Reducing CBC Clotting Rates in theNeonatal Patient Care Areas

Jennifer McCoy, Tanya Tichon, Michael Narvey

To cite: McCoy J, Tichon T,Narvey M. Reducing CBCClotting Rates in the NeonatalPatient Care Areas. BMJQuality Improvement Reports2016;5:u215456.w4946.doi:10.1136/bmjquality.u215456.w4946

Received 25 May 2016Revised 29 June 2016

Health Sciences Centre,Canada

Correspondence toJennifer McCoyjmccoy@exchange.hsc.mb.ca

ABSTRACTPerforming a complete blood count (CBC) is acommon test performed in neonatal intensive care.Samples reported as “clotted” are not able to beanalyzed and require redraw. A perceived “high”clotting rate elicits frustration among team membersand has negative effects on patient flow and patientsatisfaction. Process mapping and a root causeanalysis determined that an educational interventionwas required to optimize blood collection skills offront-line nurses. Through four rapid PDSA cycles overa three year period, the neonatal patient care areaswere able to decrease their CBC clotting rates from30% (monthly rate when the problem was identified) to16% (yearly average at the end of the project). TheCBC clotting rates continue to decease over time dueto the integration of a multi-faceted educational planinto biannual education days designed for current staffnurses, as well as into the orientation plan for newlyhired and student nurses.

PROBLEMThe Neonatal Patient Care areas at theHealth Sciences Centre in Winnipeg,Manitoba, Canada are divided into a Level 2and Level 3 Nursery: Intermediate CareNursery (IMCN), and the Neonatal IntensiveCare Unit (NICU), respectively. The IMCN isa 24 bed unit located in close proximity tothe Women’s Hospital where approximately5700 deliveries occur each year. The NICUhas 17 beds, and is located in the Children’sHospital. Between both units, approximately1,100 infants receive care on an annual basis.On July 1st, 2012, the Laboratory Service

Technicians discontinued providing services,including capillary blood sampling, or “heelpokes” to the Intermediate Care Nursery.The rationale for this change was driven bythe importance of cue-based care and pro-tecting the premature or sick neonates’ sleepby avoiding set times for blood draws.Cue-based care is a principle employed bymany NICUs where infants are handledduring their quiet-alert or active states. Thisis a relatively new method of providing careto the sick or preterm infant designed toprotect their growing central nervous system.

Historically, infants were woken routinely at0700 to have blood drawn by the lab, regard-less of where the infant was in their sleepcycle. Thereafter, bedside nurses wererequired to perform capillary blood samplingwhen appropriate as determined by the prin-ciples of developmental care. However, as apsychomotor skill, capillary blood samplingwas not easily transferred to a new set ofhands. A common blood test performed inthe NICU is a complete blood count (CBC).Once the blood has been collected it is sentto the lab for analysis. One reason the labmay not be able to perform the analysis isbecause the platelets in the blood havecaused the sample to clot. This results in thenurse having to re-draw the sample from theinfant. A unit’s “clotting rate” is the percent-age of clotted samples out of the totalnumber of samples drawn in any givenmonth. The bedside nurses in both unitsbecame frustrated, as they perceived theirCBC clotting rates as “high” in comparisonto the state before the change. Othersqueried whether clotting rates had alwaysbeen “high” and were now being highlightedsince each nurse now followed up their ownsample result. These concerns andunanswered questions led the nurse educatorto delve into a system-wide analysis, extensiveeducational roll-out, and rapid PDSA(plan-do-study-act) cycle execution.

BACKGROUNDDischarges, transfers to the healthy maternal-newborn care areas, and treatment decisionsare all impacted by the results of blood workand tests. Blood work is deliberately sampledand collected in the early hours of the morningin order to facilitate results being available forinterpretation by the team during interdiscip-linary rounds held at 0900. When clottingoccurs, the sample must be re-collected leadingto delays in the decisions described above, andinterrupts patient flow. In addition, the fre-quent skin breaks inhibits the care team’sability to provide appropriate cue-based care.

