Less is More: Rethinking Routines

By Valissa Yap

Arterial blood gas (ABG) test is a long-standing routine performed for post-operative patients. The test provides critical information on patients’ blood pH, oxygen levels, and electrolyte balance – essential indicators for detecting life-threatening breathing or metabolic issues.

In the Cardiothoracic Intensive Care Unit (CTICU), ABG tests are also habitually performed in various situations such as after continuous positive airway pressure therapy and extubation (removal of breathing tube), and when there are signs of a patient’s condition deteriorating during respiratory distress.

But is the long-established routine truly necessary?

Rethinking Routine Practices

Team Revivors analysed multiple patient datasets and discovered that not all ABG tests were clinically necessary.

Previously, ABG testing lacked a structured protocol and was instead, driven by ingrained practices. The tests were routinely carried out every four hours, sometimes even hourly depending on the patient’s condition. “Tests were conducted without clear clinical indications. The mindset was ‘just to be safe’ even when patients were stable,” shared Advanced Practice Nurse (APN) Gillian Wee, Team Leader of Team Revivors.

In high-pressure environments like the CTICU, to err on the side of caution might seem like the right approach. However, excessive testing led to higher costs, increased risk of complications like haematoma or infection, and overwhelmed staff who were more likely to make sampling errors when stretched too thin.

Building a Better Tool Together

The solution extended beyond simply reducing testing requirements. Team Revivors conducted comprehensive literature reviews and analysed the underlying causes of ABG over-testing in CTICU. Following detailed process and workflow analysis, the team adapted two existing algorithms, validated them against in-person clinical scenarios, and collaborated closely with physicians and nurses to develop a solution tailored to the local context, patient demographics, and operational environment.

The outcome is a clear, sequential flowchart grounded in clinical guidelines and research evidence, designed for quick and clear decision-making. Reference charts were strategically positioned on Computer on Wheels (COWs) throughout CTICU to ensure optimal visibility and accessibility for frontline clinical staff. Quarterly case reviews during departmental retreats and monthly ward meetings provided essential platforms for continuous education and awareness-building among the clinical team.

(L-R): Team Revivors gathering feedback from CTICU nurses and cardiothoracic surgeons to refine the ABG sampling process and increase awareness of ABG frequencies; A nurse carrying out the ABG protocol during the pilot study.

The protocol was strategically placed on CTICU’s COWs for easy reference during shifts.

Meaningful Results

ABG testing dropped by 42%, translating to $320,000 in annual cost savings and 3,000 hours saved each year in processing and running the tests. Patient safety improved through fewer unnecessary blood draws and reduced false-positive results that could have triggered overtreatment or complications. These also led to a reduction in the carbon footprint by lowering lab-related emissions and waste.

"Witnessing the positive impact on both staff and patients has been deeply satisfying," shares team member, Senior Staff Nurse (SSN) Swe Mar Oo from CTICU. "While the financial benefits are significant, the real value lies in delivering more thoughtful, patient-centred care."

Scaling Implementation

Drawing on the success of this project, the Post Anaesthesia Care Unit (PACU) has started implementing the new protocol, with careful monitoring during the critical post-operative transition period. The Intensive Care Area is also adapting the approach for cardiac surgery patients with complex post-operative needs.

For departments contemplating similar quality improvement initiatives, Team Revivors offers this encouragement: every improvement begins with someone willing to ask, 'Why do we do it this way?' Do not be afraid to challenge the norm and explore fresh approaches. Sometimes the smallest questions can lead to the biggest improvements in patient care.

Members of Team Revivors (Top row L-R): Clin Asst Prof Phillip Pang, Deputy Head & Senior Consultant, Cardiothoracic Surgery; Deputy Director Foo Lee Lian, Nursing Administration; SSN Kimbell Tan, Nursing Administration; (Front row L-R): APN Gillian Wee, Nursing Specialty Care Unit; SSN Adlin Bte Jaya Ansor, CTICU; SSN Elizabeth Tan, CTICU; Assistant Nurse Clinician (ANC) Stefanie Shuek, Ward 56. Not pictured: Senior Nurse Manager (SNM) Yeoh Lee Shien, CTICU; SSN Tang Yunwen, PACU; SSN Isabel Chin, CTICU and SSN Swe Mar Oo, CTICU.