- Email: [email protected]
An Educational Intervention Optimizes the Use of Arterial Blood Gas Determinations Across ICUs From Different Specialties
Accepted Manuscript An educational intervention optimizes the utilization of arterial blood gases across intensive care units from different specialties: a quality improvement study Carlos D. Martínez-Balzano, MD, Paulo Oliveira, MD, Michelle O’Rourke, DAP ACBPBC, Luanne Hills, BS RRT, Andrés F. Sosa, MD PII:
S0012-3692(16)62323-1
DOI:
10.1016/j.chest.2016.10.035
Reference:
CHEST 780
To appear in:
CHEST
Please cite this article as: Martínez-Balzano CD, Oliveira P, O’Rourke M, Hills L, Sosa AF, On behalf of the Critical Care Operations Committee of the UMass Memorial Healthcare Center, An educational intervention optimizes the utilization of arterial blood gases across intensive care units from different specialties: a quality improvement study, CHEST (2016), doi: 10.1016/j.chest.2016.10.035. This is a PDF file of an unedited manuscript that has been accepted for publication. As a service to our customers we are providing this early version of the manuscript. The manuscript will undergo copyediting, typesetting, and review of the resulting proof before it is published in its final form. Please note that during the production process errors may be discovered which could affect the content, and all legal disclaimers that apply to the journal pertain.
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Text word count: 2716
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Abstract word count: 248 Title: An educational intervention optimizes the utilization of arterial blood gases across
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intensive care units from different specialties: a quality improvement study.
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Running head: Optimization of ABGs in the ICU.
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Authors: Carlos D. Martínez-Balzano, MD;1 Paulo Oliveira, MD;1 Michelle O’Rourke, DAP
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ACBP-BC;2 Luanne Hills, BS RRT;3 Andrés F. Sosa, MD.1 On behalf of the Critical Care
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Operations Committee of the UMass Memorial Healthcare Center.
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Affiliations: 1. Division of Pulmonary, Allergy and Critical Care Medicine. Department of
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Medicine. University of Massachusetts Medical School, Worcester, MA. 2. Department of
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Nursing, UMass Memorial Healthcare Center, Worcester, MA. 3. Department of Respiratory
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Care, UMass Memorial Healthcare Center, Worcester, MA.
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Corresponding author: Andrés F. Sosa, MD. Division of Pulmonary, Allergy and Critical Care
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Medicine, Department of Medicine. University of Massachusetts Medical School. 55 N Lake
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Ave, Worcester, MA 01655. E-mail: [email protected].
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No conflicts of interest are reported.
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No external funding was used for the preparation of this manuscript.
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Abstract
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Background: Arterial blood gas (ABG) overutilization leads to increased costs, inefficient use of
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staff work-hours, patient discomfort and blood loss. We developed guidelines to optimize ABG
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utilization in the intensive care unit (ICU).
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Methods: ABG utilization guidelines were implemented on all adult ICUs in our institution:
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three medical, two trauma-surgery, one cardiovascular and one neurosurgical ICU. While relying
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on pulse oximetry, we encouraged the utilization of ABGs after an acute respiratory event or for
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a rational clinical concern, and discouraged obtaining ABGs for routine surveillance, after
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planned changes of PEEP or FiO2 on the mechanical ventilator, for spontaneous breathing trials,
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or when a disorder was not suspected. ABG numbers and global ICU metrics were collected
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before (year 2014) and after the intervention (year 2015).
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Results: We saw a reduction of 821.5 ± 257.4 ABGs/month (41.5%) or approximately 1
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ABG/patient/mechanical ventilation day at each month (43.1 %) after introducing the guidelines
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(p <0.001). This represented 49L of saved blood, a reduction of $39,432 in the costs of ICU care
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and 1,643 staff work-hours freed for other tasks. Appropriately indicated tests rose to 83.4%
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from a baseline 67.5% (p= 0.002). Less than 5% of inappropriately indicated ABGs changed
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patient management in the post-intervention period. There were no significant differences in
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mechanical ventilation days, severity of illness or ICU mortality among the two periods.
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Conclusion: The large scale implementation of guidelines for ABG utilization, reduced the
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number of inappropriately ordered ABGs over seven different multidisciplinary ICUs, without
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negatively impacting patient care.
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Introduction Arterial blood gas (ABG) analysis is one of the most common tests ordered in the
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intensive care unit (ICU). ABGs are time-consuming and associated with increased costs, blood
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loss and patient discomfort.1 Disproportionate ordering of ABGs is not supported by strong
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evidence and seems to be driven by cultural factors. These include the notions that every change
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in the mechanical ventilator requires a follow-up ABG, and that ICU patients on mechanical
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ventilation (MV) need at least one or more ABGs per day for “routine” monitoring by virtue of
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being the sickest patients in the hospital.2-6 Accordingly, a study from a large academic hospital
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found that only 26.4% of ABGs were ordered after an acute respiratory event.3 Similarly, other
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researchers have found that between 42.7% and 66% of ABGs were not clinically justified in
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their ICUs.5-7 The implementation of utilization guidelines in other institutions has resulted in a
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decrease in the number of ABGs, with significant savings in blood loss and costs of ICU care,
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along with an increase in the clinical appropriateness of these tests.5-8
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In early 2014, the critical care leadership at our institution was alerted to the high number of ABGs that were being drawn. Many of these tests were thought to be redundant or
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inappropriately indicated. These institutional concerns were in line with the statements of the
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Choose Wisely in critical care campaign, which calls for an optimization of medical
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interventions and a reduction of unnecessary tests that do not change clinical management.9,10 As
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a response, we set out to develop institutional guidelines and an educational project with the
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goals of increasing the appropriateness of ordered ABGs and to decrease the number of tests.
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Here we describe the results found after one year of this quality improvement intervention.
