General Surgery resident Riann Robbins is on a journey to reduce unnecessary tests. She recently shared her teams work to tackle ABG testing in critical care at the annual Surgery Value Symposium. What did she learn? Seuss said it best: “Unless someone like you cares a whole awful lot, nothing is going to get better. It’s not.”

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IMPROVING ABG UTILIZATION IN
CARDIOVASCULAR ICU PATIENTS
RIANN ROBBINS, MD
JOSEPH TONNA, MD

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INTRODUCTION
• Critical care services in the U.S. account for 1% of GDP and 13%
of overall hospital costs1
• ABGs make up 10-20% of ICU costs
• ABGs are the most commonly ordered tests in ICUs nationally
• National average of 2-6 ABG/person/day2
• changed patient management less than half the time
• ABG ordering protocols3
• decreased daily ABG use by 14%
• Reduced ICU costs by $87,565 per year
• Provider lead discussion reduced ABG use by 60%4

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SCOPE OF THE PROBLEM
• ABGs are routinely used in the CVICU
• Different ABGs cost different amounts (default
lab was most expensive)
• Extracorporeal life support patients obtain
ABGs every 2 hours per current protocol
• Anecdotal reports suggested ABGs were
ordered for inappropriate indications by
inexperienced providers

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LOCAL PRACTICE PATTERNS
• Between Feb 2017 and Dec 2017
– 15,808 ABGs ordered
– Average of 4.4 ABG per person per day
– Average CVICU length of stay 4.7 days
Source: Google Images

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Patient on VA/VV
ECMO Art line access
Patient condition
stabilized
ABG rechecked in
1-2 hours
Adjustments
made to
ventilator or
ECMO
Results placed in
EPIC
3 separate orders
for ABGs
Nurse puts in
separate ABG
order
Nurse draws ABG
+/- physician
order for ABG
ABG taken to
pulm lab
2
3
4
1.Easy access to lab draws
2.Provider communication
3.Available options
4.Protocols
1
CLINICAL PROCESS MAP

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INTERVENTION
• Address discrepancies with EPIC orders for
ABGs
• Refine existing ABG protocol
• Provide ongoing education to support staff
• Physician lead discussion on daily rounds
about ABG strategy in patients identified as
high risk for over utilization

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Indications for ABG
ABG w/ electrolytes ABG w/o electrolytes Single Analyte
• Arterial lactate
• Monitor during initial
resuscitation
• Discuss with provider when
resuscitation has ended
• Ionized calcium
• Monitor during initial
resuscitation
• Routine check of electrolytes
with no recent BMP
• ECMO pts
• To manage sweep
• Vented patients
• During changes to
minute ventilation
in non-awake
patients
Not indicated to use unless
want an arterial lactate alone
or need quick electrolyte
check
PROTOCOL EXAMPLE
ABG not indicated for:
• Change in PEEP
• Change in FiO2
• Changes in MV in spontaneously breathing pts

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POTENTIAL COST SAVINGS
• Target extracorporeal life support patients
• Order less expensive test

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CURRENT STATUS
• Preliminarily approved for University of Utah
Health Care Partners Program (UHPP)
• Initial stages of implementing interventions

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LESSONS LEARNED
• Find a champion
• Marathon not a sprint
• Be open to change
• Surround yourself with advocates
• Don’t make assumptions
• Allows solutions to evolve over time

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REFERENCES:
1. Halpern N, Pastores S. Critical Care Medicine in the United States 2000-2005:
an analysis of bed numbers, occupancy rates, payer mix, and costs. Crit Care
Med. 2010;38(1):65–71.
2. Melanson SEF, Szymanski T, Rogers SO, Jarolim P, Frendl G, Cooper Z, et al.
Utilizatin of Arterial Blood Gas measurements in a Large Tertiary Care Hospital.
Am J Clin Pathol. 2007;127(4):604–9.
3. DellaVolpe J, Chakraborti C, Cerreta K, Romero C, Firestein C, Myers L, et al.
Effects of Implementing a Protocol for Arterial Blood Gas Use on Ordering
Practices and Diagnostic Yield. Healthcare. 2014;2(2):130–5.
4. Blum FE, Lund ET, Hall HA, Tachauer AD, Chedrawy EG, Zilberstein J.
Reevaluation of the utilization of arterial blood gas analysis in the Intensive
Care Unit: Effects on patient safety and patient outcome. J Crit Care [Internet].
2015;30(2):438.e1-438.e5. Available from:
http://dx.doi.org/10.1016/j.jcrc.2014.10.025