1. WUSM Blood Conservation Phlebotomy Reduction Techniques Project CRIT Collaborative Meeting 6/25/2012 Jennifer York, MD Washington University in St. Louis

2. Hypothesis and Specific Aims Aim 1: The primary aim is to pilot the effectiveness of pairing evidence- based Phlebotomy Reduction Techniques (PRT) with evidence-based Implementation Strategies (IS). We hypothesize that the use of evidence- based IS to apply the PRT will synergistically facilitate effective implementation. Aim 2: The secondary aim is to capture data on clinical outcomes of volume overdrawn, hemoglobin drop, and transfusion rate. We hypothesize that blood wastage, iatrogenic anemia and red blood cell (RBC) transfusions will be reduced with effective implementation of PRT. Aim 3: The tertiary aim is to capture data on implementation outcomes of acceptability (perceived usefulness) and adoption (use of the system). We hypothesize that use of evidence-based IS will improve these implementation outcomes.

3. Pre-Implementation Data Preparation PhasePRT Implementation Post- Implementation Data Implementation Assessment Study Design

4. Pre-Implementation Data Detailed characterization of blood draws on 112 PICU patients Overdraw = the volume of blood removed in excess of requirements for any given lab set 87% of samples were overdrawn Mean overdraw 0.8 ± 1 ml 3.3 ± 2.5 ml blood/kg ( 0.5 ± 0.2 ml blood/kg/day) was removed

5. Pre-Implementation Data p<0.01

6. Pre-Implementation Data p<0.01 p<0.01 for group 1 vs. group 2 p<0.01 for group 2 vs. group 3 p<0.01 for group 1 vs. group 3 1 2 3 p<0.01 for all categories * p<0.01 for CVC vs. others *

7. Study Design Pre-Implementation Data Preparation PhasePRT Implementation Post- Implementation Data Implementation Assessment

8. Preparation Phase PICU Nursing Staff REDCap Survey PICU Nursing Staff Focus Groups Goals: – To identify driving forces for current practice – To identify barriers to change – To raise awareness – Ground level engagement

9. Study Design Pre-Implementation Data Preparation PhasePRT Implementation Post- Implementation Data Implementation Assessment

10. PRT Implementation Phlebotomy Reduction Techniques – Bedside Minimal Volume Reference Guide

11. Bedside Minimal Volume Reference Guide

12. PRT Implementation Phlebotomy Reduction Techniques – Bedside Minimal Volume Reference Guide – Exclusive microtube use with environmental engineering – Venous safe-draw system

13. Microtubes & Venous Safe-Draw

14. PRT Implementation Phlebotomy Reduction Techniques – Bedside Minimal Volume Reference Guide – Exclusive microtube use with environmental engineering – Venous safe-draw system – Blood Culture volume policy change

15. PRT Implementation Phlebotomy Reduction Techniques – Bedside Minimal Volume Reference Guide – Venous safe-draw system – Exclusive microtube use with environmental engineering – Blood Culture volume policy change Implementation Strategies – Educational Interventions – Nurse Champions – Audit and Feedback

16. Study Design Pre-Implementation Data Preparation PhasePRT Implementation Post- Implementation Data Implementation Assessment

17. Post-Implementation Data Repeat detailed characterization of blood draws on 112 PICU patients Clinical Outcomes – Volume Overdrawn – Hemoglobin drop – Transfusion rate

18. Pre-Implementation Data Preparation PhasePRT Implementation Post- Implementation Data Implementation Assessment Study Design

19. Implementation Assessment PICU Nursing Staff REDCap Survey PICU Nursing Staff Focus Groups Implementation Outcomes – Acceptability (Perceived usefulness) – Adoption (Use of system)

20. Acknowledgements Contributors: Washington University Allan Doctor, MD Philip Spinella, MD Enola Proctor, PhD Julie Hoerr, BSN, MSN Richard Griffey, MD Jennifer Jaffe, MPH, CCRP Jessica Richards, RN, BSN, CCRN Harvard University Stacey Valentine, MD Helen DeVos Children’s Hospital Nabil Hassan, MD Support at WUSM: WUSM Pediatric Critical Care Translational Research Program Lead by Philip Spinella 7 Research Personnel ICTS Dissemination and Implementation Methods Core Supported by WUSM CTSA Award Grant Number NIH UL1 RR024992 Washington University Network for Dissemination and Implementation Research ICTS Research Design and Biostatistics Group