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Methods
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Setting and guideline development The study was implemented at the two primary campuses of the tertiary academic UMass
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Memorial Medical Center, in Worcester, MA. These two facilities are affiliated to the University
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of Massachusetts Medical School and have seven adult ICUs: three medical units with 46 total
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beds, one 16-bed cardiovascular unit, one 12-bed neurosurgical unit and two trauma-surgery
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units with 24 total beds. Monthly ICU bed occupancy rates are consistently ≥90%. All ICUs are
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overseen by a Critical Care Operations Committee (CCOC), a multidisciplinary group of
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physicians working in collaboration with affiliate practitioners (APs), nurses, respiratory
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therapists (RTs), pharmacists, nutritionists, care coordinators and clinical quality officers.11
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A team consisting of two pulmonary and critical care attending physicians (A.S. and
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P.O.), a pulmonary and critical care fellow (C.M.B.), a nurse manager (M.O.) and a respiratory
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care manager (L.H.) was responsible for identifying areas of improvement and developing
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interventions that might decrease the total number of ABGs. During our analysis, we used a
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fishbone method to uncover potential root causes which were separated into standard categories
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including: man, method, machine and materials. The results of this analysis lead us to focus on
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the human domain and ultimately our plan for an educational intervention. A baseline survey
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among physicians and APs (43 subjects, respondent rate 68.2%) identified the following stances
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toward ordering ABGs: 90.6% would order them for routine surveillance, 69.7% during
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spontaneous breathing trials, 81.4% for every planned change in FiO2 or PEEP on MV and
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65.1% obtained them for “convenience” when an arterial line was available. As a way to
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eliminate weak indications or wrong preconceptions and, at the same time, maintain a certain
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degree of homogeneity in ordering ABGs within our institution, it was thought that the
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introduction of a guideline along with frequent education, would be the best intervention to reach
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our goal of decreasing ABG overutilization without compromising patient care. The guideline was developed by consensus after a review of the published literature by
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the team. These principles were followed: a) there are no uniform prospectively validated
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guidelines for indication of ABGs, b) ABGs are valuable tests to assess for disorders of
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oxygenation, ventilation and acid-base equilibrium, c) ABGs should be ordered in response to an
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acute event or rational concern, d) there is no role for obtaining routine ABGs, e) ABGs are
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overutilized, f) there is reasonably good evidence that ABG utilization guidelines decrease the
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number of these tests without negatively impacting patient care, g) pulse oximetry is a reliable
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resource to monitor oxygenation12 and, h) the guideline should be flexible, simple and easy to
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follow by all members of the ICU team. The guideline was presented to the CCOC on November
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2014 which approved it after minor revisions. A small pilot study of two weeks in a 16-bed
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medical ICU showed that the guideline was feasible to execute. Full implementation on all ICUs
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was started in January 2015. Figure 1 illustrates the proposed ABG protocol.
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Educational interventions
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One lecture for all members of the ICU team was given at each individual ICU between late December 2014 and early January 2015. An additional lecture was given to the nurses and
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RTs of each unit by their respective manager. We encouraged open and constructive discussion
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among the ICU staff when a disagreement for the indication of an ABG was encountered. Posters
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illustrating the guideline were placed in physician and AP working areas (e-Figure 1). Stickers
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with reminders to review the guideline were attached on the ABG portable analyzers (i-STAT
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handheld analyzer, Abbott Point of Care Inc., Princeton, NJ). The number of ABGs and
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compliance with the guideline were monitored by nurse and RT managers, as well as by the
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authors. Monthly email communication between the authors and the managers allowed for
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continuous feedback. Cumulative results were discussed at CCOC meetings during February,
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May, July and September of 2015; these meetings were also used as an opportunity to reinforce
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education.
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Data collection and statistical analysis
Absolute number of ABGs for all ICUs were tracked for the calendar year of 2015 and
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compared to the numbers from the previous year. A sample of random ABGs over two periods of
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3 weeks between November and December 2014 (pre-intervention), and March and April 2015
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(post-intervention) were collected retrospectively and compared for appropriateness of
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indications, as defined by the guideline. Physician, nurse and RT notes were reviewed to this
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end. Our Institutional Review Board approved a waiver of consent for the chart evaluation
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(#H00007053). Global ICU metrics, including number of ICU patients, average number of
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ventilator-days, ICU length of stay, average Acute Physiology and Chronic Health Evaluation
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(APACHE) IV scores and ICU mortality, among others, for the years 2014 and 2015 were
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collected and compared.
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Continuous variables are presented as means ± standard deviation and compared using a two tailed Student’s t-test. Categorical variables are presented as counts or percentages and
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compared using X2. Variables with nonparametric distributions are presented as medians with
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interquartile ranges. Statistical significance was defined by a p value <0.05. Statistical analysis
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was performed using STATA version 10 (StataCorp; College Station, TX).
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Results
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After the educational intervention was implemented, we saw a significant reduction of
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monthly ABGs of 41.5% (821.5 ± 257.4 ABGs/month, p <0.001), consistent with an absolute
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reduction of 9,858 ABGs for the year 2015 (Figure 2A). A reduction in the number of ABGs was
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consistently seen in all ICUs regardless of medical specialty (Figure 2B). When the ABGs were
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adjusted for the number of patients on MV and the number of MV days, we a saw a reduction of
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approximately 1 test/patient/day at each month, corresponding to a 43.1% decline (0.9 ± 0.2
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ABG/patient/day, p <0.001) (Figure 2C). A statistically significant decline in the number of
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adjusted ABGs was retained for each individual ICU (Figure 2D), except for one of the medical
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ICUs which had a marginal p value of 0.05. The cardiovascular ICU had the largest change with
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approximately two less ABG/patient/day per month.
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The reduction was cumulative through the year 2015 and more pronounced during its last third (Figure 2E). The adjusted ABG medians for each consecutive quarter of 2014 were 1.9
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(1.5-3.6), 2.1 (1.4-4), 1.7 (1.3-3) and 1.7 (1-3.3). In comparison, the 2015 medians were: 1 (0.8-
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2.4), 1.2 (0.9-2.4), 1.4 (0.7-2) and 0.8 (0.6-1.3). Other commonly ordered ICU tests did not
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decline in numbers during the study period (Figure 3).
