The Initial Problem and its Impact

Leeds Children’s Hospital is part of the LTHT (Leeds Teaching Hospital Trust) and funds 18.75 hours of WTE (Working Time Equivalent) from the phlebotomy services and covers 6 wards. The role of the phlebotomy services available was poorly understood and underutilised with “routine” bloods being requested to be done by the night team.

This was an ineffective and unsustainable use of the on-call junior doctor’s time often with tests not done due to other clinical priorities. The patient experience was poor with the child being woken early for a blood test without the option of play support. Anecdotally many children with chronic conditions preferred the phlebotomists to do their bloods and when on the ward would request to go to outpatients rather than the junior doctor.

Causes of the Problem

At the beginning of the project after an initial meeting to form the team, baseline data for two weeks was collected daily and demonstrated that on average the junior doctor team overnight was doing 4.9 blood tests per/day compared to 0.7 per/day by the phlebotomists. The drivers towards why blood test were done by the night team were explored using a fishbone diagram and factors identified included:

Environmental

• The hospital layout – spread over separate wards and wings (journey time).
• Play support availability (9am-5pm).

Policies and procedures

• Lack of awareness/clear pathway for how to request tests by phlebotomy and days of service (weekends/bank holidays).
• What sites phlebotomists could take blood from (antecubital fossa vs back of hands).
• Venepuncture vs fingerprick.
• Specialised blood needed to be in a taxi for processing by 11am each day.
• Rules that the phlebotomist could not bleed children under 2 years of age (but also did rounds on the neonatal unit).

Equipment

• Small bottles/blood volume.
• Ametop/cold spray.

People

• It had become the norm/culture to ask the night team.
• Some questioned if phlebotomists had skills to take blood from paediatric patients.
• Phlebotomists needed 2 people to do rounds.

Project Aim Statement

• Agreed shared purpose: Children to have a positive blood taking experience & bloods test to be done at the right time by the right person.
• Project aim: To decrease the number of blood tests done by junior doctors overnight and improve the patient experience of routine blood taking.

Stakeholders

Junior doctor, leads for phlebotomy, clinical director for children’s services and general paediatric consultant – the project team.

PDSA Cycles / Solution(s) Tested

Outcome measures:

1. Number of routine blood tests done by Doctors overnight.
2. Number of routine blood tests done by phlebotomists.

Balancing measurements:

1. Number of blood forms “handed back”.
2. Completion of phlebotomy round within allocated hours.

Cycle 1:

• Service reduced to 4 pilot wards.
• Each phlebotomy folder on the wards update with a A4 flyer about what the service included.
• Doctors tasks: date & time on forms, forms in place before 8am.
• Phlebotomists trained to do venepuncture & fingerpicks, education on sites they can access and which test they can’t do.
• Regular communication at joint handovers, via email & in discussions with ward managers of each participating ward.
• Feedback: Run charts of progress were reviewed at handover meetings.

Cycle 2:

• L10 was to be the first ward on the round for phlebotomists to ensure tacrolimus levels were done before the daily laboratory 10am run.
• Expansion of rounds out to 6 wards.

Data Results

• There was a reduction in the number of blood tests done by the junior doctors from 4.9 to 0.7 blood tests/day.
• There was an increase in the number of blood tests done by the phlebotomy team from 0.7 to 6.1 blood tests/day. The “hand back” rate was 8%.
• The ward L10 was an initial outlier for the number of bloods done by junior doctors at the Day 70 review & further exploration of this led to a 2nd cycle with L10 being the first ward on the phlebotomy round to ensure time critical bloods were done.

How This Improvement Will Be Sustained

A year after the project completed (in April 2016) there was a 2 week period of measurement done based on the original outcome measures. The results showed:

• 0  routine blood tests were done by junior doctors.
• 8.5 blood tests/day done by phlebotomy team.
• Forms handed back were stable at 8%.
• All rounds completed within allocated hours.

At present the phlebotomy services are now well embedded and offers a twice daily service 7 days a week.

Challenges and Learnings

Our project utilised the NHS change model which helped with its ultimate sustainability. The main challenge on a practical level was the data collection. It was already a routine part of the phlebotomist practice to collect data on number of tests done and unsuccessful attempts/forms handed back. The collection of blood done by the team overnight relied on collection of data at each morning handover done by the junior doctor (myself). Think carefully about what data you need and how realistically it can be collected in the planning phase. It was difficult to persuade the senior colleagues in the group to begin the next PDSA cycle.

It was important to have open communication and two-way feedback. The balancing measures were key for combating negativity and resistance. The phlebotomists were worried of being overwhelmed and not completing tasks within time and the “day teams” were worried that the work of the blood tests would be moving from day to night if the phlebotomists failed.

Suggestions For Further Implementation

The most important step in the beginning was having a meeting of the stakeholders and discussing the problem. It was useful to use a fishbone diagram to make us think about all the different potential problems and then focus on what was the biggest problem. The clear lack of understanding of the services was key.

Amanda discusses her project for RCPCH Progress below:

Project Lead: Dr Amanda Newnham

Organisation: Leeds Children’s Hospital

Published: April 2020