Background: Blood gas analysis should be performed within 30 minutes of collection to ensure accurate results. Venous blood gas (VBG) data can help evaluate critically ill patients, but it has little role in routine use in non-critically ill hospitalized patients. Nonetheless, we noted that at our urban safety-net hospital, many general medicine patients had VBGs ordered as part of their morning labs without a clinical indication. Excessive ordering of VBGs causes delays in processing times, leading to abnormal values for all patients, including the critically ill. This, in turn, can result in further unnecessary testing and even erroneous interventions.
Purpose: Our project aimed to reduce the average daily number of morning VBGs on general medicine wards by 25% within two months.
Description: We collected data on the number of morning VBGs ordered daily on general medicine wards from May 2023 to April 2024. Morning VBGs from 4 AM to 8 AM were targeted since these had the longest processing times due to peak laboratory load.For our first PDSA cycle, we surveyed Internal Medicine residents to understand their rationale for ordering VBGs and to gauge their awareness of the existence of a separate plasma lactate order and hospital policy requiring nurses to do separate blood draws for VBGs. The survey had a 65% response rate and found that the vast majority of residents ordered VBGs to look for pH (98.0%), pCO2 (90.2%), and lactate (88.2%). Most residents (76.5%) thought that VBGs were drawn by phlebotomists and were unaware that a separate blood draw was required, and 37.3% were unaware of a separate order for plasma lactate. The survey was followed by three 10-minute educational sessions over five days to review the survey results and indications for VBGs, highlight the negative effects of excessive VBG ordering, and explain the biochemical basis of false readings.We followed PDSA 2 intervention directly with a “Cut the Crap” campaign, which humorously referred to inaccurate readings of morning VBGs and used visual reinforcement, such as posters with crossed-out poop emoji displayed in team rooms and poop emoji keychains as prizes. Our interventions led to a 67% decrease in morning VBGs from 8.2 per day pre-intervention to 2.7 post-intervention. This result was sustained for over six months. Our initial plan for the next PDSA cycle was to incorporate EMR changes, such as removing “blood gas” from “lactate” synonyms and deleting outdated preference lists that included morning VBGs in routine lab orders. However, the sustained decrease in morning VBGs that persisted for over six months made those further interventions unnecessary.
Conclusions: Although educational interventions are typically the least likely QI interventions to lead to sustained change, we believe that our project was successful in achieving this unlikely result for several reasons. Raising awareness of the causes of false values of VBGs and showing residents that excessive VBGs resulted in suboptimal care for all patients, especially the critically ill, strongly motivated residents to change their practice. The deliberate use of an irreverent title and imagery for the campaign also helped increase word-of-mouth spread. We expect the substantial decrease in unnecessary VBGs to result in reduced patient discomfort, lower lab costs and workload for lab personnel, and, best of all, improved accuracy of VBGs due to decreased processing times.