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Adequately indicated tests increased to 83.4% from a baseline of 67.5% (p= 0.002) (Figure 4). The inappropriate indications found at baseline were routine monitoring (81.5%,
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31/38) and follow-up of small changes of PEEP or FiO2 with a reliable SpO2 (18.4%, 7/38). This
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distribution was similar for the lower number of inappropriate ABGs found after the
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intervention, with 91.3% (21/23) and 8.6% (2/23), respectively. Appropriately indicated tests
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were more likely to change patient management in comparison to inappropriately indicated ones,
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for both baseline, 70.8% (56/79) vs. 7.8% (3/38) (p <0.001), and post-intervention, 56% (65/116)
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vs. 4.3% (1/23) (p= 0.001). The changes in management prompted by the four inappropriately
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indicated tests were: an increase in VE for two patients with metabolic acidosis, another increase
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in VE due to unclear reasons, and an escalation of the flow of oxygen-- in spite of adequate PaO2
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and SaO2 on ABG-- based on a clinician’s personal preference.
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There were no significant differences in markers of disease severity and ICU outcomes for the two periods that were compared (Table 1). There was no difference in the variation of
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attending physicians in the ICUs. All units were attended by the same group of nurses and RTs
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for the two years without major staff changes.
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The intervention translated into an approximate 49L of saved blood, when all ABG data
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were pooled, based on a reported average of 5 mL of blood drawn per ABG. There was a direct
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reduction of $39,432 in the costs of ICU care (this only accounts for the $4 i-STAT ABG
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cartridge) and 1,643 work-staff hours were freed for other tasks. These time savings were
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estimated based on the self-reported average time to draw an ABG and run it through the
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portable analyzer (10 min) and could represent potential savings of $98,580, if one assumes $60
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of nursing care/hour.
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Discussion
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Previously published experiences with different ABG utilization protocols have shown
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that redundant blood gas testing can be reduced safely.5-8 Although all of these studies based
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their criteria for drawing an ABG on an acute respiratory event or a rational clinical concern,
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they allowed for some degree of routine utilization. We instead decided to part away completely
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with the notion of obtaining routine ABGs. In our protocol, every ABG is effectively obtained as
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a response to an acute clinical change, an intervention related to that change, or a clinician’s
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concern. To follow this approach, we relied on continuous pulse oximetry monitoring and open
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and honest discussions among all of the ICU team members. Our intervention led to an adjusted
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ABG reduction of 43% that was similar to previously reported rates of 41%, 44% and 48%,5,7,8
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and higher than an additional report of 24%.6
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Our study demonstrates that this intervention can be feasibly and safely implemented on a large scale over multiple ICUs of different specialties. While the previous studies were
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conducted on one or two ICUs, 5-8 we present results from 7 different ICUs with 98 total beds,
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making this the largest intervention for ABG optimization reported to date. The decrease in ABG
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utilization seen in our study was due to the implementation of the guideline and not driven by
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other factors such as a change in disease severity, volume of patients, number of MV days or
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cultural trends in the reduction of tests.
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pH, we instead focused on a flexible and simple guideline based on a clinical concern. This relies
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heavily on the assumption of having a well-trained ICU team with good and open
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communication. This may limit the generalization of our study to other ICUs with less staff
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support. We believe that providing ICU team members with a guideline that encourages them to
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think critically about their patients improves their clinical acumen, in particular for the housestaff
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in training, and allows them to retain their decision-making autonomy.13,14
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Frequent reinforcement is required for an educational intervention to effectively change
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culture. Accordingly, we provided regular reeducation and feedback about the utilization of the
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guideline which likely led to its adherence. We also made the protocol easily available and
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provided the staff with reminders in order to modify behavior.
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Some obstacles were encountered to the implementation of the guidelines. Part of the housestaff and RTs felt that they needed to limit the number of drawn ABGs to follow hospital
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policy and avoid potential reprisals. This issue was solved by re-educating the ICU team,
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detailing what the guideline entailed and explaining that it was not a substitute, but rather an
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aide, for clinical judgment. We also found that the ARDS guideline in our hospital had a vague
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recommendation for “consideration of frequent blood gas sampling” which was resolved by
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addressing this issue specifically with our committee. The impact of the utilization protocol did
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not decrease over time and we did not find any significant rebounds in the numbers of ordered
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ABGs. This was probably a result of the continuous education and feedback.
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Our study has limitations. We assessed the appropriateness of ABG utilization as dictated by the guideline but we did not evaluate the patients without ABGs. This did not translate in
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patient harm, as shown by a lack of change in meaningful ICU metrics, but one could argue that
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studying these patients would provide insight on the attitudes and factors that drive the need for
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obtaining, or withholding, blood gas analysis. It would have also been interesting to study the
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appropriateness of all ABGs, instead that of a sample, but the sheer amount of tests made that
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logistically impossible. We also did not assess for the potential reduction in nosocomial
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infections, by decrease in the number of needlesticks, which this intervention could have
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induced. We were also not able to track if the intervention caused a decrease in the number of
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arterial lines that were placed, or the days that they remained inserted. This protocol will be
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prospectively evaluated by acquiring ABG numbers, repeating educational interventions,
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addressing concerns and potential problems that may arise as the guideline continues to be
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implemented. Additionally, our interventions may have fostered a change in institutional culture,
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which we plan to fully analyze in the near future.
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We believe that the decision to do an intervention in the healthcare setting should be based on a rational concern paired with the best available evidence. Previous reports have shown
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that cultural attitudes in healthcare do not necessarily go along with a clinical benefit. Medical
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studies have shown that routine ABGs do not change extubation outcomes and may, in fact,
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prolong MV,15,16 arterial line placement does not change mortality retrospectively and requires
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prospective and case-by-case validation,17,18 and the practice of obtaining venous blood gases for
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ScvO2 monitoring in sepsis does not change outcomes.19-21 These examples demonstrate the need
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to individualize interventions, based on rational evidence, and to avoid unnecessary tests and
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procedures that carry significant cost-burdens, discomfort and potential harms. In this sense, we
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believe that our study offers important results that could influence future ICU care.