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Another concern stems from the potential to impactlong term outcomes for the neonate. While besidenurses use a plethora of non-pharmacological methodsto reduce the pain experienced by a capillary bloodsample (for example, sucrose, containment, positioning,skin-to-skin, breast-feeding), the procedure breaks theskin and elicits pain. A second sampling required is justas painful as the first. Pain in the preterm infant canhave long lasting consequences such as neurodevelop-mental impairment, altered response to pain as adultsand internalizing behaviours.1 Non pharmacologic mea-sures to reduce pain such as skin-to-skin care reduce theincidence of apnea as well as many significant morbid-ities in the NICU.2 Conversely, untreated pain in thepreterm or sick neonate may increases oxygen require-ments, apnea and bradycardia and ultimately lead to alonger duration of treatments such as ventilation (inva-sive or non-invasive), supplemental oxygen, or caffeineadministration.3 In addition to potentially delaying dis-charge, these treatments are not without risks them-selves, as for example increasing risks of retinopathy ofprematurity from increased oxygen administration.4

While a second capillary blood sampling may often beperceived as benign, it’s important to consider thecumulative effects of multiple recollections.

BASELINE MEASUREMENTIn May 2012, prior to the discontinuation of laboratoryservices, the clotting rate in IMCN was 16% while that inNICU during the same time period was 17%. In July ofthe same year after the bedside nurses were assigned theresponsibility of capillary blood sampling the CBC clot-ting rate increased to 32% for the Intermediate CareNursery and 30% for the Neonatal Intensive Care Unit.This 100% increase in IMCN and 76% increase forNICU in CBC sample clotting rates validated thebedside nurses’ concerns and provided the units with abaseline and motivation to improve upon these results.At the same time, the laboratory began to use new sam-pling tubes to facilitate mass sample processing bymachine rather than by hand. This was the result oftheir own cost-saving process improvement project.However, little education was provided to front line staffregarding this change.

DESIGNThe team leader of this project was the nurse educator.Other team members included the patient care managersfrom both units, a clinical practice consultant from thelaboratory, a laboratory information management special-ist who provided the team with the monthly clotting rates,and a product representative for the company that sup-plies the blood collection tubes and the lancets used tobreak the skin. After mapping out the process of bloodcollection, sample delivery, analysis, and results reportingin the neonatal patient care areas the nursing educatorfocused her efforts on assessing sample collection and

implementing interventions to improve successful initialblood draws from neonatal patients by the bedside nurses.Over the next three years, psychomotor education ofbedside nurses with extensive collaboration of several sta-keholders was the primary intervention utilized to achievethe desired goal of decreasing clotting rates in the neo-natal patient care areas.In terms of a SMARTaim, our goal was to have the neo-

natal bedside nurses responsible for collecting bloodsamples for CBC testing, decrease their clotting ratesfrom 30% observed in August 2012 to 7-10%, as was thecase in a another neonatal intensive care unit in our city.

STRATEGYCycle 1Plan: The first intervention was the development of ajoint plan between nursing and laboratory staff to assessand address potential contributing factors. The discus-sion between the laboratory personnel and nursingrevealed that a well-mixed CBC sample would not clot,regardless of the length of time between collection andanalysis. This finding reinforced the appropriateness offocusing intervention on collection methods and theskills of the bedside nurse, rather than investigatingtransport processes such as Patient Transport and thepneumatic tube system.Do: The joint plan was communicated via an action

plan newsletter developed by the nurse educator anddisseminated by email and print copy to all patient careareas. As a second step, consultation with a product spe-cialist from the manufacturer of the capillary blood col-lection tubes offered additional advice on best practicewhich was then communicated to nursing at educationalsessions consisting of “hands-on” practice, informationposters, and a representative from the manufacturer toanswer questions posed by staff. This model of educationdelivery facilitated effective practice change in a varietyof learning domains.Study: Less than one month after these sessions were

complete, representatives from the manufacturer cameto the IMCN and NICU to directly observe the bedsidenurses’ collection methods and provided real-time,face-to-face feedback to the staff. Regular data collectionof CBC clotting rates began.Act: The observations of laboratory staff informed the

team that further education, hands on training, andmonitoring of CBC clotting rates was needed to affectpositive change.

