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Blood Gas Analyzer Changeover Helps Improve Quality of Care and Workflow at a Large Urban Respiratory Care Center

Shelly Brown, MBA, RRT-NPS, NCTTP, Baptist Health Medical Center Candi Curtis, BS, RRT, Baptist Health Medical Center Niccolo Dosto, MHS, Boston Strategic Partners Halit O. Yapici, MD, MBA, MPH, Boston Strategic Partners

Background

Critical care settings such as respiratory centers and trauma wards often rely on quick, accurate tools to help providers make appropriate clinical decisions. Blood gas analyzers are essential in high-volume medical units since they rapidly measure key parameters, including carbon dioxide, oxygen, acidity, and multiple metabolites/electrolytes (e.g., glucose, calcium,and potassium)1 . These measurements give clinicians crucial data for diagnosis and treatment. For instance, combinations of blood gas, pH, electrolyte, and metabolite readings are used in respiratory centers to evaluate oxygen delivery efficiency and the presence of a respiratory, metabolic, or kidney disorder1 .

Laboratory assays have long been considered the gold standard for blood gas analysis. However, core lab equipment is often bulky and takes longer to provide results due to transport time associated with moving samples from medical units to the lab. Handheld and benchtop point-of-care (POC) devices have thus been developed to analyze samples on-site in various medical settings for rapid management and treatment of patients2. The accuracy of POC analyzers is comparable to standard hospital lab equipment. A cross-sectional study comparing arterial blood readings from lab assays and a handheld POC device found statistically similar results when testing for pH, oxygen, carbon dioxide, and lactate levels3. Modern POC devices can also perform oximetric analyses and detect carboxyhemoglobin and total hemoglobin concentrations2 .

POC devices are commonly used in fast-paced clinical settings, making them particularly prone to testing errors that lead to adverse patient outcomes4. Blood gas analysis requires an invasive procedure to obtain arterial blood; thus, the need for additional needle sticks can be highly unpleasant for the patient and should be avoided. The effect is more severe for older patients or

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patients with difficult venous access who must undergo numerous blood draws5. Neonates may also suffer from anemia caused by frequent blood draws because of their relatively low total blood volume6. Therefore, the ideal POC device should be precise and reliable while requiring a minimal amount of sample volume and needle sticks to deliver high-quality patient care7 .

The Baptist Health System

Baptist Health is Arkansas’ most comprehensive healthcare system, spanning 250 pointsof access that include 11 hospitals, multiple urgent care centers, a senior living community, andover 100 primary and specialty care facilities all over Arkansas and Eastern Oklahoma. The system has six main campuses, the largest of which is in the heart of Little Rock, supported by satellite clinics scattered throughout the state8. With about 11,000 employees serving several thousand more patients annually, it is essential that Baptist Health maintain a modern arsenal of medical equipment to ensure efficient workflows, especially in its critical care units.

The ideal POC device should be precise and reliable while requiring a minimal amount of sample volume and needle sticks to deliver high-quality patient care.

A Catalyst for Change

The flagship hospital in the Baptist System is the Baptist Health Medical Center in Little Rock, AR, which includes a comprehensive respiratory unit, critical care facilities, and a neonatal intensive care unit9. When the contract for blood gas analyzers was due in 2013, BaptistHealth leadership ended up renewing the agreement with the existing vendor; the hospital then received an updated version of the device in use. Before long, the technical issues caused by these new analyzers “created a perfect storm” of clinical, workflow, and cost-related challenges at the health system10

The analyzers’ cartridge supplier was changed soon after the contract renewal, which caused a deterioration in the quality of cartridges that led to multiple issues. First, the devices began taking in samples without providing an analysis (i.e., “eating the sample”), requiring clinicians to perform redraws that are highly undesirable as patients often experience pain and discomfort due to multiple needle sticks. Second, the analyzers tended to provide inaccurate results instead of informing the user about potential issues when samples were contaminated or unfit for testing. Considering its possible impact on clinical decision-making, these inaccurate results can be particularly problematic for patients and providers. Third, the devices routinely stopped working in the middle of analyses, causing the staff to spend valuable time — sometimes 30 minutes or more — troubleshooting the analyzers instead of seeing patients. The interruptions in service regularly caused the respiratory care center to grind to a halt while the blood gas analyzers took time to reboot or be repaired. Spare parts were provided only after the devices stopped functioning instead of

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allowing Baptist Health to keep them in stock for emergency repairs. Furthermore, when supplied, the parts were usually refurbished, leading to inefficiencies in the repair process.

