Introduction: The emergency department (ED) serves as the primary access point to the healthcare system. ED throughput efficiency is critical. The percentage of patients who leave before treatment completion (LBTC) is an important marker of department efficiency. Our study aimed to assess the impact of an ED phlebotomist, dedicated to obtaining blood specimen collection on waiting patients, on LBTC rates.

Methods: This study was conducted as a retrospective observational analysis over approximately 18 months (October 5, 2015-March 31, 2017) for patients evaluated by a triage provider with a door-to-room (DtR) time of > 20 minutes (min). LBTC rates were compared in 10-min DtR increments for when the ED phlebotomist collected the patient’s specimen vs not.

Results: Of 71,942 patient encounters occurring during the study period, 17,349 (24.1%) met study inclusion criteria. Of these, 1842 (10.6%) had blood specimen collection performed by ED phlebotomy. The overall LBTC rate for encounters included in the analysis was 5.26% (95% confidence interval [CI], 4.94%-5.60%). Weighting the LBTC rates for each 10-min DtR interval using the fixed effects model led to an overall LBTC rate of 2.74% (95% CI, 2.09%-3.59%) for patient encounters with ED phlebotomist collection vs 5.31% (95% CI, 4.97%-5.67%) in those which did not, yielding a relative reduction of 48% (95% CI, 34%-63%). The effect of the phlebotomist on LBTC rates increased as DtR times increased. The difference in the rate of the rise of LBTC percentages, per 10-min interval, was 0.50% (95% CI, 0.19%-0.81%) higher for non-ED phlebotomist encounters vs phlebotomist encounters.

Conclusion: ED phlebotomy demonstrated a significant reduction in ED LBTC rates. Further, as DtR times increased, the impact of ED phlebotomy became increasingly significant. Adult EDs with increased rates of LBTC patient encounters may want to consider the implementation of ED phlebotomy.

Despite multiple advantages, subclavian vein (SCV) cannulation via the traditional landmark approach has become less used in comparison to ultrasound (US) guided internal jugular catheterization due to a higher rate of mechanical complications. A growing body of evidence indicates that SCV catheterization with real-time US guidance can be accomplished safely and efficiently. While several cannulation approaches with real-time US guidance have been described, available literature suggests that the infraclavicular, longitudinal “in-plane” technique may be preferred. This approach allows for direct visualization of needle advancement, which reduces risk of complications and improves successful placement. Infraclavicular SCV cannulation requires simultaneous use of US during needle advancement, but for an inexperienced operator, it is more easily learned compared to the traditional landmark approach. In this article, we review the evidence supporting the use of US guidance for SCV catheterization and discuss technical aspects of the procedure itself.