Cycle 2Plan: Following the production of the November 2012action plan from the first PDSA cycle, a product changewas introduced. The Quickheel Lancet© was announcedas the primary device for accessing a patient’s capillaryblood supply. To maintain staff engagement, updatedmonthly reports were circulated to nursing, indicatingthe clotting rates for both units which further containedsummaries of practice changes from the PDSA cycles.

2 McCoy J, et al. BMJ Quality Improvement Reports 2016;5:u215456.w4946. doi:10.1136/bmjquality.u215456.w4946

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Demonstrating positive change with their efforts wasdeemed essential to facilitate acceptance of theQuickheel Lancet©. In January 2013 a meeting betweenstaff and the hospital Quality and Safety team culmi-nated in a decision to obtain more frequent data.Do: Following the meeting with hospital Quality and

Safety team, the laboratory agreed to provide weekly clot-ting rates to the neonatal patient care units. The nursingleadership team began to encourage bedside and chargenurses to complete Patient Safety Event Reports eachtime a sample was received as clotted thereby cognitivelyescalating this issue as a true safety issue in the eyes ofstaff. Another update was circulated to staff.Study: The nurse educator networked with the other

level III NICU in the city (St. Boniface Hospital) in May2013 to obtain a comparison data set. The neighboringunit was found to have significantly lower CBC clottingrates (2%-8% compared with Health Sciences Centre’s16%-27% for the same time period). It was found thatSt. Boniface Hospital still utilized LaboratoryTechnicians for capillary blood sampling. The technicianteam was small, potentially allowing greater opportunityfor each technician to practice their technique andbecome proficient.

Act: The weekly clotting rate reports and the compari-son with the other hospital informed the team thatfurther gains in decreasing clotting rates may yet beattainable as the bedside staff become skilled in capillaryblood sampling.

Cycle 3Plan: From June 2013 to the start of the next PDSA cyclein June 2014, combined clotting rates had returned tonear baseline at 20%. One third of the time, the com-bined clotting rates were less than 20%. In June of 2014,the nurse educator visited St. Boniface NeonatalIntensive Care Unit again and directly observed capillaryblood sampling techniques performed by their experi-enced laboratory technicians. The nurse educator onthis occasion recognized additional practice differences,the most important of which was pre-warming of theinfant’s limb prior to performing the skin break.Do: The practice differences observed at St. Boniface

were communicated in conjunction with a practicechange recommendation to all staff at Health SciencesCentre neonatal patient care areas. In October 2014, arepresentative from the supplier of the collection tubesreturned to provide guidance and a “hands on”

Figure 1 Blood Collection Process Map

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demonstration to many of the new hires since the startof the improvement project.Study: Ongoing clotting rate reports were being pro-

vided to the team and circulated to the bedside staff tofacilitate engagement in the project.Act: Improvements in clotting rates continued to be

seen. The median clotting rate over the span of thethird PDSA cycle was 18%. This was the first time sincethe beginning of the project where the median for thecycle was less than 20%.

Cycle 4Plan: In the March of 2015, it was identified that nursingstudents completing their senior practicum in the neo-natal patient care areas were not provided with the sameeducational package during their training. Many ofthese students are hired into the NICU and IMCN envir-onment and therefore a possible gap might exist priorto them receiving scheduled education to reduceclotting.Do: Training for senior practicum students was there-

fore added to ensure that from the start, any care pro-vider who may practice capillary blood sampling wasequipped the necessary skill set.Study: The Laboratory Information Management

Specialist continued to provide the nurse educator withmonthly clotting rates for both units. The nurse educatorin turn disseminates this information to front line staff.Act: Hands-on education for senior practicum staff

and newly hired staff has been sustained since thisproject.

RESULTSPost MeasurementCycle 1The evaluation of the first PDSA cycle occurred inNovember 2012 with all pertinent findings and recom-mendations emailed to all of the bedside nurses.Appendix 2 contains a copy of the communication staffreceived. The action plan highlighted CBC clotting ratesfor both IMCN and NICU. During the planning phasein August and September the units experienced anincrease from 18% to 22% overall clotting rates com-bined. After the data collection and correspondence tonursing was completed the rate returned to a combinedrate of 19% for both units. This recovery was interpretedas a success and validated the practice recommendationsand the benefit of hands-on in-services.

