Emergency department evaluation of nurse triage questions about safe-at-home and abuse or neglect in traumatic ocular injuries.

OBJECTIVES: Approximately 10 million Americans experience acts of physical violence by an intimate partner (IPV). Ocular injuries can present as a symptom of IPV in the emergency department, but IPV remains underreported in the literature. Understanding the incidence and trends in IPV-associated ocular injuries in the emergency department could increase the detection of at-risk patients otherwise overlooked. DESIGN: Retrospective chart review. PARTICIPANTS: Emergency department patients evaluated for traumatic ocular injuries between January 2018 and April 2023 at a large tertiary care health system. METHODS: The study population was identified by ICD-10 code and their responses to being screened at triage for home safety and any nursing concerns for abuse or neglect. Patient screening consisted of a 2-part questionnaire inquiring first about whether the patient feels safe at home ("Yes" or "No") and second regarding nurses' concerns for abuse, neglect, domestic violence, sexual assault, or human trafficking. RESULTS: There were 2,653,993 emergency department visits and 16,737 traumatic ocular injuries in the study period. Of them, 1.1% of patients (154 of 14,457) responded "No" to feeling safe at home. In only 0.6% of patients (82 of 14,457), a nursing concern was documented. Patients responding "No" to feeling safe at home presented with more severe ocular injuries such as maxillary fractures. On regression analysis, married, divorced, and widowed patients as well as patients on private insurance were less likely to report feeling unsafe at home than single patients on public insurance (p < 0.05). CONCLUSION: Traumatic ocular injuries in emergency departments should raise concerns about IPV. Opportunity exists to improve education, screening, and management of these patients.

Antemortem Health System Utilization in People Experiencing Homelessness Who Died in the Emergency Department.

People experiencing homelessness (PEH) have high rates of mortality, medical and psychiatric comorbidities, and emergency department utilization. In this study, a health system's emergency department encounters were evaluated to identify PEH who died in the emergency department. Patient demographics, medical history, prehospital and emergency department characteristics, and health care utilization patterns were collected. Descriptive statistics were calculated. We identified 48 PEH pronounced dead in the emergency department; mean age at death was 46.5. Forty-four (92%) decedents presented in cardiac arrest, 12 (25%) of which were substance use-related; 4 (8%) presented with trauma. Out of 44 patients presenting in cardiac arrest, (20.5%) had bystander cardiopulmonary resuscitation (CPR) performed before arrival of emergency medical services. In the year prior to death, 15 (32%) decedents had no documented health care utilization, while 16 (33%) had 10 or more emergency department/outpatient visits. Our study is the first to characterize PEH who died in the emergency department, analyzing the pre-hospital and in-hospital characteristics and antemortem health system utilization in this population. A sizeable proportion of deceased PEH had no health system contact in the 12 months prior to death, suggesting that those with high mortality risk may underutilize health services. Conversely, a similar proportion of decedents had extensive (more than 10) health system utilization in the year prior to death, representing possible opportunities to reduce mortality.

Emergency department utilization among patients who receive outpatient specialty care for headache: A retrospective cohort study analysis.

