Moving forward, our “How I Make Change Happen” series will feature both the philosophies and wisdom of experienced change agents in medicine as well as an example of change made. To complement Dr. Ashoo’s first post on “How I Make Change Happen, we now present his change case study!
What Prompted The Change
There is evidence supporting the use of venous blood gasses instead of arterial blood gasses in many clinical scenarios. Venous gasses offer an alternative to decrease patient discomfort while maintaining rapid results for critical patients. Once I became convinced of the benefits of this test, and its interpretations, I set out to implement its use. There were several points to consider with problems at each stage:
Key Steps to Change
- Background & Needs Assessment: search the order catalog to be sure the test didn’t already exist. No need to duplicate efforts if someone else in the institution has already done the work. At our hospital, the answer was no.
- Identify who is involved in the current process: Lab admin, respiratory therapy, nursing admin.
- Determine who will be impacted by the change: Patients (in a positive way), nurses (in a neutral way), respiratory therapy (in a positive way), lab (minimal additional work burden)
- Cost Analysis: Cartridges to run VBG on point of care equipment were readily available. As utilization increases, the cartridge cost can be significant, especially if there is duplication of lab testing making the VBG test un-reimbursed. Tracking is necessary.
- Education: convince my fellow physicians and nursing administration that the test was needed and would make caring for patients safer, less painful, and faster. For this stage, I used clips of the EM:RAP podcast featuring Mel Herbert as he explained why he uses the test and its utility. I also explained the benefits of reducing arterial puncture.
- Resources: what equipment and personnel will be necessary to begin? For this stage, we had an actual meeting with our respiratory therapy leaders, lab supervisors and nursing admin. Eventually, it was decided that nursing personnel would draw the sample, and RT would run it.
Challenges Encountered, Assessment, and Reassessment
- Implementation: Arterial Blood gasses in our ED are performed by the respiratory therapist and run on a point of care ABG analyzer. We needed evidence that the same system had could be used for venous blood gas analysis. The manufacturer had to be queried for FDA approval and then came the big question… who would draw the sample? Our respiratory therapists were not trained for IV care or venous access. This seems silly but in the hospital world education is provided and tracked for each type of healthcare staff member. Our Respiratory Therapists were not credentialed by hospital procedure to draw venous samples. However, none of our nursing staff were credentialed to use the point of care blood gas analyzer. So we compromised (after much debate) and decided the nurse would draw the sample and hand it to the respiratory therapist.
- Testing: At this point, we built a short protocol starting with order placement and including the complete procedure from nurse to RT to lab result. Then, we implemented it.
- Assessment: Any new process needs to be examined to be sure the goals were met. At this point we discovered some issues. When nurse staffing and RT staffing was ideal, the process was relatively quick, but the wait for RT to arrive just to run a point of care test was wasteful. We returned for a second meeting and began trouble shooting. We decided to move forward with education and credentialing of a handful of nurses so they could use the point of care blood gas analyzer. Off to round two of testing.
- Testing 2: This process was trialed and we quickly realized that there was not always one of the handful of trained nurses working, and no one knew who it was during any given shift.
- Re-Assessment: After another meeting and more debate, we settled on going back to old processes and personnel, but in a new manner. It was suggested that our lab techs, already trained in point of care use in our mini-lab in the ER, could run the test. They were staffed 24/7 and education was consistent and tracked by the lab already. Also, the nurse would continue to draw the sample but deliver it to the lab instead. RT was removed from the process and the protocol was shortened.
- Testing 3: The final phase of testing demonstrated consistent results, adequate process time, and an overall significant improvement compared to testing 1. Also, our goals of reducing arterial puncture, pain and complications were realized.
#FOAMed and other Resources
Dr. Sam Ashoo is a board certified emergency physician. He completed his Emergency Medicine residency training at Orlando Regional Medical Center. He has been in practice at Tallahassee Memorial Hospital for the past 12 years, serving as the Medical Director for the two emergency centers for the last 5 years. He also serves as the Chief Medical Officer for Aristo E|R, providing leadership for their staffing, management, and consulting clients. His clinical interests include patient flow, health care administration, and teaching. He is a regular contributor to the EM:RAP (Emergency Medicine: Review and Perspectives ) audio CME program and serves as clinical faculty for the Florida State University College of Medicine.