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Conclusions
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The implementation of guidelines for arterial blood gas testing reduced the number of
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inappropriately ordered ABGs across seven different multidisciplinary ICUs, with significant
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costs savings and reduction of blood loss without negatively impacting patient care.
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Acknowledgements
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C.M.B, A.S., P.O., L.H. and M.O. participated in the concept and design of the study and
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executed the educational interventions.
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C.M.B. and A.S. collected and interpreted data.
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C.M.B. performed statistical analyses and drafted the manuscript.
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A.S., P.O., L.H. and M.O. revised and approved the final manuscript.
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A.S. served as the principal investigator, had access to all of the data and is the guarantor of the
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study.
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We thank all the UMass ICU physicians, APs, nurses, RTs, clinical data and quality officers for
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making this intervention a success. We also thank Jennifer MacPherson, Gurudev Lotun, BE,
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BSc(Comp); and Teresa Rincon RN, BSN, CCRN-E, FCCM, for providing us with ancillary
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data.
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Preliminary results of this study were presented in abstract form at the annual ATS conference,
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5/16/16 in San Francisco, CA. An ATS travel grant was awarded to C.M.B. for this purpose.
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C.M.B is now in the Division of Pulmonary, Critical Care and Sleep Medicine at SUNY Upstate
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Medical University, Syracuse, NY.
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Figure 1. Guideline for the utilization of arterial blood gases. ABG: arterial blood gas, SBT:
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spontaneous breathing trial, VBG: venous blood gas, FiO2: fraction of inspired oxygen, PEEP:
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positive end-expiratory pressure, SaO2: arterial blood oxygen saturation, SpO2: peripheral
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capillary oxygen saturation.
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Figure 2. A- Overall number of monthly ABGs at baseline (year 2014) and after introduction
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(year 2015) of the guidelines, *= p <0.001. B- Average monthly reduction of ABGs for each
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individual ICU, *= p <0.001, θ= p value of 0.003. C and D- ABG reduction adjusted by number
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of patients on MV and MV days at each month for all (C) and each individual ICU (D), *= p
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<0.001, ξ= p value of 0.001. E- Median number of ABGs with interquartile ranges across all
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ICUs over time. ABG: arterial blood gas, ICU: intensive care unit, MICU: medical intensive
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care unit, MV: mechanical ventilation, SICU: surgical intensive care unit. Bars in figures A,B,C
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and D: standard deviation.
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Figure 3. Average monthly numbers for laboratory studies in the ICU. A significant reduction
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was seen only for the ABGs. Bars: standard deviation. ICU: intensive care unit, ABG: arterial
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blood gas, CBC: complete blood count, BMP: basic metabolic panel, PT: prothrombin time,
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PTT: partial thromboplastin time.
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Figure 4. Adequacy of indications for ABG testing before and after the guideline
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implementation. ABG: arterial blood gas.
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Table 1. Combined metrics for all ICUs before and after the introduction of the guideline. Year 2014
Year 2015
p value
Average number of patients per month ± SD
626 ± 30
642 ± 29
0.21
Average APACHE IV score ± SD
63.8 ± 5.02 62.5 ± 4.30
0.33
Average length of ICU stay (days ± SD)
4.2 ± 0.12
0.92
Average number of ventilator days ± SD
3.18 ± 0.18 3.24 ± 0.32
0.59
Actual ventilator days/predicted ventilator days ± SD 1.11 ± 0.20 1.19 ± 0.24
0.22
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4.2 ± 0.27
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9.67 ± 1.25 10.43 ± 0.92 0.10
ICU mortality (% ± SD)
0.88 ± 0.23 0.95 ± 0.17
0.29
ICU readmission rate (% ± SD)
4.03 ± 0.42 4.04 ± 0.43
0.97
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Actual mortality/predicted mortality ± SD
ICU: intensive care unit, SD: standard deviation, APACHE: Acute Physiology and Chronic
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Health Evaluation.
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e-Figure 1. Poster illustrating the guideline. ABG: arterial blood gas, SBT: spontaneous
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breathing trial, VBG: venous blood gas, FiO2: fraction of inspired oxygen, PEEP: positive end-
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expiratory pressure, SaO2: arterial blood oxygen saturation, SpO2: peripheral capillary oxygen
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saturation, A-line: arterial line, ICU: intensive care unit, FiO2: fraction of inspired oxygen.
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Abbreviations
ARDS: acute respiratory distress syndrome CCOC: Critical Care Operations Committee
ICU: intensive care unit MV: mechanical ventilation
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PEEP: positive end-expiratory pressure
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RT: respiratory therapist
SaO2: arterial blood oxygen saturation
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SpO2: peripheral capillary oxygen saturation ScvO2: central venous oxygen saturation VE: minute ventilation
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APACHE: Acute Physiology and Chronic Health Evaluation
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ABG: arterial blood gas
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e-Figure 1. Poster illustrating the guideline. ABG: arterial blood gas, 326 SBT: spontaneous breathing trial, VBG: venous blood gas, FiO2: fraction of inspired oxygen, PEEP: positive end expiratory pressure, SaO2: arterial blood oxygen saturation, SpO2: peripheral capillary oxygen saturation, A-line: arterial line, ICU: intensive care unit, FiO2: fraction of inspired oxygen.
161250 Online supplements are not copyedited prior to posting and the author(s) take full responsibility for the accuracy o all data.
S0012-3692(16)62323-1
DOI:
10.1016/j.chest.2016.10.035
Reference:
CHEST 780
To appear in:
CHEST
Please cite this article as: Martínez-Balzano CD, Oliveira P, O’Rourke M, Hills L, Sosa AF, On behalf of the Critical Care Operations Committee of the UMass Memorial Healthcare Center, An educational intervention optimizes the utilization of arterial blood gases across intensive care units from different specialties: a quality improvement study, CHEST (2016), doi: 10.1016/j.chest.2016.10.035. This is a PDF file of an unedited manuscript that has been accepted for publication. As a service to our customers we are providing this early version of the manuscript. The manuscript will undergo copyediting, typesetting, and review of the resulting proof before it is published in its final form. Please note that during the production process errors may be discovered which could affect the content, and all legal disclaimers that apply to the journal pertain.