OBJECTIVES: To compare clinical characteristics among outpatient headache clinic patients who do and do not self-report visiting the emergency department for headache. BACKGROUND: Headache is the fourth most common reason for emergency department visits, compromising 1%-3% of visits. Limited data exist about patients who are seen in an outpatient headache clinic but still opt to frequent the emergency department. Clinical characteristics may differ between patients who self-report emergency department use and those who do not. Understanding these differences may help identify which patients are at greatest risk for emergency department overutilization. METHODS: This observational cohort study included adults treated at the Cleveland Clinic Headache Center between October 12, 2015 and September 11, 2019, who completed self-reported questionnaires. Associations between self-reported emergency department utilization and demographics, clinical characteristics, and patient-reported outcome measures (PROMs: Headache Impact Test [HIT-6], headache days per month, current headache/face pain, Patient Health Questionnaire-9 [PHQ-9], Patient-Reported Outcomes Measurement Information System [PROMIS] Global Health [GH]) were evaluated. RESULTS: Of the 10,073 patients (mean age 44.7 ± 14.9, 78.1% [7872/10,073] female, 80.3% [8087/10,073] White patients) included in the study, 34.5% (3478/10,073) reported visiting the emergency department at least once during the study period. Characteristics significantly associated with self-reported emergency department utilization included younger age (odds ratio = 0.81 [95% CI = 0.78-0.85] per decade), Black patients (vs. White patients) (1.47 [1.26-1.71]), Medicaid (vs. private insurance) (1.50 [1.29-1.74]), and worse area deprivation index (1.04 [1.02-1.07]). Additionally, worse PROMs were associated with greater odds of emergency department utilization: higher (worse) HIT-6 (1.35 [1.30-1.41] per 5-point increase), higher (worse) PHQ-9 (1.14 [1.09-1.20] per 5-point increase), and lower (worse) PROMIS-GH Physical Health T-scores (0.93 [0.88-0.97]) per 5-point increase. CONCLUSION: Our study identified several characteristics associated with self-reported emergency department utilization for headache. Worse PROM scores may be helpful in identifying which patients are at greater risk for utilizing the emergency department.

Evaluation of missed influenza vaccination opportunities in the emergency department.

BACKGROUND: Seasonal influenza is associated with significant healthcare resource utilization. An estimated 490,000 hospitalizations and 34,000 deaths were attributed to influenza during the 2018-2019 season. Despite robust influenza vaccination programs in both the inpatient and outpatient setting, the emergency department (ED) represents a missed opportunity to vaccinate patients at high risk for influenza who do not have access to routine preventive care. Feasibility and implementation of ED-based influenza vaccination programs have been previously described but have stopped short of describing the predicted health resource impact. The goal of our study was to describe the potential impact of an influenza vaccination program in an urban adult emergency department population using historic patient data. METHODS: This was a retrospective study of all encounters within a tertiary care hospital-based ED and three freestanding EDs during influenza season (defined as October 1 - April 30) over a two-years, 2018-2020. Data was obtained from the electronic medical record (EPIC®). All ED encounters during the study period were screened for inclusion using ICD 10 codes. Patients with a confirmed positive influenza test and no documented influenza vaccine for the current season were reviewed for any ED encounter at least 14 days prior to the influenza-positive encounter and during the concurrent influenza season. These ED visits were deemed a missed opportunity to provide vaccination and potentially prevent the influenza-positive encounter. Healthcare resource utilization, including subsequent ED encounters and inpatient admissions, were evaluated for patients with a missed vaccination opportunity. RESULTS: A total of 116,140 ED encounters occurred during the study and were screened for inclusion. Of these, 2115 were influenza-positive encounters, which represented 1963 unique patients. There were 418 patients (21.3%) that had a missed opportunity to be vaccinated during an ED encounter at least 14 days prior to the influenza-positive encounter. Of those with a missed vaccination opportunity, 60 patients (14.4%) had subsequent influenza-related encounters, including 69 ED visits and 7 inpatient admissions. CONCLUSION: Patients presenting to the ED with influenza frequently had opportunities to be vaccinated during prior ED encounters. An ED-based influenza vaccination program could potentially reduce influenza-related burden on healthcare resources by preventing future influenza-related ED encounters and hospitalizations.

Cancer Diagnoses and Use of Radiation Therapy Among Persons Experiencing Homelessness.