The lack of adequate vendor support while Baptist Health struggled with an array of device-related issues only worsened the situation. The manufacturer delivered sub-par customer service and failed to respond to the issues outlined above or rectify these problems when staff brought up their concerns. As such, the numerous cartridge-related obstacles led to direct and downstream impacts for various stakeholders. In fact, Baptist Health also incurred additional costs due to the deterioration of cartridge quality since the new cartridges had lower testing capacities and lasted fewer cycles. The increased use of cartridges also generated more hazardous waste that was expensive to dispose of and environmentally harmful.

Suboptimal connectivity of the analyzers and a lack of essential software features also led to multiple inefficiencies in the hospital system. The devices did not automatically communicate with Baptist Health’s electronic medical record (EMR) software and occasionally lost connectionwith the hospital servers. Manual data inputs were required for reports to show up on the physicians’ charts, leading to delays in the “effective” turnaround time (TAT, i.e., the time from the analysis until physicians can access the results for clinical decision-making). Staff had to switch between the analyzer and a desktop computer to enter patient information. Clinicians also could not modify records or correct errors without going through a middleware, which demanded additional time and costs from the health system. Workflow efficiency was thus severely affected by a host of connectivity and softwarerelated problems.

Analyzer Selection & Evaluation

Considering the clinical, workflow, and cost implications of the issues caused by the blood gas analyzers, the devices quickly became unpopular with stakeholders at Baptist Health, which prompted them to look for an alternative to their analyzers. The health system formed a committee headed by two leaders from its respiratory department to identify and evaluate multiple devices in the market. The committee traveled to conferences, talked to peers in similar healthcare positions, and consulted other members of the Baptist Health network to narrow down a list of potential

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replacement options. The committee considered multiple device features in the blood gas analyzer selection process, prioritizing TAT, EMR integration, and product reliability. Another key consideration was the product support provided by the vendor, especially due to their recent experiences with the previous manufacturer that exacerbated the device-related issues.

Respiratory care is a small world, and it did not take long for Radiometer America’ s reputation to reach the Baptist Health team. Following substantial positive feedback concerning Radiometer’ s devices and customer support, the committee decided to bring in the vendor team for a live demonstration in front of a group of stakeholders, several of whom had decades of relevant healthcare experience. The hospital staff was impressed with the analyzer after the presentation followed by an opportunity to run tests on the new device. Radiometer America also offered flexible contract options, clinical representatives to assist Baptist Health throughout the implementation process, and continuous product support post-implementation. Based on a thorough assessment, Baptist Health leadership chose the ABL90 Flex Plus (Radiometer MedicalApS, Copenhagen, DK) for its long-term blood gas analyzer needs.

Device Adoption & Observed Impacts

Following the device selection, respiratory care leaders at Baptist Health proceeded to the implementation phase, and collaborated with the internal (i.e., hospital IT team) and external (i.e., Radiometer America team) stakeholders to ensure a smooth transition. The hospital began the adoption of the devices at the flagship Little Rock campus first, followed by other large hospitals, and finally to the other regional hospitals in the Baptist Health System. This approach would allow initial implementation challenges to be addressed at larger hospitals with access to more resources first, then for the process to be streamlined, before smaller facilities transitioned to the new devices. By January 2021, eight devices were introduced to the respiratory care center of the Little Rock campus. Once implemented, Baptist Health stakeholders felt “more confident with the new changes” as the analyzers instantly presented significant improvements in clinical, workflow, and cost-related outcomes10 .