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Text word count: 2716
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Abstract word count: 248 Title: An educational intervention optimizes the utilization of arterial blood gases across
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intensive care units from different specialties: a quality improvement study.
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Running head: Optimization of ABGs in the ICU.
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Authors: Carlos D. Martínez-Balzano, MD;1 Paulo Oliveira, MD;1 Michelle O’Rourke, DAP
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ACBP-BC;2 Luanne Hills, BS RRT;3 Andrés F. Sosa, MD.1 On behalf of the Critical Care
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Operations Committee of the UMass Memorial Healthcare Center.
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Affiliations: 1. Division of Pulmonary, Allergy and Critical Care Medicine. Department of
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Medicine. University of Massachusetts Medical School, Worcester, MA. 2. Department of
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Nursing, UMass Memorial Healthcare Center, Worcester, MA. 3. Department of Respiratory
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Care, UMass Memorial Healthcare Center, Worcester, MA.
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Corresponding author: Andrés F. Sosa, MD. Division of Pulmonary, Allergy and Critical Care
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Medicine, Department of Medicine. University of Massachusetts Medical School. 55 N Lake
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Ave, Worcester, MA 01655. E-mail: [email protected].
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No conflicts of interest are reported.
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No external funding was used for the preparation of this manuscript.
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Abstract
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Background: Arterial blood gas (ABG) overutilization leads to increased costs, inefficient use of
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staff work-hours, patient discomfort and blood loss. We developed guidelines to optimize ABG
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utilization in the intensive care unit (ICU).
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Methods: ABG utilization guidelines were implemented on all adult ICUs in our institution:
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three medical, two trauma-surgery, one cardiovascular and one neurosurgical ICU. While relying
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on pulse oximetry, we encouraged the utilization of ABGs after an acute respiratory event or for
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a rational clinical concern, and discouraged obtaining ABGs for routine surveillance, after
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planned changes of PEEP or FiO2 on the mechanical ventilator, for spontaneous breathing trials,
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or when a disorder was not suspected. ABG numbers and global ICU metrics were collected
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before (year 2014) and after the intervention (year 2015).
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Results: We saw a reduction of 821.5 ± 257.4 ABGs/month (41.5%) or approximately 1
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ABG/patient/mechanical ventilation day at each month (43.1 %) after introducing the guidelines
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(p <0.001). This represented 49L of saved blood, a reduction of $39,432 in the costs of ICU care
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and 1,643 staff work-hours freed for other tasks. Appropriately indicated tests rose to 83.4%
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from a baseline 67.5% (p= 0.002). Less than 5% of inappropriately indicated ABGs changed
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patient management in the post-intervention period. There were no significant differences in
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mechanical ventilation days, severity of illness or ICU mortality among the two periods.
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Conclusion: The large scale implementation of guidelines for ABG utilization, reduced the
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number of inappropriately ordered ABGs over seven different multidisciplinary ICUs, without
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negatively impacting patient care.
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Introduction Arterial blood gas (ABG) analysis is one of the most common tests ordered in the
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intensive care unit (ICU). ABGs are time-consuming and associated with increased costs, blood
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loss and patient discomfort.1 Disproportionate ordering of ABGs is not supported by strong
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evidence and seems to be driven by cultural factors. These include the notions that every change
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in the mechanical ventilator requires a follow-up ABG, and that ICU patients on mechanical
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ventilation (MV) need at least one or more ABGs per day for “routine” monitoring by virtue of
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being the sickest patients in the hospital.2-6 Accordingly, a study from a large academic hospital
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found that only 26.4% of ABGs were ordered after an acute respiratory event.3 Similarly, other
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researchers have found that between 42.7% and 66% of ABGs were not clinically justified in
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their ICUs.5-7 The implementation of utilization guidelines in other institutions has resulted in a
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decrease in the number of ABGs, with significant savings in blood loss and costs of ICU care,
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along with an increase in the clinical appropriateness of these tests.5-8
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In early 2014, the critical care leadership at our institution was alerted to the high number of ABGs that were being drawn. Many of these tests were thought to be redundant or
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inappropriately indicated. These institutional concerns were in line with the statements of the
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Choose Wisely in critical care campaign, which calls for an optimization of medical
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interventions and a reduction of unnecessary tests that do not change clinical management.9,10 As
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a response, we set out to develop institutional guidelines and an educational project with the
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goals of increasing the appropriateness of ordered ABGs and to decrease the number of tests.
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Here we describe the results found after one year of this quality improvement intervention.
