health care systems to impact provider ordering practices and behavior. In future initiatives, investigators should evaluate the effects of similar interventions on caregiver and provider perceptions of patient- and family-centeredness, satisfaction, and the quality of patient care.

Biological variables influencing the estimation of reference limits

Reference limits (RLs) are required to evaluate laboratory results for medical decisions. The establishment of RL depends on the pre-analytical and the analytical conditions. Furthermore, biological characteristics of the sub-population chosen to provide the reference samples may influence the RL. The most important biological preconditions are gender, age, chronobiological influences, posture, regional and ethnic effects. The influence of these components varies and is often neglected. Therefore, a list of biological variables is collected from the literature and their influence on the estimation of RL is discussed. Biological preconditions must be specified if RL are reported as well for directly as for indirectly estimated RL. The influence of biological variables is especially important if RL established by direct methods are compared with those derived from indirect techniques. Even if these factors are not incorporated into the estimation of RL, their understanding can assist the interpretation of laboratory results of an individual.

Postural change during venous blood collection is a major source of bias in clinical chemistry testing

BACKGROUND

To investigate the influence of different phlebotomy postures on clinical chemistry testing.

MATERIALS AND METHODS

Nineteen volunteers were recruited from the laboratory staff. A first set of samples was drawn after 25 min of resting in supine position, a second after 20 min in sitting position, and a third after 20 min in upright position. Clinical chemistry testing was performed on Roche Cobas C501.

RESULTS

The plasma volume change (PVC) was -3.4% from supine to sitting, -14.1% from supine to standing and -9.7% from sitting to standing. Compared to quality specifications for bias, hemoglobin, hematocrit, albumin and total proteins exhibited meaningful increases from supine to sitting, whereas meaningful increases were observed for hemoglobin, hematocrit, albumin, alkaline phosphatase (ALP), amylase, aspartate aminotransferase (AST), total bilirubin, calcium, total and high-density lipoprotein (HDL) cholesterol, gamma-glutamyl transferase (GGT), glucose, lactate dehydrogenase (LDH), magnesium, total protein and triglycerides from sitting to standing. The parameters with meaningful bias from sitting to upright were hemoglobin, hematocrit, albumin, ALP, total bilirubin, calcium, total and HDL cholesterol, glucose, LDH and total protein.

CONCLUSIONS

These results provide further support to the need of standardizing patient's posture during phlebotomy.