182 - Reducing Iatrogenic Blood Losses in Very Low Birth Weight (VLBW) Infants by Promoting Provider Awareness and Optimal Use of Electronic Medical Record (EMR)

Poster Number: 182
Publication Number: 182.234

Megha Sharma, University of Arkansas for Medical Sciences, Little Rock, AR, United States; Feng Zheng, Baylor College of Medicine, Houston, TX, United States; Horace J. Spencer, UAMS, Little Rock, AR, United States; Kevin W. Sexton, UAMS, Little Rock, AR, United States; Sara J. Landes, University of Arkansas for Medical Sciences, Little Rock, AR, United States; Richard W. Hall, Pediatrics/neonatology, Little Rock, AR, United States; Geoffrey M. Curran, University of Arkansas for Medical Sciences, Little Rock, AR, United States

Background: Multiple professional societies list avoidance of unnecessary lab testing as a Choose Wisely recommendation. Iatrogenic blood losses from unnecessary testing in preterm infants are linked to repeated blood transfusions, increased skin-breaking procedures, health care costs and unnecessary downstream testing.

Objective: We hypothesize a priori that our strategies, facilitated by Implementation Science (IS) methods, would reduce iatrogenic blood losses in VLBW infants in the first 3 weeks of life by 15% within 1 year.

Design/Methods: An IS approach combining quantitative and qualitative methods, guided by Consolidated Framework for Implementation Research (CFIR), was used. Prior to implementation, semi-structured qualitative interviews were conducted (Nf14 neonatologists) to identify barriers and facilitators to intervention strategies. Number and type of lab tests, amount of blood drawn (ml/kg), blood transfusions during pre-implementation (pre-I) (Jul 2019-Sept 2020, Nf178) and post- implementation (post-I) (Oct 2020-Oct 2021, Nf132) phases were obtained. Implementation strategies included (1) Nurse documentation of 'blood out' in EMR and incorporation into physician progress notes and rounds, (2) Display of blood volume and lab charges within EMR order sets and on laminated cards on clinician work stations, (3) Defaulting blood gases to 24h to discourage daily standing orders and removal of pre-selected daily labs from order sets, and (4) Monthly training modules for trainees on appropriate ordering practices. Data are shown as Median [IQR] and analyzed using Wilcoxon rank sum test.

Results: The neonatal characteristics were similar pre-I and post-I. Template analysis from qualitative interviews revealed three major themes - provider-specific factors,  EMR-related recurring orders, and blood ‘Lost and Cost’ awareness - which informed intervention strategies. The most frequent lab tests were blood gas (36%), Total Parenteral Nutrition (TPN) panel (17%) and bilirubin (20%). There was a 15% reduction in the total number of lab tests (54 [36, 80] pre-I vs 46 [28, 69] post-I, p=0.008) and a 20% decrease in blood drawn (ml/kg) (23.0 [12.9, 42.1] pre-I vs 18.3 [10.1, 35.3] post-I, p= 0.01). Subgroup analyses of labs drawn showed statistically significant decrease in the 1000-1500 gm birthweight subgroup (39.0 [29, 51] pre-I vs 31.5 [25, 49] post-I, p=0.04), with a trend towards decrease in < 1000 gm strata. TPN panel, bilirubin, glucose and electrolytes were significantly reduced. Conclusion(s): IS methodology resulted in decreased total lab tests and blood drawn in VLBW infants in the first 3 weeks of life.
Comparison of neonatal characteristics and Main Outcomes in pre- and post- intervention phases.Medians and interquartile ranges (IQR) are presented for gestational age, birthweight, total labs, amount of blood drawn and specific labs. Percentages and counts are presented for gender and transfusions.
a Pearson’s chi-squared test; b Wilcoxon rank-sum test; c Negative Binomial regression
Main outcomes – Total labs, blood out (ml/kg)Box plots showing distribution of (A) total labs (B) blood out (ml/kg) and (C) total labs within birthweight subgroups (1000g).