NR 520 Week 5 Decision Analysis, Morning Labs Example

Decision Analysis: Three Ways to Handle Morning Labs on a 30-Bed Medical Unit, Each Written at Its Strongest, the One Chosen and What It Gives Up

Student Name

College of Nursing, Chamberlain University

NR 520: Applied Theoretical Foundations, Scientific Inquiry, and Decision-Making

Instructor Name

Month Day, Year

Decision Analysis: Three Ways to Handle Morning Labs on a 30-Bed Medical Unit, Each Written at Its Strongest, the One Chosen and What It Gives Up

The Decision

The unit practice council on our 30-bed adult medical unit must decide, by the end of the quarter, how the unit will handle morning laboratory draws. At present, nearly every patient is woken at about 0400 for blood so results are ready for 0700 rounds, and most daily labs are ordered at admission as "daily until discontinued." The council's members include night and day nurses, the nurse manager, a hospitalist representative and the phlebotomy supervisor. This analysis sets out three options at their strongest, recommends one, and states what the chosen option gives up.

Criteria, Set Before the Options

The council agreed on four criteria before comparing options, so that the choice would not be argued backward from a preference. The first is patient sleep and comfort, measured by how many patients are woken at night. The second is timely information for decisions that depend on it, measured by whether results that will change the morning plan are available at rounds. The third is safety, measured by whether any clinically important abnormal result is found later than it would otherwise have been. The fourth is feasibility for the people who must carry the option out, phlebotomy, nurses and physicians, within current staffing. Each option below is described at its strongest and then held against those four criteria.

The analysis was shared with the council a week before its meeting so that members who favored Option A could prepare their strongest case rather than respond on the spot.

Option A: Keep the 0400 Round and Change Nothing Else

Its strongest case. Results are available before rounds, so physicians can make decisions early, discharges are not delayed while waiting for labs, and patients with abnormal results are treated sooner. The routine is predictable for phlebotomy, which can cover the whole hospital efficiently in one early round. Changing it risks results arriving after rounds, which could delay discharges on a unit where every bed is needed. The current system also catches the occasional unexpected abnormal result in a patient who seemed stable.

Its weakness. It wakes most patients every night, including those whose results have not changed for days, and continues tests whose value is low.

Option B: Move the Round Later for Everyone

Its strongest case. Moving the unit's draw to 0600, with the morning vital signs, would give every patient two more hours of uninterrupted sleep without asking anyone to decide who needs a test. It is simple, fair and easy to explain. Sleep in hospital is already short: one national survey of inpatients found nights nearly an hour and a half shorter than at home, with staff among the usual culprits (Wesselius et al., 2018).

Its weakness. Results would arrive around 0800, after rounds begin, so physicians would need to round twice or delay decisions. The phlebotomy team cannot cover every unit at 0600, so the change would push other units earlier. And it does nothing about tests that are not needed at all.

Option C: Stop Unneeded Labs and Time the Rest by Need

Its strongest case. Standing daily tests would lapse two days after they begin unless a physician writes a fresh reason, following the professional recommendation against repetitive testing in clinically stable patients (Bulger et al., 2013) and reviews showing that many daily labs can safely be stopped (Eaton et al., 2017). Patients whose results will change a morning decision, such as those on intravenous diuretics or potassium replacement, would stay on the 0400 list. Others would be drawn at 0600 with vital signs, or not at all. Fewer draws would also mean less blood taken; in heart attack patients, each additional volume of blood removed for testing carried more risk of becoming anemic in hospital (Salisbury et al., 2011).

Its weakness. It depends on physicians renewing orders thoughtfully rather than automatically, on nurses and phlebotomists sorting patients each night, and on a change to the order set that requires medical staff approval.

The Recommendation

The recommendation is Option C. It addresses both problems, unneeded tests and badly timed tests, while keeping early results for patients who need them. Option A was the option that almost won, and it deserves a direct answer: its best argument is early results for decisions. Option C keeps that benefit for the patients whose decisions depend on it, which is a minority on most nights, and removes the cost for the rest. Option B treats the timing problem but not the value problem, and it moves the burden to other units.

Who Must Act for Option C to Work

Option C depends on four groups doing something new. Physicians must renew or stop daily labs at 48 hours and say why. Night nurses must review the list at 2200 and flag patients whose results will change the next morning's care, such as those receiving potassium or diuretics. Phlebotomy must run two smaller rounds instead of one large one. And the practice council must report the measures monthly for six months. If any group cannot take on its part, the option should be adjusted before it starts, for example by having the pharmacist rather than the physician review renewals, rather than launched and left to fail.

What Option C Gives Up

The recommendation has costs, and a reader who prefers Option A should be able to see them. First, simplicity: every night, someone must sort patients into those drawn at 0400, those at 0600 and those not drawn, and that sorting will sometimes be wrong. Second, a small safety margin: an unexpected abnormal result in a patient whose labs were stopped will be found later than it would have been under Option A. Third, time: physicians must spend a moment at 48 hours deciding whether to renew each order. Fourth, it requires the order set change, which will take the medical staff several months to approve.

The council should accept these costs knowingly, and it should measure them: the number of patients woken at 0400, the proportion of results available before rounds for patients on the early list, any delayed detection of abnormal results, and the number of daily labs drawn per patient-day. If delayed detection proves to be more than rare, the council should return to this analysis rather than defend the choice.

References

Bulger, J., Nickel, W., Messler, J., Goldstein, J., O'Callaghan, J., Auron, M., & Gulati, M. (2013). Choosing wisely in adult hospital medicine: Five opportunities for improved healthcare value. Journal of Hospital Medicine, 8(9), 486-492. https://doi.org/10.1002/jhm.2063

Eaton, K. P., Levy, K., Soong, C., Pahwa, A. K., Petrilli, C., Ziemba, J. B., Cho, H. J., Alban, R., Blanck, J. F., & Parsons, A. S. (2017). Evidence-based guidelines to eliminate repetitive laboratory testing. JAMA Internal Medicine, 177(12), 1833-1839. https://doi.org/10.1001/jamainternmed.2017.5152

Salisbury, A. C., Reid, K. J., Alexander, K. P., Masoudi, F. A., Lai, S.-M., Chan, P. S., Bach, R. G., Wang, T. Y., Spertus, J. A., & Kosiborod, M. (2011). Diagnostic blood loss from phlebotomy and hospital-acquired anemia during acute myocardial infarction. Archives of Internal Medicine, 171(18), 1646-1653. https://doi.org/10.1001/archinternmed.2011.361

Wesselius, H. M., van den Ende, E. S., Alsma, J., ter Maaten, J. C., Schuit, S. C. E., Stassen, P. M., de Vries, O. J., Kaasjager, K. H. A. H., Haak, H. R., van Doormaal, F. F., Hoogerwerf, J. J., Terwee, C. B., van de Ven, P. M., Bosch, F. H., van Someren, E. J. W., & Nanayakkara, P. W. B. (2018). Quality and quantity of sleep and factors associated with sleep disturbance in hospitalized patients. JAMA Internal Medicine, 178(9), 1201-1208. https://doi.org/10.1001/jamainternmed.2018.2669