PURPOSE: Persons experiencing homelessness (PEH) have low rates of cancer screening and worse cancer mortality compared with persons not experiencing homelessness. Data regarding cancer diagnosis and treatment in PEH are limited. We investigated cancer prevalence and use of radiation therapy (RT) in PEH. METHODS AND MATERIALS: Patients presenting between January 1, 2014, and September 27, 2021, at a large metropolitan hospital system were assessed for homelessness via intake screening or chart search. PEH data were cross-referenced with the institution's cancer database to identify PEH with cancer diagnoses. Demographic, clinical, and treatment variables were abstracted. RESULTS: Of a total of 9654 (9250 evaluable) PEH with a median age of 42 years, 81 patients (0.88%) had at least 1 cancer diagnosis and 5 had multiple diagnoses, for a total of 87 PEH with at least 1 cancer diagnosis. The median age at diagnosis was 60 years. In total, 43% were female and 51% were Black, and 43% presented with advanced or metastatic disease. Lung (17%), prostate (15%), leukemia/lymphoma (13%), and head/neck (9%) were the most common diagnoses. In total, 17% of patients underwent surgery alone, 13% received chemotherapy alone, 14% received RT alone, and 6% received hormone therapy alone. A total of 8% of patients underwent no treatment, and 43% underwent multimodality therapy. In total, 58% of treated patients never achieved disease-free status. Of the 31 patients who received RT, 87% received external beam RT. Most patients (70%) received hypofractionated regimens. For patients who had multifraction treatment, the treatment completion rate was 85%, significantly lower than the departmental completion rate of 98% (P < .00001). CONCLUSIONS: In a large cohort of PEH in a metropolitan setting, cancer diagnoses were uncommon and were frequently in advanced stages. Most patients underwent single-modality treatment or no treatment at all. Despite the use of hypofractionation, the RT completion rate was low, likely reflecting complex barriers to care. Further interventions to optimize cancer diagnosis and treatment in PEH are urgently needed.

Emergency Department Co-testing for Human Immunodeficiency Virus When Testing for Gonorrhea and Chlamydia: A Readily Available, Missed Opportunity for Targeted HIV Testing in Emergency Departments.

OBJECTIVES: Conducting human immunodeficiency virus (HIV) testing in emergency departments (EDs) can be an effective approach to testing and reaching populations at highest risk of contracting HIV. METHODS: All gonorrhea and chlamydia (G/C) and HIV tests ordered in the Cleveland Clinic Health System's 14 EDs were included in the analysis. Data were collected from electronic health records. Descriptive statistics, with medians and means, were computed. RESULTS: From January 1, 2019, to December 31, 2021, we reviewed ED visits for the purpose of sexually transmitted infection (STI) screening, with an emphasis on G/C screening. In October 2019, both HIV rapid testing and G/C testing began across all 14 Cleveland Clinic EDs. The overall rate of co-testing for HIV when obtaining a G/C test for STI evaluation increased overall to around 30% for our health system EDs, with some individual EDs approaching 60%. CONCLUSIONS: The approach the Cleveland Clinic implemented is an effective way to test for HIV in the ED. Local health departments and stakeholders in HIV communities should support and collaborate with EDs in their jurisdictions to accelerate HIV testing initiatives by using an HIV plus G/C co-testing metric.

Cotesting for Human Immunodeficiency Virus and Sexually Transmitted Infections in the Emergency Department.

BACKGROUND: The Centers for Disease Control and Prevention (CDC) and US Preventive Services Task Force (USPSTF) guidelines recommend screening for human immunodeficiency virus (HIV) in patients aged 15 to 65 years, as well as those at increased risk. Patients screened in the emergency department (ED) for gonorrhea (GC) and/or chlamydia represent an increased-risk population. Our aim was to assess compliance with CDC and USPSTF guidelines for HIV testing in a national sample of EDs. METHODS: We examined data from the 2010 to 2018 Nationwide Emergency Department Sample, which can be used to create national estimates of ED care to query tests for GC, chlamydia, HIV, and syphilis testing. Weighted proportions and 95% confidence intervals (CIs) were reported, and Rao-Scott χ 2 tests were used. RESULTS: We identified 13,443,831 (weighted n = 3,094,214) high-risk encounters in which GC/chlamydia testing was performed. HIV screening was performed in 3.9% (95% CI, 3.4-4.3) of such visits, and syphilis testing was performed in 2.9% (95% CI, 2.7-3.2). Only 1.5% of patients with increased risk encounters received both HIV and syphilis cotesting. CONCLUSIONS: Despite CDC and USPSTF recommendations for HIV and syphilis screening in patients undergoing STI evaluation, only a small proportion of patients are being tested. Further studies exploring the barriers to HIV screening in patients undergoing STI assessment in the ED may help inform future projects aimed at increasing guidance compliance.

Characterization of ophthalmic presentations to emergency departments in the United States: 2010-2018.