Improved TAT & EMR Integration

One of the most significant improvements with the ABL90 Flex Plus was the faster TAT:The new analyzers could generate test results in 35 seconds. Furthermore, the devices came equipped with AQURE (Radiometer Medical ApS, Copenhagen, DK), a companion software that provided POC data management, direct EMR integration, and convenient updates from the vendor as well as the elimination of the need for middleware. Through this software, the analyzers connected seamlessly with Baptist Health’s EMR system and uploaded analysis results directly without the need for additional data entry. Not only did the connectivity and software features of the analyzers improve the “effective TAT,” but they also saved valuable time for clinicians that could instead be spent on patient care.

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Robust Reliability & Minimized Redraws

The ABL90 Flex Plus provided accurate results using a single sample without the need for additional needle sticks. The analyzer performed measurements on 17 different parameters reliably and did not consume samples without providing a result, unlike the previous devices. When there was a samplerelated issue, the analyzer informed users that the blood specimen was contaminated or otherwise unfit for analysis, then urged providers to investigate the errors further. Moreover, the reliability of the analyzers helped minimize the need for redraws, preventing significant discomfort for the patients. Hospital staff also did not have to allocate valuable patient-care time to device maintenance and troubleshooting because of the increased reliability of their analyzers.

Enhanced Clinical Efficiency

Implementation of the ABL90 Flex Plus provided significant benefits to the workflow. Staff appreciated that they could modify patient data using the analyzer’ s easy-to-use interface without having to operate a separate computer or middleware. Respiratory leads could monitor the status of devices and troubleshoot issues from the comfort of their home or office thanks to the connectivity of the analyzer and the software features of AQURE. Instead of cartridges, the analyzer featured a cassette system, which estimated how many more samples the cassettes could run before needing to be replaced. Respiratory leads also appreciated the analyzer’s mobility; the device could be unplugged, wheeled to a new location, then plugged back as needed. The wire adaptability removed concerns about battery life, and the analyzer was large enough not to get lost in fast-paced, high-volume settings. Finally, the staff appreciated not needing to file extra paperwork considering the devices’ exemption from Individualized Quality Control Plan regulations.

Decreased Costs

Since the ABL90 Flex Plus did not require cartridges for sample analysis, the hospital realized significant cost reduction from the disposal of hazardous substances. The cassette-based system produced less waste and could process more samples before needing to be replaced, which considerably helped increase efficiency. Software features of AQURE also eliminated the need for middleware, potentially leading to additional cost savings. Baptist Health also experienced further convenience and cost reductions from the “all-inclusive, long-term contract”that Radiometer offered to support its analyzers, which differed from the charge-per-service practice of the previous devices10 .

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Vendor Involvement

One of Baptist Health’s chief considerations in switching analyzers was a lack of vendor support from the previous manufacturer, which amplified the device-related issues. Radiometer America’ s approach before, during, and after the implementation process provided a refreshing change from this experience.

Before device adoption, Radiometer America offered

Organizations may Baptist Health a reasonable, cost-effective five-year significantly improve contract option that included servicing and technical their clinical practice, support. The vendor also worked with various stakeholders at the health system to enable a smooth workflow efficiency, transition. For example, vendor representatives and and patient-provider hospital IT staff collaborated to build additional satisfaction by network capacity to improve the analyzers' connectivity and ensure that the AQURE software was able transitioning to medical to integrate with the EMR system. devices that effectively During the implementation process, a Radiometer meet their needs. clinical application specialist was directly involved in planning, calibrating, and verifying the analyzers. Staff members reported Radiometer America representatives to be prompt and attentive, noting that they came ahead of time to observe the hospital’s workflow and determined how their analyzer can best provide value. Furthermore, representatives were also present for on-site service as soon as the analyzers went live for any troubleshooting that may have been necessary. Even after device adoption, the Radiometer America teams continue to maintain constant technical support for Baptist Health. The vendor provides a sales representative solely dedicated to the hospital, as well as a technical helpline and weekly phone call check-ins, to ensure the quality of care at the health system. From planning stages to device adoption and continuous product support, Radiometer America's commitment assured Baptist Health administrators that they had made the correct choice for their new blood gas analyzers.