Cycle 2In June 2013 at the end of this PDSA cycle, clotting rateswere reported to the front line staff showing a downwardtrend and bolstering support for the initiative. For theentire year of 2013, combined rates for the NICU andIMCN were as low as 16% (mean 22%) and a lowestmonth’s rate in the NICU of 9%. Reinforcement of thisinitiative continued, with monthly clotting reports andtwice yearly educational sessions for nursing that remainin place.

Cycle 3As a result of the efforts of this cycle, the combined CBCclotting rates for November and December 2014 were17% and 16% respectfully. Between June and December,

Figure 2 PDSA Map

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inclusive, the combined CBC clotting rates were lessthan 20% more than half of the time.

Cycle 4Combined unit CBC clotting rates fell from a baseline of21%, 18%, and 21% for January, February, and March,2015 respectively to 14%, 13%, and 7% for October,November, and December, 2015. The 2015 yearlyaverage was 16%. The lowest monthly clotting rate wascomparable to those of St. Boniface Hospital NICU at6%. This rate was achieved by both neonatal patient careareas independently (IMCN in December, 2015 and bythe NICU in September, 2015).This project had little to no costs associated with its

implementation. Existing resources were utilized andexpanded upon to optimize their value. Resources usedincluded the nurse educator, Neonatal Education Days,hands-on in-services, and newsletter communication.The human resources such as the nurse educator, spe-cialists from the manufacturer of the collection tubes,laboratory technicians, and others who were consultedincorporated this project into their existing workload.No additional persons were hired for the project. Thepurchase of the Quickheel Lancet© replaced anotherproduct. Therefore, the net cost was virtually zero andwas part of an existing cost centre budget.In addition to the project having little if any expense,

the consequential decrease in clotted CBC samplesreduced overall spending in the neonatal patient careareas. Fewer repeated sample collection decreases theaverage number of supplies used per patient and posi-tively effects the bedside nurse productivity since lesstime is spent repeating tasks. In terms of patient flow, areduction in clotted CBC samples, increases the numberof samples’ results available for interpretation at a con-venient and appropriate time for care providers. Thereadiness of results expedites decision making related todischarge, transfer, or further investigations.See supplementary file: ds8731.doc – “BMJ

Appendices”

LESSONS AND LIMITATIONSPrior to using a formalized approach with sequentialPDSA cycles, staff assumed that high CBC clotting rateswere related to Laboratory or Patient Transport pro-cesses. After completing the process map and investigat-ing those areas of concern, we discovered that theseperceptions could not be supported. As the extensiveeducational plan was implemented, it became apparentthat improving the blood sampling skills of the bedsidenurses yielded the greatest positive change. This rigor-ous process highlighted to all staff the importance ofQuality Improvement in the region.The importance of ongoing diverse education cannot

be underappreciated. The demographics of the approxi-mately 200 bedside nurses in the neonatal patient careareas varied widely. Both novice and expert nurses bene-fited from the expansive approaches taken to address

this issue. The education provided to nurses addressedthe three domains of learning: cognitive, affective, andpsychomotor.5 Auditory, visual, and kinesthetic learnerswere supported through the varied media and toolsused to present information such as email, newsletter,posters, diagrams, and physical props. Learning in differ-ent styles was also facilitated by the different forums toaddress the target audience such as large, small, andone-on-one groups as well as indirect communication. Interms of generalizability, while the CBC clotting rateissue was unit-specific, the methods used to address theproblem could be applied to many psychomotor skills inthe health care field, regardless of specialty and patientpopulation. The breadth of educational strategies usedwould likely yield comparable success for other teams.Maintaining these results will take continued deter-