BACKGROUND: Both traumatic and nontraumatic ocular issues often present to the emergency department. Understanding the epidemiology of ocular presentations to the emergency department not only informs current resource allocation, but also provides opportunities to evaluate the efficacy of prior healthcare access interventions. PURPOSE: To characterize emergency department utilization in the United States for ophthalmic encounters between 2010 and 2018. METHODS: Cross-sectional analysis of the National Hospital Ambulatory Medical Care Survey database, a nationally representative sample of United States emergency department visits. 4284 deidentified emergency department patient encounters with an ICD-10 ophthalmic diagnosis from 2010 to 2018 were analyzed. The main outcome measures were the composition and characteristics of ophthalmic emergency department encounters over time. MAIN FINDINGS: 4284 ophthalmic visits were identified which represented an estimated 23.1 million visits (95% CI, 20.8 million-25.5 million). 31.6% (95% CI, 29.6-33.8) of ophthalmic visits were traumatic. Conjunctivitis was the most common non-traumatic diagnosis (32.8%, 95% CI, 30.7-35.0), while superficial injury of the cornea was the most common traumatic diagnosis (13.9%, 95% CI, 12.5-15.3). A greater proportion of emergency department visits involving the sclera and cornea were made by men (58.7%, 95% CI, 53.7%-63.6%; P = 0.02), whereas more women visited for visual disturbances (57.8%, 95% CI, 51.3%-64.4%; P = 0.01). Longitudinal trends of ophthalmic visits revealed an increase in public insurance payers in 2014, which corresponds to Medicaid expansion and implementation of mandated coverage for pediatric vision care. After stratification, this increase continued to be present in nontraumatic visits, but not traumatic ones. CONCLUSIONS: Ophthalmic emergency department visits in the United States between 2010 and 2018 were typically for non-traumatic eye issues. Diagnoses varied greatly by patient demographics, such as age and gender. Understanding these variations is valuable for preparing emergency departments for ocular presentations and providing guidance for future practice.

The Hidden Cost of Hemolyzed Blood Samples in the Emergency Department.

BACKGROUND: On average, patients with hemolyzed potassium samples spend about 1 h longer in the emergency department (ED), regardless of acuity level or disposition. We aimed to quantify the direct expenses associated with poor-quality preanalytic blood samples collected in the ED. METHODS: We created a simple table with a range of direct expenses (i.e., costs) and rates of hemolyzed sample draws, allowing for identification of potential high-level cost-of-care impact analysis. We included a range of costs informed by review of literature on the topic. Those costs range from $600 to $3000 per bed-hour. This amount was inflation adjusted from 1996 to 2020 (1.68 × [direct cost per visit] × [100 000 visits per year/365 days/24 h]). We provided a range of hemolysis incidence based on previously reported data. RESULTS: We showed that for an ED with 100 000 annual visits, a 40% draw rate for routine chemistries (including potassium), and a 10% hemolysis incidence, the direct cost impact of hemolysis waste is approximately $4 million/year as a result of the 1 h of added length of stay on average for a patient with a hemolyzed blood sample. This amount represents an annualized estimated cost of caring for a patient in the ED with an avoidable extended length of stay. CONCLUSIONS: The financial burden of poor-quality blood samples can be estimated using cost per bed-hour and rate of sample failure. Similar methodology may identify additional QC issues with previously invisible financial implications.

Emergency Nurses' Knowledge, Attitudes, and Practices Related to Blood Sample Hemolysis Prevention: An Exploratory Descriptive Study.