Overcoming Hurdles

Though the ABL90 Flex Plus provided significant benefits to the respiratory department at Baptist Health, the adoption of the new device did not come without challenges. The global COVID-19 pandemic severely affected delivery and supply chains, which delayed device implementation efforts. The hospital thus was not able to install the new analyzers as quickly as it wanted. The pandemic made in-person meetings difficult, leading to barriers in coordination between the vendor and Baptist Health teams and a lapse in time between training and rollout. Organizing testing and

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training sessions with staff was also time-consuming and entailed a learning curve. Despite these challenges, the teams at Radiometer America and Baptist Health were able to work together to tackle these hurdles and successfully install the new blood gas analyzers within a few months.

Final Thoughts and Next Steps

This case study suggests that organizations may significantly improve their clinical practice, workflow efficiency, and patient-provider satisfaction by transitioning to medical devices that effectively meet their needs. Extensive vendor involvement and customer service proved valuable during the pre-and post-implementation processes. After fully transitioning to the new analyzers at its largest campus, a key stakeholder at Baptist Health commented that they were “extremely likely to recommend” these new devices to similar institutions mainly for their “reliability and user friendliness”10. Currently, the health system is in the process of employing these new analyzers in its regional hospitals with Little Rock campus staff members leading training and adoption efforts.

Citations

1.Hill, J. (2007). Blood Gas Analysis. Biomedical Instrumentation & Technology, 41(1), 55–56. doi:10.2345/0899-8205(2007)41[55:bga] 2.Acute care testing handbook. Radiometer Medical ApS, 2700 Brønshøj, Denmark, 2014. Asaccessed on http://www.radiometer.com/en/knowledge-center/handbooks/acute-care-testing-handbook. 3.Indrasari, N. D., Wonohutomo, J. P., & Sukartini, N. (2019). Comparison of point‐of‐careand central laboratory analyzers for blood gas and lactate measurements. Journal of Clinical Laboratory Analysis, e22885. doi:10.1002/jcla.22885 4.Dukić L, Kopčinović LM, Dorotić A, Baršić I. Blood gas testing and related measurements:National recommendations on behalf of the Croatian Society of Medical Biochemistry and Laboratory Medicine. Biochem Med (Zagreb). 2016;26(3):318-336. doi:10.11613/BM.2016.036 5.Awasthi S, Rani R, Malviya D. Peripheral venous blood gas analysis: An alternative toarterial blood gas analysis for initial assessment and resuscitation in emergency and intensive care unit patients. Anesth Essays Res. 2013;7(3):355-358. doi:10.4103/0259-1162.123234 6.Hinds, L. E., Brown, C. L., & Clark, S. J. (2007). Point of care estimation of haemoglobin inneonates. Archives of Disease in Childhood - Fetal and Neonatal Edition, 92(5), F378– F380. doi:10.1136/ adc.2006.107771 7.Kapoor D, Srivastava M, Singh P. Point of care blood gases with electrolytes and lactates in adult emergencies. Int J Crit Illn Inj Sci. 2014;4(3):216-222. doi:10.4103/2229-5151.141411 8.About Baptist Health of Arkansas: Our History of Caring. Baptist Health. https://www.baptist-health.com/ about-baptist-health-arkansas/. Published 2021. AccessedSeptember 7, 2021. 9.Baptist Health. Encyclopedia of Arkansas. https://encyclopediaofarkansas.net/entries/baptist-health-5118/. Published 2021. AccessedSeptember 7, 2021. 10.Data on File. Interviews conducted at Baptist Health of Arkansas by Boston StrategicPartners, Inc. July 2021.

Radiometer, the Radiometer logo, ABL, AQURE are trademarks of Radiometer Medical ApS. © Radiometer Medical ApS, 2700 Brønshøj, Denmark, 2020. All Rights Reserved.

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