Supply chain challenges have plagued the clinical laboratory throughout the COVID-19 pandemic. Increased, unpredictable demand for laboratory testing has coincided with global delays and raw material shortages. The pandemic exposed the weaknesses of “just in time” inventory management, leaving many laboratories without inventory. Laboratories worldwide have endured alternating shortages, from nasal swabs, viral transport media, and pipette tips, to molecular testing reagents.
In the spring of 2021, the lab industry confronted its biggest challenge of the pandemic: The global shortage of blood collection tubes. This article is about how our lab at Ochsner Health System responded using principles of laboratory stewardship.
A Different Kind of Fear
Upon hearing of the FDA’s alert on June 10, 2021, about citrate tube shortages, the laboratory teams at Ochsner predicted that the problem would extend beyond blue tops. Our fears were confirmed in the fall when we noted increased allocations and difficulty obtaining inventory from our primary tube supplier. We were critically low on inventory of blue, green, gold, and purple tops, often with only 1–2 days on hand before the next limited shipment arrived.
Our lab teams felt that if we could survive four COVID waves, staffing shortages, and a category 4 hurricane, we could endure anything. But this? This was a different kind of fear. How can a lab run with no blood collections? How can we tell our clinical teams they may be forced to treat patients without diagnostic testing? How can we manage patient expectations, particularly after their care has already been delayed repeatedly? Being the messenger of scarcity to our overwhelmed colleagues felt insurmountable.
Fortunately, we are lab people. The Ochsner laboratory has a strong, sustained value-based infrastructure to rely upon. Thus, we were able to quickly adopt some of the established tenets of laboratory stewardship to navigate the challenge.
Data Collection and EMR Collaboration
The first step toward a solution was understanding the nature of the problem by collecting and analyzing data. We relied on our Epic electronic medical record (EMR), laboratory information system, and laboratory management to create a tube utilization snapshot of the previous month. This illustrated how many tubes of each type were used daily at every location in the system.
The data highlighted three principal targets for intervention: rainbow draws, extra tubes, and physician ordering patterns. The rainbow and extra tube data revealed an average monthly wastage of more than 20,000 tubes, while the physician-focused reports highlighted individual providers with aberrant ordering patterns.
As we explored our options for interventions, we learned that for data to be effective, it had to be monitored frequently, then translated and shared with each target group. This allowed timely visualization and feedback on each intervention. Manually manipulating data so that it made sense to every team was challenging, but it proved essential for successful stewardship communication.
Best Practices and Published Guidelines
Eliminating rainbow draw and extra tube collection were the first interventions. These were palatable since they did not require a major change in patient management; they relied predominantly upon practice changes from nursing and phlebotomy teams. But after several weeks, it was obvious that these efforts would not suffice to sustain tube inventory. We needed to use the painful interventions of restricting laboratory testing for both inpatients and outpatients.
This proved a formidable task in a stressed healthcare system. Physicians and patients were highly attuned to COVID-19-related care delays and were more fearful of underdiagnosis than overdiagnosis. Patient-centric, evidence-based recommendations were required to ensure collaboration and practice changes from clinical teams.
Our laboratory team looked to the Choosing Wisely initiative and Britain’s National Health Service retesting interval guidance to make recommendations. Our experts in endocrinology, primary care, cardiology, and hospital medicine then vetted and approved the changes. Collaborating with clinical leaders, we restricted daily orders on stable hospitalized patients for common labs such as complete blood count, comprehensive metabolic panel, c-reactive protein, lipids, sedimentation rate, lactic acid, lipase, ferritin, procalcitonin, and iron studies. In outpatients, we deactivated low-yield or obsolete tests including free T3, reverse T3, and vitamin D. We also imposed order interval restrictions on lipid panels (6 months), A1C (3 months), prostate-specific antigen screening (6 months), and thyroid peroxidase antibodies (no repeats).
To make these changes, we partnered with our EMR analysts, who analyzed each order set. They identified those requiring modification by either removing obsolete tests or removing the daily option for common tests. Epic was able to generate both hard stops and best practice advisory guidance for appropriate testing intervals.
A Solid Foundation in Good Governance
Our laboratory governance was foundational to Ochsner Health’s success in managing this systemwide stewardship initiative. The care variation committee contains multiple specialties and geographic regions. Monthly meetings have focused on improving laboratory value and care by reducing variation and employing evidence-based guidelines to optimize resources. The committee members were accustomed to debating utilization, and this frequently produced effective compromises. This group vetted and voted on the proposed test restrictions and achieved majority agreement. The care variation committee not only validated our suggestions but also provided an effective forum for complaints and discussion by clinicians.
Tailored communication to diverse teams across multiple geographic regions was the cornerstone of our tube-management strategy. The first task was to rapidly inform clinical services of the situation’s seriousness through two systemwide email distributions occurring 2 weeks apart. To increase readership, these were distributed from the chief medical officer and senior executive team. The communications emphasized the global nature of the shortage, expected duration, and projected impact to critical testing if no interventions were taken. We also explained our plans to restrict testing and manage inventory, along with a strong request to clinical teams to make mindful test ordering a part of their daily patient care goals.
Pathology leaders participated in biweekly departmental chair meetings and staff meetings of primary care, hospital medicine, and surgery. This allowed clinical teams to ask questions about effects on their departments. For example, primary care favored restrictions on some screening labs for routine health maintenance, yet they feared backlash from patients due to unmet expectations. Lab and executive leadership responded by collaborating with primary care on a script that addressed key discussion points and questions patients might have once they learn of the lab shortages. This acknowledged physician concerns and decreased the physician’s communication burden.
Nursing and phlebotomy required a different communication strategy as their impact was not on order restriction but on proper collection. This was accomplished by nursing and lab operational leaders who collaborated on illustrated tip sheets highlighting the importance of proper blood draw technique and tube filling, recognizing that a rejected tube is a wasted tube. We used data compiled from individual phlebotomists, locations, and draw sites to communicate to team leaders which areas and individuals had a high rejection rate and/or extra tube rate, thus promoting targeted interventions to improve competence.
Our True North
Our experience maintaining tube inventory has been both gratifying and imperfect. We continue to have days where the inventory becomes dangerously low, and some physicians have remained unhappy with lab ordering restrictions. However, overall, using the stewardship interventions, teamwork, and communication strategies described here, we have maintained our true north of providing testing to all patients who truly need it.
Elise Occhipinti, MD, is the laboratory medicine director at Ochsner Medical Center in New Orleans. +Email: [email protected]