INTRODUCTION: The aim of the study was to identify emergency nurses' knowledge, attitudes, and practices related to blood sample hemolysis prevention and explore associations between these factors and demographic characteristics. The current state is unknown. Understanding baseline knowledge, attitudes, and practices addresses a gap in the literature. METHOD: An exploratory, descriptive design with cross-sectional survey methodology employing a study-specific instrument was used. RESULTS: Request for participation email was sent to a random sample of 5000 Emergency Nurses Association members, and 427 usable surveys were returned (response rate = 8.5%). Mean years in nursing was 13.85 (standard deviation = 10.78), and 226 (52.9%) were certified emergency nurses. Only 85 participants (19.9%) answered all 3 knowledge questions correctly. Answering the 3 knowledge questions correctly was significantly associated with being a certified emergency nurse (χ2 = 7.15, P < .01). Participant responses to attitude items about the sequelae of blood sample hemolysis were skewed toward agreement, and most attitude items were associated with whom participants reported as being primarily responsible for phlebotomy. Emergency nurses remain primarily responsible for phlebotomy as well as addressing hemolyzed samples, but few reported that blood sample hemolysis was addressed at a departmental level. DISCUSSION: Findings suggest that emergency nurses lack some knowledge related to blood sample hemolysis prevention best practices. Attitudes toward phlebotomy practices may be 1 reason practice has not changed. Every effort should be made to prevent hemolyzed blood samples to decrease delays and costs in emergency care.

Management of migraine in the emergency department: Findings from the 2010-2017 National Hospital Ambulatory Medical Care Surveys.

OBJECTIVE: The study objective was to describe trends in the medical management of migraine in the emergency department (ED) using the 2010-2017 National Hospital Ambulatory Medical Care Survey (NHAMCS) datasets. METHODS: Using the 2010-2017 NHAMCS datasets, we analyzed visits with a discharge diagnosis of migraine. Drug prescription frequencies between years were compared with the Rao-Scott chi-squared test. Adjusted odds ratios of opioid administration from 2010 to 2017 were calculated using weighted multivariable logistic regression with sex, age, race/ethnicity, pain-score, primary expected source of payment, and year as predictor variables. RESULTS: Our analysis captured 1846 ED visits with a diagnosis of migraine from 2010 to 2017, representing a weighted average of 1.2 million US ED visits per year. Parenteral opioids were prescribed in 49% (95% CI: 40, 58) of visits in 2010 and 28% (95% CI: 15, 45) of visits in 2017 (p = 0.03). From 2010 to 2017, there was a 10% yearly decrease in opioid prescriptions. Metoclopramide and ketorolac were prescribed more frequently in years 2015 through 2017 than in 2010. Increased opioid administration was associated with female sex, older age, white race, higher pain score, and having Medicare or private insurance as the primary expected source of payment for all years. CONCLUSION: Opioid administration for migraine in EDs across the US declined 10% annually between 2010 and 2017, demonstrating improved adherence to migraine guidelines recommending against opioids. We identified several factors associated with opioid administration for migraine, identifying groups at higher risk for unnecessary opioids in the ED setting.

Seeing Red: Blood Sample Hemolysis Is Associated with Prolonged Emergency Department Throughput.

INTRODUCTION: Hemolyzed emergency department (ED) blood specimens impose substantial burdens on various aspects of delivering care. The ED has the highest incidence of hemolysis among hospital departments. This study assessed the association and potential impact of hemolyzed blood samples on patient throughput time using ED length of stay (LOS) as the primary outcome measure. METHODS: This study was a secondary analysis of data collected during a performance improvement project aimed at reducing the incidence of hemolysis in ED blood specimens. The electronic medical record was queried for potassium orders and results and for key patient throughput time points. Throughput times were stratified according to hemolysis, ED disposition (admitted vs discharged), and Emergency Services Index (ESI) triage categorization. Two-tailed t tests were used to compare throughput times for patients with and without hemolysis. RESULTS: Potassium values were reported for 11 228 patient visits. The mean ED LOS was 287 minutes for patients with nonhemolyzed samples and 349 minutes for patients who had hemolyzed samples, a mean delay of 62 minutes. The mean throughput time for discharged patients was 92 minutes shorter in the group without hemolysis (337 vs 429 minutes). The mean throughput time for admitted patients was 28 minutes shorter in the group without hemolysis (264 vs 292 minutes). The increased LOS for patients with a hemolyzed blood sample was independent of the most commonly encountered ESI levels. CONCLUSION: Hemolysis of blood samples obtained in the ED is associated with prolonged patient throughput via delays in patient disposition, independent of various markers of acuity, such as the patients' ultimate disposition or triage categorization.

