•Patient’s safety concerns - Nurses behind closed curtains having to assists with the early morning blood draw poses safety concerns for fall risks patients etc.

•Disturbed patients’ sleep/rest - Patient had to be woken up from their sleep for blood draw which  can affect patient’s rest , recovery and satisfaction.

•Resource constraints faced by Nurses during these peak period.

•Only  two  Night Phlebotomy services  covering  6 wards  across all 22 wards .

•Nurses  need to complete all blood test requests during their night shift.

Data on average blood orders from August 2020 to October 2020  shows early morning draw peaks from 0400hrs to 0600hrs  in CGH Main Building (MB).

 

PROJECT AIM

A project was initiated to review appropriateness of the timing of blood orders between 4am to 6am and to streamline the ordering processes at Inpatient Wards in CGH Main Building. The project aimed to reduce the blood order to patient ratio from 10 to 6; reduce early morning (4am-6am) blood order peaks by 50% from 5000 to below 2500.

 

METHODS

Team was formed with representative from Nursing,  Surgical, Orthopedics, Medical, Cardiology, Laboratory, Phlebotomy and Office of Improvement Science (OIS). The team met and analysed the current situation. A quality improvement intervention was conducted in phases.

Phase 1- Analysis of the Current Situation

Early morning blood draw across CGH MB were analyzed and baseline data were collected from August to October 2020. General Surgery (26%), General Medicine (30%), Orthopaedic disciplines (21%) are the top 3 disciplines in terms of early morning blood order volumes. Full Blood Count and Renal Panel are the most frequently ordered routine early morning bloods which could be taken at a later timing.

A review of Nursing, Phlebotomy and Laboratory resources were conducted on 28th January 2021. Manpower constraints across all areas were evident during the early morning ( 4am to 6am) peak blood volume order.

Phase 2-  Pilot Trial 

Working closely with representatives from various clinical specialties, a Decision Matrix for Blood Ordering & Taking was implemented. Pilot Trial in one Surgical and one Medical Ward was carried out on 14 June 2021.  After approval from Clinical HOD’s, staff training on the process change and briefing were conducted to the nursing staff from the two Pilot wards and Clinical teams as well as Laboratory staff. Feedbacks were gathered  and the Priority Matrix was further improved based on  the feedback. No 6am bloods to be ordered unless indicated by the Consultant as per Priority Matrix to determine which bloods should be taken as higher priority and at the appropriate timing,  with exceptions such as tests for Clinically Unstable patients, Time-Sensitive Blood Tests & Tests that are to be taken by doctors

To ensure sustainability in compliance, a laminated copy of the Priority Matrix was given to all wards and New Nurses are also briefed in the respective inpatient wards to enhance understanding and compliance

Phase 3- Implementation to all Inpatient Wards at MB

The team reviewed the feedback and further fine tuned the process change before implementation to all inpatient wards at CGH MB in July 2021.

 

RESULTS

Evidence of decrease in volume of blood orders and the average blood orders taken per patient indicating that unnecessary blood orders had been reduced.

A tiger-text secured messaging group was implemented to share difficulties and enforce compliance measures. Any feedback and compliance issues were raised  to Clinical Leads with this platform. To ensure the change would not cause any negative effect as a result of reduction in the night shift’s early morning 4-6am bloods,  any unmanageable increase in blood orders later during the day was monitored. There was an increase in the “after 8am” workload, however the greater availability of manpower both phlebotomists and nurses during this timing meant that the workload was manageable. Data collected from Baseline, Pilot and Implementation phases showed a significant decrease in early morning blood orders across CGH Main Building

 

CONCLUSION

The project has received positive feedback and with ongoing plans to scale up from CGH Main Building wards to CGH Integrated Building (IB) wards. Although there were challenges to build compliance especially when new doctors or nurses are posted to the department, constant briefing to the Clinical and Nursing departments were conducted to ensure compliance  to the Decision Matrix.

With the success of this project, the initiative was also shared to Joy At Work (JAW) workgroup, which was later adopted as a CGH JAW initiative and shared to the SingHealth cluster in November 2021, with interest from Sengkang General Hospital to adopt this best practice in June 2022.