A Quality Improvement Project Decreasing Time Delay in Laboratory Coagulation Test Results After Cardiopulmonary Bypass at UCH A Quality Improvement Project June 6, 2016 Antasia Giebler CA1, Benjamin Lippert CA2, Nathaniel Brown CA3 Faculty Mentors: Leslie Jameson MD, Holger Eltzschig MD, PhD Thanks also to Barbara Wilkey, MD

Introduction After cardiopulmonary bypass (CPB), patients can be coagulopathic to varying degrees CPB is a potent stimulator of inflammatory cascades, which can exacerbate coagulopathies These coagulopathies often require treatment to control bleeding and ensure a safe transition from surgery to the CTICU

Introduction Routine labs drawn post-CPB: ABG and TEG are processed in the OR lab and reliably return results within 15 mins CBC, PT/INR, PTT, and Fibrinogen are sent STAT to the main lab for analysis with results taking ~60-90 minutes??? Bleeding is thus treated clinically (and with TEG as it develops) without the aid of coagulation studies, in this precarious post-CPB stage

Introduction Benefits of faster accessibility of coagulation values: Guide which products and drugs are given (i.e. cryoprecipitate vs factor concentrates for bleeding refractory to other interventions) Possibly reduce overall blood products transfused Decrease post-CPB bleeding, and enhance patient recovery times Reduce hospital costs (i.e. less blood products transfused, fewer duplicate lab studies, shorter ICU and/or hospital stays etc)

OBJECTIVES Objectives: Quantify time from blood draw to results available in Epic Assess lab priority of intraoperative post-CPB studies Identify specific time delays (e.g. getting to the lab, lab processing time, etc.) Improve hospital efficiency Enhance patient care

Methods Time blood was drawn was recorded Data initially collected on 17 pts

Initial discoveries Epic does not, by default, time stamp lab results when the data are uploaded. Default is to display timestamp from when lab label was printed Verified that Epic itself cannot retrieve this data Data to come from Beaker, the lab’s software

Travel Time

Tube station The average time is a little over 8 minutes, NOT including time spent “waiting in line” The main OR tube station has the lowest priority (out of 9 priority levels)

Lab processing time Once the sample reaches the lab it is time stamped. It is again time stamped when the results are released. (These time stamps are NOT available in EPIC.)

Average lab processing times Difficulty in getting lab processing time Waiting on the lab to get back to us on the data of the 17 cases we submitted

PDSA — first cycle We planned out our problem and identified several possible points of delay Attended a lab meeting discussing perceived delays in these cases (dovetailed with an attending pursuing the same goal) The first cycle identified delays in tubing the samples. These delays are being addressed with tube station priority to be upgraded by the end of this month

PDSA — next cycle The next cycle will involve observations of the samples from collection to the tube station to see, on average, how many handoffs are encountered Further cycle will include observation of lab sequence once samples arrive Long term solutions might include expanding POC testing in the STAT lab