Ongoing and Focused Provider Performance Evaluations in Emergency Medicine: Current Practices and Modified Delphi to Guide Future Practice.

The Joint Commission requires ongoing and focused provider performance evaluations (OPPEs/FPPEs). The authors aim to describe current approaches in emergency medicine (EM) and identify consensus-based best practice recommendations. An online survey was distributed to leaders in EM to gain insight into current practices. A modified Delphi approach was then used to develop consensus to recommend best practice. A variety of strategies are currently in use for OPPE/FPPE. "Peer reviewed cases with opportunity for improvement" was identified as a preferred metric for OPPE. Although the preference was for use of peer review in OPPE, a consistent and standard adoption of robust internal care review processes is needed to establish expected norms. National benchmarking is not available currently. This was a limited survey of self-identified leaders, and there is an opportunity for additional engagement of leaders in EM to identify a unified approach that appropriately relates to patient outcomes.

Direct patient care activities and interventions of emergency medicine pharmacists.

Background Emergency medicine (EM) pharmacists are increasingly recognized as integral team members in the care of emergency department (ED) patients but there is variability in the scope of direct patient care services. Objectives The primary objective was to categorize direct patient care activities and drug therapy recommendations. The secondary objectives were to categorize recommendations based on drug class and to determine the proportion of recommendations associated with Institute for Safe Medication Practices (ISMP) high-alert medications. Methods This retrospective, single-center, chart review was conducted in an academic ED with 65,000 annual visits. EM pharmacists documented direct patient care activities in the electronic health record. Documented activities from 1/1/2015 through 3/31/2015 were abstracted electronically for analysis by a trained reviewer. Results There were 3567 interventions and direct patient care activities documented. The most common activities were facilitation of medication histories (n = 1300) and drug therapy recommendations (n = 1165). Of 1165 drug therapy recommendations, 986 were linked to a drug class such as antimicrobial agents (31.9%), cardiovascular agents (16.6%), and analgesic agents (13.2%) and 20% of these interventions were associated with ISMP high-alert medications. Conclusion EM pharmacists documented several types of direct patient care activities with the majority being drug therapy recommendations and medication histories.

An intervention based on the Electronic Medical Record to improve smoking cessation guidance in an urban tertiary care center emergency department.

INTRODUCTION: Smoking remains a major public health issue and a leading cause of death and disability in the United States. The objective of this study was to determine the effect of a simple intervention on smoking guidance, based on the electronic medical record (EMR), including providing discharge instructions and/or cessation counseling to emergency department (ED) patients who smoke. METHODS: This was an interventional before-and-after study in an ED with 70000 visits per year. A pre-intervention and post-intervention chart review was performed on a random sample of ED visits occurring in 2014 and 2016, identifying smokers and the frequency with which smokers received discharge instructions and/or cessation counseling. In the fall of 2015, our EMR was programmed to deploy smoking cessation discharge instructions automatically. RESULTS: In all, 28.7% (172/600; 95% CI: 25.2-32.4%) reported current smoking in the pre-intervention ED population and 27.6% (166/600; 95% CI: 24.2-31.4%) reported smoking in the post-intervention population. Smoking cessation guidance was provided to a total of 3.5% of self-reported smokers in the pre-intervention group (6/172; 95% CI: 1.4-7.6%); 1.2% (2/172; 95% CI: 0.3-4.1%) were informed of smoking cessation resources as part of their printed ED discharge instructions and 2.3% (4/172; 95% CI: 0.9-5.8%) received smoking cessation counseling by the ED provider. There was a statistically significant increase in the proportion of patients receiving any smoking cessation guidance after the intervention. All patients (166/166; 95% CI: 97-100% in this period received ED discharge instructions and a list of smoking cessation resources and 3.6% of smokers (6/166; 95% CI: 1.7-7.7%) received smoking cessation counseling by the ED provider. CONCLUSIONS: Automated deployment of smoking cessation discharge instructions in the EMR improves smoking cessation discharge instructions, and also has a positive impact on improving rates of in-person counseling by ED providers.

Impact of Interventions to Change CBC and Differential Ordering Patterns in the Emergency Department.

