Presented at the Neonatal Society 2012 Autumn Meeting.
Butler K, Doherty C
School of Medicine, University of Cardiff & University Hospital Wales, Cardiff
Background: There has been a recent drive for efficient working practice to allow more time for direct clinical care and reduce unnecessary expenditure within the NHS (1). The European working time directive (EWTD) and the balance of service versus training for junior doctors are further drivers for efficiency. Furthermore, with a potential reduction in medical trainees it is important not only to ascertain transferable skills but to identify unnecessary tasks, particularly if they impact on the patient. Within intensive care many blood tests are labelled ‘routine’ and thought necessary however pathology services have identified a 20% increase in tests over the last decade (2). We have previously calculated that approximately 50 hours per week are spent performing blood tests within our tertiary neonatal unit (3). Our aim was to determine which indications for blood tests were associated with a clinical intervention post results and to determine whether ‘unnecessary’ blood tests could be identified.
Methods: A prospective, observational study was performed over 120 hours on a tertiary NICU in two rooms which had level 3 babies. Each blood test performed was recorded including information on the indication for testing and any clinical intervention following test results. To help standardise the blood test ‘indications’, a checklist was developed. Minute-by-minute process mapping for each blood test was also recorded. The 120 hours consisted of five 12 hour night shifts (9pm-9am) and five 12 hour day shifts (9am-9pm). Verbal consent was obtained from all NICU staff on duty prior to the start of each ‘study’ shift.
Results: 285 blood tests were taken over 120 hours accounting for a total of 2147 minutes (30% of total time). There were 30 (10.5%) ‘failed’ or ‘lost’ samples. 154 (54%) tests led to an action changing patient management. Clinical interventions were then related to the test indicator. ‘Monitoring ventilation’, ‘monitoring trends’ and ‘change in ventilation type/settings’ were the three commonest indicators identified with interventions made in 41%, 73%, and 83% of test results respectively. 101 (35.5%) resulted in no clinical intervention.
Conclusion: Within a tertiary NICU 54% of blood tests on level 3 babies resulted in a clinical intervention post result. However 35.5% blood tests resulted in no intervention. Whilst doing some apparent ‘unnecessary’ tests may be unavoidable, more consideration when deciding whether or not a test is performed could reduce laboratory costs and free up time for training. More importantly however neonatal pain and blood loss could be minimised.
Corresponding author: Butlerk1@cardiff.ac.uk
1. http://www.wales.nhs.uk/sites3/page.cfm?orgId=781&pid=31388 sited 11/11/2011
2. Rao G, et al. Pathology tests: is the time for demand management ripe at last? Journal of clinical Pathology 2003; 56(4): 243–248
3. Taylor A., Doherty C. 5000 minutes in NICU – An observational study of doctors’ time on a tertiary NNU as part of the Transforming Care Initiative, presented Neonatal Society, March 2012