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Reducing unnecessary diagnostic phlebotomy in intensive care: a prospective quality improvement intervention
  1. Thomas Bodley1,2,
  2. Olga Levi3,4,
  3. Maverick Chan3,5,
  4. Jan O Friedrich6,7,
  5. Lisa K Hicks1,3,5
  1. 1 Department of Medicine, University of Toronto, Toronto, Ontario, Canada
  2. 2 Department of Critical Care Medicine, Sunnybrook Health Sciences Centre, Toronto, Ontario, Canada
  3. 3 Li Ka Shing Knowledge Institute, Unity Health Toronto-St Michael’s Hospital, Toronto, Ontario, Canada
  4. 4 Medical Surgical Intensive Care, Unity Health Toronto-St Michael's Hospital, Toronto, Ontario, Canada
  5. 5 Division of Hematology/Oncology, Unity Health Toronto-St Michael’s Hospital, Toronto, Ontario, Canada
  6. 6 Interdepartmental Division of Critical Care Medicine, University of Toronto, Toronto, Ontario, Canada
  7. 7 Critical Care and Medicine Departments, Unity Health Toronto-St Michael’s Hospital, Toronto, Ontario, Canada
  1. Correspondence to Dr Thomas Bodley, Department of Medicine, University of Toronto, Toronto, Canada; thomas.bodley{at}


Background Critically ill patients receive frequent routine and recurring blood tests, some of which are unnecessary.

Aim To reduce unnecessary routine phlebotomy in a 30-bed tertiary medical-surgical intensive care unit (ICU) in Toronto, Ontario.

Methods This prospective quality improvement study included a 7-month preintervention baseline, 5-month intervention and 11-month postintervention period. Change strategies included education, ICU rounds checklists, electronic order set modifications, an electronic test add-on tool and audit and feedback. The primary outcome was mean volume of blood collected per patient-day. Secondary outcomes included the number blood tubes used and red cell transfusions. Balancing measures included the timing and types of blood tests, ICU length of stay and mortality. Outcomes were evaluated using process control charts and segmented regression.

Results Patient demographics did not differ between time periods; total number of patients: 2096, median age: 61 years, 60% male. Mean phlebotomy volume±SD decreased from 41.1±4.0 to 34.1±4.7 mL/patient-day. Special cause variation was met at 13 weeks. Segmental regression demonstrated an immediate postintervention decrease of 6.6 mL/patient-day (95% CI 1.8 to 11.4 p=0.009), which was sustained. Blood tube consumption decreased by 1.4 tubes/patient-day (95% CI 0.4 to 2.4, p=0.005) amounting to 13 276 tubes (95% CI 4602 to 22 127 tubes) saved over 11 months. Red blood cell transfusions decreased from 10.5±5.2 to 8.3±4.4 transfusions/100 patient-days (incident rate ratio 0.56, 95% CI 0.35 to 0.88, p=0.01). There was no impact on length of stay (2 days, IQR 1–5) and mortality (18.1%±2.0%).

Conclusion Iterative improvement interventions targeting clinician test ordering behaviour can reduce ICU phlebotomy and may impact red cell transfusions. Frequent stakeholder consultation, incorporating stewardship into daily workflow, and audit and feedback are effective strategies.

  • Critical care
  • Quality improvement
  • Laboratory medicine

Data availability statement

Data are available on reasonable request. Data related to this study are available on reasonable request.

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Data availability statement

Data are available on reasonable request. Data related to this study are available on reasonable request.

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  • Contributors All study authors (TB, OL, MC, JOF, LKH) were involved in study conceptualization. Improvement diagnostics to developed study interventions were led by OL with support from TB and oversite by LKH. All study authors were involved in final intervention selection and development. Intervention implementation was led by OL with support from MC and oversite by LKH. Data collection and synthesis was completed by MC, OL, and TB. Data presentation and statistical analysis was completed by TB with support from JOF and LKM. The manuscript was prepared by TB, with review and iterative contributions from OL, JOF, and LKM. Each author had full access to all the data in the study and take responsibility for the integrity of the data and the accuracy of the data analysis. TB is the corresponding author and responsible for the overall content as the study guarantor.

  • Competing interests None declared.

  • Provenance and peer review Not commissioned; externally peer reviewed.

  • Supplemental material This content has been supplied by the author(s). It has not been vetted by BMJ Publishing Group Limited (BMJ) and may not have been peer-reviewed. Any opinions or recommendations discussed are solely those of the author(s) and are not endorsed by BMJ. BMJ disclaims all liability and responsibility arising from any reliance placed on the content. Where the content includes any translated material, BMJ does not warrant the accuracy and reliability of the translations (including but not limited to local regulations, clinical guidelines, terminology, drug names and drug dosages), and is not responsible for any error and/or omissions arising from translation and adaptation or otherwise.

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