mination by the health care team. From May 2012 toMarch 2016, the NICU collected an average of 124samples for CBC analysis per month, while the IMCN,84. During these years the monthly sample totals showeda downward trend as strategies to minimize blood sam-pling in our smallest infants took hold. In an era ofdeclining opportunities to practice proper technique itwill be imperative to ensure continuance of the devel-oped educational strategies to prevent creep towardsrates seen prior to the intervention. As shown in figure 1the median demonstrated a gradual reduction in clottedsamples with each PDSA cycle. In spite of decliningsample collections, analysis of the last PDSA cycle timeperiod suggests an accelerated decrease in clotting ratescompared to the slow and steady linear decrease experi-enced in the first three PDSA cycles. As shown in figure1 in the first three PDSA cycles there was significant vari-ation in clotting rates as evidenced by the low R valuesof 0.1632, 0.0866, and 0.1354 respectively. More consist-ent reductions were noted after the last PDSA cycle(March 2015 to April 2016 inclusive) with a line of bestfit having a higher R2 of 0.6331. It is unclear whetherthe improvement in consistency was due to a greatercontribution of the strategies employed in cycle 4 or thecumulative efforts of all four cycles but this reduction invariability has persisted since the conclusion of the lastPDSA cycle.As this project only sought to address clotting from

capillary samples we do not have data demonstratingcomparative rates for venipuncture and central lineaccess. Although questioned by our health care team,data collection to address this began, but was neverreviewed. If concerns arise again in the future regardingthe clotting rates of CBC samples, this may be an avenueto explore.

CONCLUSIONAs part of the obtaining background data, we discoveredthat CBC clotting rates for the site as a whole are greaterwhen compared to neighboring acute care centres inthe city. Other departments such as Children’s

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Emergency Department and the ambulatory care areashave also completed process maps for blood collectionand results reporting. These departments are primarilyfocusing on the transit time between the nurse or phle-botomist obtaining the sample from the patient and theappropriate care provider receiving the results. In add-ition to CBC clotting, these areas express frustrationwith high hemolysis of electrolyte samples. The work theneonatal patient care areas did to improve their clottingrates and subsequently, patient flow and client experi-ence may serve as a foundation for other departments tostrive for the same improvements. While the CBCsamples collected from neonates are unique due to theuse of capillary blood sampling, the educational frame-work used to affect change and monitoring strategiesare not. Other departments and patient care areas,regardless of population demographic, can benefit fromthe lessons learned in the neonatal patient care areas atHealth Sciences Centre.After collaboration with all stake holders, an action

plan was formed and re-formed several times over toaddress an issue identified by front-line staff caring forthe most vulnerable patients. Hands-on small-group orone-on-one teaching was done in the clinical area threetimes. The issue, recommendations, and progress todate has been presented to staff at their NeonatalEducation Days seven times between 2012 and 2015 andcontinues to be included in the sessions held twiceyearly. Progress is reported to staff on a monthly basis.The target audience has expanded beyond employedregistered nurses to include student nurses completingtheir senior practicum in the neonatal patient careareas. The combined effort of these initiatives has pro-duced a significant and sustainable change in the clot-ting rates of CBC samples drawn by bedside nurses inthe neonatal population at the Health Sciences Centre.Due to the positive outcomes yielded by this project,

evidence now exists to frame future quality improvementinitiatives where staff education is pivotal to success.

Acknowledgements▸ Shelley Probizanski, Manager, Quality, Patient Safety & Risk▸ Sybil Russell RN BN, Patient Care Manager▸ Alun Carter, Laboratory Information Management Specialist▸ Jenny Dimanauhan, Quality Analysist▸ Susan Csatari RN, BD Diagnostic & Prenalytical Systems▸ Jennifer Prichodko, BD Medical Surgical Systems

Declaration of interests The authors have no conflicts of interest to declare.

Ethical approval Ethical review was not sought since the project was one ofquality improvement and was therefore not required by the institution.Patients were not subjected to more or less testing than was deemedmedically necessary as per the Health Sciences Centre usual ethicallyapproved practices.

Open Access This is an open-access article distributed under the terms ofthe Creative Commons Attribution Non-commercial License, which permitsuse, distribution, and reproduction in any medium, provided the original workis properly cited, the use is non commercial and is otherwise in compliancewith the license. See:• http://creativecommons.org/licenses/by-nc/2.0/• http://creativecommons.org/licenses/by-nc/2.0/legalcode

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