Objectives: A CBC with leukocyte differential (CBC-DIFF) is a frequently ordered emergency department (ED) test. The DIFF component often does not add to clinical decision making. Our objective was to evaluate the impact of a performance improvement project on CBC ordering. Methods: ED orders for CBC-DIFF were identified through the laboratory information system. Two interventions were evaluated: an educational intervention regarding CBC-DIFF uses and a reprioritization of ED CBC-DIFF and CBC in the electronic medical record (EMR) orders. Pearson χ2 tests were used to assess for differences in the proportions. Results: There was no difference in the proportion of CBC tests performed after the education intervention (175/6,192, 2.8% [95% CI, 2.39%-3.21%] vs 219/6,270, 3.5% [95% CI, 3.05%-3.95%]). There was a significant increase in CBC samples ordered following the EMR intervention (604/6,044, 9.1% [95% CI, 8.37%-9.83%]; P < .01). Conclusions: Reprioritizing EMR laboratory orders can reduce overutilization of CBC-DIFF testing.

Preanalytic Factors Associated With Hemolysis in Emergency Department Blood Samples.

CONTEXT: - Hemolysis of emergency department blood samples is a common occurrence and has a negative impact on health care delivery. OBJECTIVES: - To determine the effect of preanalytic factors (straight stick, intravenous [IV] line, needle gauge, location of blood draw, syringe versus vacuum tube use, tourniquet time) on hemolysis in emergency department blood samples. DESIGN: - A single 65 000-visit emergency department's electronic health record was queried for emergency department potassium results and blood draw technique for all samples obtained in calendar year 2014, resulting in 54 531 potassium results. Hemolyzed potassium was measured by hemolysis index. Comparisons of hemolysis by sampling technique were conducted by χ2 tests. RESULTS: - Overall hemolysis was 10.0% (5439 of 54 531). Hemolysis among samples obtained from straight stick was significantly less than among those obtained with IV line (5.4% [33 of 615] versus 10.2% [4821 of 47 266], P < .001). For IV-placed blood draws, antecubital location had a statistically significant lower overall hemolysis compared with other locations: 7.4% (2117 of 28 786) versus 14.6% (2622 of 17 960) ( P < .001). For blood drawn with a syringe compared with vacuum, hemolysis was 13.0% (92 of 705) and 11.0% (1820 of 16 590), respectively ( P = .09, not significant). For large-gauge IV blood draws versus smaller-gauge IV lines, a lower hemolysis was also observed (9.3% [3882 of 41 571] versus 16.7% [939 of 5633]) ( P < .001). For IV-drawn blood with tourniquet time less than 60 seconds, hemolysis was 10.3% (1362 of 13 162) versus 13.9% for more than 60 seconds (532 of 3832), P < .001. CONCLUSIONS: - This study confirmed previous findings that straight stick and antecubital location are significantly associated with reduced hemolysis and indicated that shorter tourniquet time and larger gauge for IV draws were significantly associated with lower hemolysis.

Impact of Use of Smaller Volume, Smaller Vacuum Blood Collection Tubes on Hemolysis in Emergency Department Blood Samples.

OBJECTIVES: Hemolyzed blood samples commonly occur in hospital emergency departments (EDs). Our objective was to determine whether replacing standard large-volume/high-vacuum sample tubes with low-volume/low-vacuum tubes would significantly affect ED hemolysis. METHODS: This was a prospective intervention of the use of small-volume/vacuum collection tubes. We evaluated all potassium samples in ED patients and associated hemolysis. We used χ2 tests to compare hemolysis incidence prior to and following utilization of small tubes for chemistry collection. RESULTS: There were 35,481 blood samples collected during the study period. Following implementation of small-volume tubes, overall hemolysis decreased from a baseline of 11.8% to 2.9% (P < .001) with corresponding reductions in hemolysis with comment (8.95% vs 1.99%; P < .001) gross hemolysis (2.84% vs 0.90%; P < .007). CONCLUSIONS: This work demonstrates that significant improvements in ED hemolysis can be achieved by utilization of small-volume/vacuum sample collection tubes.