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Methods
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Setting and guideline development The study was implemented at the two primary campuses of the tertiary academic UMass
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Memorial Medical Center, in Worcester, MA. These two facilities are affiliated to the University
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of Massachusetts Medical School and have seven adult ICUs: three medical units with 46 total
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beds, one 16-bed cardiovascular unit, one 12-bed neurosurgical unit and two trauma-surgery
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units with 24 total beds. Monthly ICU bed occupancy rates are consistently ≥90%. All ICUs are
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overseen by a Critical Care Operations Committee (CCOC), a multidisciplinary group of
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physicians working in collaboration with affiliate practitioners (APs), nurses, respiratory
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therapists (RTs), pharmacists, nutritionists, care coordinators and clinical quality officers.11
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A team consisting of two pulmonary and critical care attending physicians (A.S. and
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P.O.), a pulmonary and critical care fellow (C.M.B.), a nurse manager (M.O.) and a respiratory
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care manager (L.H.) was responsible for identifying areas of improvement and developing
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interventions that might decrease the total number of ABGs. During our analysis, we used a
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fishbone method to uncover potential root causes which were separated into standard categories
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including: man, method, machine and materials. The results of this analysis lead us to focus on
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the human domain and ultimately our plan for an educational intervention. A baseline survey
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among physicians and APs (43 subjects, respondent rate 68.2%) identified the following stances
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toward ordering ABGs: 90.6% would order them for routine surveillance, 69.7% during
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spontaneous breathing trials, 81.4% for every planned change in FiO2 or PEEP on MV and
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65.1% obtained them for “convenience” when an arterial line was available. As a way to
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eliminate weak indications or wrong preconceptions and, at the same time, maintain a certain
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degree of homogeneity in ordering ABGs within our institution, it was thought that the
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introduction of a guideline along with frequent education, would be the best intervention to reach
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our goal of decreasing ABG overutilization without compromising patient care. The guideline was developed by consensus after a review of the published literature by
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the team. These principles were followed: a) there are no uniform prospectively validated
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guidelines for indication of ABGs, b) ABGs are valuable tests to assess for disorders of
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oxygenation, ventilation and acid-base equilibrium, c) ABGs should be ordered in response to an
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acute event or rational concern, d) there is no role for obtaining routine ABGs, e) ABGs are
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overutilized, f) there is reasonably good evidence that ABG utilization guidelines decrease the
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number of these tests without negatively impacting patient care, g) pulse oximetry is a reliable
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resource to monitor oxygenation12 and, h) the guideline should be flexible, simple and easy to
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follow by all members of the ICU team. The guideline was presented to the CCOC on November
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2014 which approved it after minor revisions. A small pilot study of two weeks in a 16-bed
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medical ICU showed that the guideline was feasible to execute. Full implementation on all ICUs
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was started in January 2015. Figure 1 illustrates the proposed ABG protocol.
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Educational interventions
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One lecture for all members of the ICU team was given at each individual ICU between late December 2014 and early January 2015. An additional lecture was given to the nurses and
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RTs of each unit by their respective manager. We encouraged open and constructive discussion
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among the ICU staff when a disagreement for the indication of an ABG was encountered. Posters
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illustrating the guideline were placed in physician and AP working areas (e-Figure 1). Stickers
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with reminders to review the guideline were attached on the ABG portable analyzers (i-STAT
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handheld analyzer, Abbott Point of Care Inc., Princeton, NJ). The number of ABGs and
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compliance with the guideline were monitored by nurse and RT managers, as well as by the
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authors. Monthly email communication between the authors and the managers allowed for
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continuous feedback. Cumulative results were discussed at CCOC meetings during February,
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May, July and September of 2015; these meetings were also used as an opportunity to reinforce
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education.
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Data collection and statistical analysis
Absolute number of ABGs for all ICUs were tracked for the calendar year of 2015 and
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compared to the numbers from the previous year. A sample of random ABGs over two periods of
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3 weeks between November and December 2014 (pre-intervention), and March and April 2015
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(post-intervention) were collected retrospectively and compared for appropriateness of
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indications, as defined by the guideline. Physician, nurse and RT notes were reviewed to this
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end. Our Institutional Review Board approved a waiver of consent for the chart evaluation
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(#H00007053). Global ICU metrics, including number of ICU patients, average number of
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ventilator-days, ICU length of stay, average Acute Physiology and Chronic Health Evaluation
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(APACHE) IV scores and ICU mortality, among others, for the years 2014 and 2015 were
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collected and compared.
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Continuous variables are presented as means ± standard deviation and compared using a two tailed Student’s t-test. Categorical variables are presented as counts or percentages and
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compared using X2. Variables with nonparametric distributions are presented as medians with
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interquartile ranges. Statistical significance was defined by a p value <0.05. Statistical analysis
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was performed using STATA version 10 (StataCorp; College Station, TX).
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Results
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After the educational intervention was implemented, we saw a significant reduction of
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monthly ABGs of 41.5% (821.5 ± 257.4 ABGs/month, p <0.001), consistent with an absolute
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reduction of 9,858 ABGs for the year 2015 (Figure 2A). A reduction in the number of ABGs was
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consistently seen in all ICUs regardless of medical specialty (Figure 2B). When the ABGs were
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adjusted for the number of patients on MV and the number of MV days, we a saw a reduction of
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approximately 1 test/patient/day at each month, corresponding to a 43.1% decline (0.9 ± 0.2
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ABG/patient/day, p <0.001) (Figure 2C). A statistically significant decline in the number of
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adjusted ABGs was retained for each individual ICU (Figure 2D), except for one of the medical
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ICUs which had a marginal p value of 0.05. The cardiovascular ICU had the largest change with
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approximately two less ABG/patient/day per month.
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The reduction was cumulative through the year 2015 and more pronounced during its last third (Figure 2E). The adjusted ABG medians for each consecutive quarter of 2014 were 1.9
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(1.5-3.6), 2.1 (1.4-4), 1.7 (1.3-3) and 1.7 (1-3.3). In comparison, the 2015 medians were: 1 (0.8-
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2.4), 1.2 (0.9-2.4), 1.4 (0.7-2) and 0.8 (0.6-1.3). Other commonly ordered ICU tests did not
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decline in numbers during the study period (Figure 3).
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Adequately indicated tests increased to 83.4% from a baseline of 67.5% (p= 0.002) (Figure 4). The inappropriate indications found at baseline were routine monitoring (81.5%,
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31/38) and follow-up of small changes of PEEP or FiO2 with a reliable SpO2 (18.4%, 7/38). This
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distribution was similar for the lower number of inappropriate ABGs found after the
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intervention, with 91.3% (21/23) and 8.6% (2/23), respectively. Appropriately indicated tests
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were more likely to change patient management in comparison to inappropriately indicated ones,
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for both baseline, 70.8% (56/79) vs. 7.8% (3/38) (p <0.001), and post-intervention, 56% (65/116)
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vs. 4.3% (1/23) (p= 0.001). The changes in management prompted by the four inappropriately
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indicated tests were: an increase in VE for two patients with metabolic acidosis, another increase
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in VE due to unclear reasons, and an escalation of the flow of oxygen-- in spite of adequate PaO2
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and SaO2 on ABG-- based on a clinician’s personal preference.
