Multifaceted Interventions to Enable Elimination of Clinician-ordered Blood Smear Reviews: A Rural Academic Medical Center Experience

Abstract Introduction/Objective Blood smears (BS) evaluate a variety of clinical disorders. At Geisinger, clinician ordered pathologist review of blood smears (CBS) have increased despite usage of highly sophisticated hematology analyzers and automatic blood smear (ABS) review criteria. We hypothesized that CBS impact pathologists’ and technologists’ workloads and increase costs and turn-around times, with rare improvement in value-based patient care. This study aimed to analyze CBS ordering practices and improve the utilization of BS review. Methods/Case Report In October 2020, a prospective CBS utilization study was completed by 8 clinical pathologists for 172 CBS. Subsequently, a clinical question was required for CBS orders from January 1, 2022, to January 1, 2023, to investigate clinician ordering practices based on campus, department, and indications. Findings were used to support new interventions including: clinician education; cancellation of repeat BS ordered within 24 hours, creation of alternative tests (schistocyte technologist smear review, clinician order for independent slide review), standardization of morphology reporting, ABS audits, and elimination of orderable CBS replaced by an electronic BS review request, that is reviewed by a clinical pathologist prior to determine if a BS is indicated. Results (if a Case Study enter NA) Part of the Conclusions section for Lab Practice abstract. Conclusion Prospective utilization audit of 172 CBS orders showed 17% changed clinical management. Audit of 3,693 CBS orders demonstrated common reasons for review included tick-borne illness, hemolysis, erythrocytosis, thrombocytosis, and iron deficiency anemia. Systematic implementation of multiple interventions enabled the elimination of CBS, with no known adverse effect on patient management to date. The streamlined BS review guidelines allowed for better-allocation of resources, appropriate patient turn-around times, empowerment of laboratory technologists and reduced hospital costs. We propose maximizing the incorporation of technologist skills to improve the utilization and efficiency of BS reviews and establishing standardized, evidence-based, and institutional- specific guidelines to determine BS reviews.