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There were no significant differences in markers of disease severity and ICU outcomes for the two periods that were compared (Table 1). There was no difference in the variation of
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attending physicians in the ICUs. All units were attended by the same group of nurses and RTs
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for the two years without major staff changes.
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The intervention translated into an approximate 49L of saved blood, when all ABG data
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were pooled, based on a reported average of 5 mL of blood drawn per ABG. There was a direct
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reduction of $39,432 in the costs of ICU care (this only accounts for the $4 i-STAT ABG
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cartridge) and 1,643 work-staff hours were freed for other tasks. These time savings were
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estimated based on the self-reported average time to draw an ABG and run it through the
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portable analyzer (10 min) and could represent potential savings of $98,580, if one assumes $60
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of nursing care/hour.
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Discussion
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Previously published experiences with different ABG utilization protocols have shown
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that redundant blood gas testing can be reduced safely.5-8 Although all of these studies based
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their criteria for drawing an ABG on an acute respiratory event or a rational clinical concern,
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they allowed for some degree of routine utilization. We instead decided to part away completely
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with the notion of obtaining routine ABGs. In our protocol, every ABG is effectively obtained as
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a response to an acute clinical change, an intervention related to that change, or a clinician’s
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concern. To follow this approach, we relied on continuous pulse oximetry monitoring and open
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and honest discussions among all of the ICU team members. Our intervention led to an adjusted
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ABG reduction of 43% that was similar to previously reported rates of 41%, 44% and 48%,5,7,8
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and higher than an additional report of 24%.6
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Our study demonstrates that this intervention can be feasibly and safely implemented on a large scale over multiple ICUs of different specialties. While the previous studies were
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conducted on one or two ICUs, 5-8 we present results from 7 different ICUs with 98 total beds,
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making this the largest intervention for ABG optimization reported to date. The decrease in ABG
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utilization seen in our study was due to the implementation of the guideline and not driven by
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other factors such as a change in disease severity, volume of patients, number of MV days or
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cultural trends in the reduction of tests.
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pH, we instead focused on a flexible and simple guideline based on a clinical concern. This relies
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heavily on the assumption of having a well-trained ICU team with good and open
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communication. This may limit the generalization of our study to other ICUs with less staff
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support. We believe that providing ICU team members with a guideline that encourages them to
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think critically about their patients improves their clinical acumen, in particular for the housestaff
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in training, and allows them to retain their decision-making autonomy.13,14
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culture. Accordingly, we provided regular reeducation and feedback about the utilization of the
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guideline which likely led to its adherence. We also made the protocol easily available and
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provided the staff with reminders in order to modify behavior.
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Some obstacles were encountered to the implementation of the guidelines. Part of the housestaff and RTs felt that they needed to limit the number of drawn ABGs to follow hospital
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policy and avoid potential reprisals. This issue was solved by re-educating the ICU team,
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detailing what the guideline entailed and explaining that it was not a substitute, but rather an
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aide, for clinical judgment. We also found that the ARDS guideline in our hospital had a vague
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recommendation for “consideration of frequent blood gas sampling” which was resolved by
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addressing this issue specifically with our committee. The impact of the utilization protocol did
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not decrease over time and we did not find any significant rebounds in the numbers of ordered
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ABGs. This was probably a result of the continuous education and feedback.
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Our study has limitations. We assessed the appropriateness of ABG utilization as dictated by the guideline but we did not evaluate the patients without ABGs. This did not translate in
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patient harm, as shown by a lack of change in meaningful ICU metrics, but one could argue that
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studying these patients would provide insight on the attitudes and factors that drive the need for
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obtaining, or withholding, blood gas analysis. It would have also been interesting to study the
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appropriateness of all ABGs, instead that of a sample, but the sheer amount of tests made that
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logistically impossible. We also did not assess for the potential reduction in nosocomial
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infections, by decrease in the number of needlesticks, which this intervention could have
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induced. We were also not able to track if the intervention caused a decrease in the number of
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arterial lines that were placed, or the days that they remained inserted. This protocol will be
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prospectively evaluated by acquiring ABG numbers, repeating educational interventions,
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addressing concerns and potential problems that may arise as the guideline continues to be
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implemented. Additionally, our interventions may have fostered a change in institutional culture,
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which we plan to fully analyze in the near future.
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We believe that the decision to do an intervention in the healthcare setting should be based on a rational concern paired with the best available evidence. Previous reports have shown
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that cultural attitudes in healthcare do not necessarily go along with a clinical benefit. Medical
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studies have shown that routine ABGs do not change extubation outcomes and may, in fact,
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prolong MV,15,16 arterial line placement does not change mortality retrospectively and requires
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prospective and case-by-case validation,17,18 and the practice of obtaining venous blood gases for
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ScvO2 monitoring in sepsis does not change outcomes.19-21 These examples demonstrate the need
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to individualize interventions, based on rational evidence, and to avoid unnecessary tests and
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procedures that carry significant cost-burdens, discomfort and potential harms. In this sense, we
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believe that our study offers important results that could influence future ICU care.
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Conclusions
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The implementation of guidelines for arterial blood gas testing reduced the number of
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inappropriately ordered ABGs across seven different multidisciplinary ICUs, with significant
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costs savings and reduction of blood loss without negatively impacting patient care.
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Acknowledgements
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C.M.B, A.S., P.O., L.H. and M.O. participated in the concept and design of the study and
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executed the educational interventions.
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C.M.B. and A.S. collected and interpreted data.
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C.M.B. performed statistical analyses and drafted the manuscript.
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A.S., P.O., L.H. and M.O. revised and approved the final manuscript.
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A.S. served as the principal investigator, had access to all of the data and is the guarantor of the
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study.
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We thank all the UMass ICU physicians, APs, nurses, RTs, clinical data and quality officers for
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making this intervention a success. We also thank Jennifer MacPherson, Gurudev Lotun, BE,
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BSc(Comp); and Teresa Rincon RN, BSN, CCRN-E, FCCM, for providing us with ancillary
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data.
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Preliminary results of this study were presented in abstract form at the annual ATS conference,
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5/16/16 in San Francisco, CA. An ATS travel grant was awarded to C.M.B. for this purpose.
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C.M.B is now in the Division of Pulmonary, Critical Care and Sleep Medicine at SUNY Upstate
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Medical University, Syracuse, NY.
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14. Young T, Rohwer A, Volmink J, Clarke M. What are the effects of teaching evidence-based
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health care (EBHC)? Overview of systematic reviews. PLoS One. 2014;9(1):e86706.
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15. Pawson SR, DePriest JL. Are blood gases necessary in mechanically ventilated patients who
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have successfully completed a spontaneous breathing trial? Respir Care. 2004;49(11):1316-
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1319.
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16. Salam A, Smina M, Gada P, et al. The effect of arterial blood gas values on extubation
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decisions. Respir Care. 2003;48(11):1033-1037.
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17. Hsu DJ, Feng M, Kothari R, Zhou H, Chen KP, Celi LA. The association between indwelling
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arterial catheters and mortality in hemodynamically stable patients with respiratory failure: a
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propensity score analysis. Chest. 2015;148(6):1470-1476.
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18. Gershengorn HB, Wunsch H, Scales DC, Zarychanski R, Rubenfeld G, Garland A.
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Association between arterial catheter use and hospital mortality in intensive care units. JAMA
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Intern Med. 2014;174(11):1746-1754.
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19. ARISE Investigators; ANZICS Clinical Trials Group, Peake SL, Delaney A, Bailey M, et al.
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Goal-directed resuscitation for patients with early septic shock. N Engl J Med.
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2014;371(16):1496-1506.
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20. ProCESS Investigators, Yealy DM, Kellum JA, Huang DT, et al. A randomized trial of
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protocol-based care for early septic shock. N Engl J Med. 2014;370(18):1683-1693.
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21. Mouncey PR, Osborn TM, Power GS, et al; ProMISe Trial Investigators. Trial of early, goal-
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directed resuscitation for septic shock. N Engl J Med. 2015;372(14):1301-1311.
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Figure 1. Guideline for the utilization of arterial blood gases. ABG: arterial blood gas, SBT:
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spontaneous breathing trial, VBG: venous blood gas, FiO2: fraction of inspired oxygen, PEEP:
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positive end-expiratory pressure, SaO2: arterial blood oxygen saturation, SpO2: peripheral
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capillary oxygen saturation.
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Figure 2. A- Overall number of monthly ABGs at baseline (year 2014) and after introduction
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(year 2015) of the guidelines, *= p <0.001. B- Average monthly reduction of ABGs for each
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individual ICU, *= p <0.001, θ= p value of 0.003. C and D- ABG reduction adjusted by number
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of patients on MV and MV days at each month for all (C) and each individual ICU (D), *= p
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<0.001, ξ= p value of 0.001. E- Median number of ABGs with interquartile ranges across all
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ICUs over time. ABG: arterial blood gas, ICU: intensive care unit, MICU: medical intensive
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care unit, MV: mechanical ventilation, SICU: surgical intensive care unit. Bars in figures A,B,C
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and D: standard deviation.
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Figure 3. Average monthly numbers for laboratory studies in the ICU. A significant reduction
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was seen only for the ABGs. Bars: standard deviation. ICU: intensive care unit, ABG: arterial
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blood gas, CBC: complete blood count, BMP: basic metabolic panel, PT: prothrombin time,
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PTT: partial thromboplastin time.
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Figure 4. Adequacy of indications for ABG testing before and after the guideline
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implementation. ABG: arterial blood gas.
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Table 1. Combined metrics for all ICUs before and after the introduction of the guideline. Year 2014
Year 2015
p value
Average number of patients per month ± SD
626 ± 30
642 ± 29
0.21
Average APACHE IV score ± SD
63.8 ± 5.02 62.5 ± 4.30
0.33
Average length of ICU stay (days ± SD)
4.2 ± 0.12
0.92
Average number of ventilator days ± SD
3.18 ± 0.18 3.24 ± 0.32
0.59
Actual ventilator days/predicted ventilator days ± SD 1.11 ± 0.20 1.19 ± 0.24
0.22
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Variable
4.2 ± 0.27
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9.67 ± 1.25 10.43 ± 0.92 0.10
ICU mortality (% ± SD)
0.88 ± 0.23 0.95 ± 0.17
0.29
ICU readmission rate (% ± SD)
4.03 ± 0.42 4.04 ± 0.43
0.97
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Actual mortality/predicted mortality ± SD
ICU: intensive care unit, SD: standard deviation, APACHE: Acute Physiology and Chronic
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Health Evaluation.
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e-Figure 1. Poster illustrating the guideline. ABG: arterial blood gas, SBT: spontaneous
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breathing trial, VBG: venous blood gas, FiO2: fraction of inspired oxygen, PEEP: positive end-
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expiratory pressure, SaO2: arterial blood oxygen saturation, SpO2: peripheral capillary oxygen
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saturation, A-line: arterial line, ICU: intensive care unit, FiO2: fraction of inspired oxygen.
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Abbreviations
ARDS: acute respiratory distress syndrome CCOC: Critical Care Operations Committee
ICU: intensive care unit MV: mechanical ventilation
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NP: nurse practitioner
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FiO2: fraction of inspired oxygen
PEEP: positive end-expiratory pressure
EP
RT: respiratory therapist
SaO2: arterial blood oxygen saturation
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SD: standard deviation
SpO2: peripheral capillary oxygen saturation ScvO2: central venous oxygen saturation VE: minute ventilation
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APACHE: Acute Physiology and Chronic Health Evaluation
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ABG: arterial blood gas
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e-Figure 1. Poster illustrating the guideline. ABG: arterial blood gas, 326 SBT: spontaneous breathing trial, VBG: venous blood gas, FiO2: fraction of inspired oxygen, PEEP: positive end expiratory pressure, SaO2: arterial blood oxygen saturation, SpO2: peripheral capillary oxygen saturation, A-line: arterial line, ICU: intensive care unit, FiO2: fraction of inspired oxygen.
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