Laboratory Stewardship-Expanded Slides for Handout

CONSULTATIVE SERVICES │ LABORATORY STEWARDSHIP

LABORATORYSTEWARDSHIP:

TAKING THE FIRST STEPSTO DOWNSTREAM

SAVINGSANDREW FLETCHER MD

CONSULTATIVE SERVICES │ LABORATORY STEWARDSHIP

Background

13 Billion test performed70% decisions based10-30% unnecessary

CONSULTATIVE SERVICES │ LABORATORY STEWARDSHIP

Background

3 most significant causes of patient harm• Ordering the wrong test• Failing to retrieve a test

result• Misinterpreting a test result

CONSULTATIVE SERVICES │ LABORATORY STEWARDSHIP

73%

53%

72%

47%

the frequency of unnecessary tests and procedures is a very or somewhat serious problem

that even if they know a medical test is unnecessary, they order it if a patient insists

the average medical doctor prescribes an unnecessary

test or procedure at least once a week

their patients ask for an unnecessary test or procedure at

least once a week

CONSULTATIVE SERVICES │ LABORATORY STEWARDSHIP

Trends in Healthcare

Laboratory Stewardship

Pharmacy Utilization management

Antimicrobial Stewardship

Blood Utilization

Radiology Utilization management

CONSULTATIVE SERVICES │ LABORATORY STEWARDSHIP

of labs have a stewardship program

1/3

of those labs have a productive and progressing committee

1/2Data Analysis

Formal Governance

Evidence-Based Recommendations

IT Engagement and Support

Project Management

Measurement and Reporting

Success Factors

Creating Successful Laboratory Stewardship

CONSULTATIVE SERVICES │ LABORATORY STEWARDSHIP

NCLS Publication

CONSULTATIVE SERVICES │ LABORATORY STEWARDSHIP

Test ConsolidationHow many reference labs do you use?

Reference test formularyCreation & Implementation

In-House Testing Daily recurring labs Inappropriate test intervals

Three Initial areas of Focus

Where to Start?

CONSULTATIVE SERVICES │ LABORATORY STEWARDSHIP

Free Phenytoin at Lab X $106Free Phenytoin at Primary Lab vendor $13

Test ConsolidationHow many reference laboratories do you use?

1. Is there a primary Vendor?2. Why are tests sometimes not consolidated?

-Physician Request-Patient Request-Insurance requirement-Easier process for lab staff

CONSULTATIVE SERVICES │ LABORATORY STEWARDSHIP

Test ConsolidationHow many reference labs do you use?

Reference test formularyCreation & Implementation

In-House Testing Daily recurring labs Inappropriate test intervals

Three Initial areas of Focus

Where to Start?

CONSULTATIVE SERVICES │ LABORATORY STEWARDSHIP

Test Formulary

all send out testing performed in 1 year

test listing in menu if ordered <4 times in 1 year

remaining test on menu to see if reasonable

ReviewReview Eliminate

CONSULTATIVE SERVICES │ LABORATORY STEWARDSHIP

POE Optimization

Vitamin D• 1,25-Dihydroxy vitamin D• 25-Hydroxy vitamin D

Flu• Flu PCR• Flu respiratory viral panel• Flu screen

Folate• Folate (RBC)• Folate (serum)

Gonorrhea• Gonorrhea culture• Gonorrhea DNA probe

CONSULTATIVE SERVICES │ LABORATORY STEWARDSHIP

POE Optimization

POE Optimization

CONSULTATIVE SERVICES │ LABORATORY STEWARDSHIP

Inpatient Reference test cost

Monthly average pre Formulary $31,054 Monthly average post Formulary $20,028 Percent decrease 35% Average monthy savings $11,026 Projected yearly savings $132,309

CONSULTATIVE SERVICES │ LABORATORY STEWARDSHIP

Commonly Misordered TestingTest Removal & Reflex Path Implementation

0

2

4

6

8

10

12

14

16

18

MTHFR 2 Mutations Factor V Leiden APC w/reflex to Factor VLeiden

85% 86%

CONSULTATIVE SERVICES │ LABORATORY STEWARDSHIP

Test ConsolidationHow many reference laboratories do you use?

Reference test formularyCreation & Implementation

In-House Testing Daily recurring labs Inappropriate test intervals

Three Initial areas of Focus

Where to Start?

CONSULTATIVE SERVICES │ LABORATORY STEWARDSHIP

Don’t perform repetitive CBC and chemistry testing in the face of clinical and lab stability.

Don’t order diagnostic tests at regular intervals (such as every day), but rather in response to specific clinical questions.

Daily Orders

CONSULTATIVE SERVICES │ LABORATORY STEWARDSHIP

Intervention Methods

Proactive

Appropriate order setsOrder management

Preference list managementPhysician education

Physician report cards

Reactive

Duplicate alertsFormulary restriction alerts

Best Practice AlertsPhysician education

CONSULTATIVE SERVICES │ LABORATORY STEWARDSHIP

76548965

Zyne Cotopaxi, MD09/04/2016 15:47

76548965

09/04/2016 13:00

Thyroid Stimulating Hormone 4.0 IU/mL

CONSULTATIVE SERVICES │ LABORATORY STEWARDSHIP

Test ConsolidationHow many reference labs do you use?

Reference test formularyCreation & Implementation

In-House Testing Daily recurring labs Inappropriate test intervals

Justification for StewardshipNCLS RecommendationsThree Initial areas of Focus:

Summary

CONSULTATIVE SERVICES │ LABORATORY STEWARDSHIP

13 Billion

laboratory tests performed annually

in the U.S.3%

of U.S. healthcare expenditures spent on Laboratory Services

70%of medical decisions are influenced by laboratory

data

CONSULTATIVE SERVICES │ LABORATORY STEWARDSHIP

Downstream impact

• Length of stay

• Pharmacy

• Radiology

• Others……

CONSULTATIVE SERVICES │ LABORATORY STEWARDSHIP

Troponin orders and Chest Pain LOS

23

CONSULTATIVE SERVICES │ LABORATORY STEWARDSHIP

Identify order mechanisms that drive the repeat interval

Modify the repeat time to be 3-6 hours after

Improve the time-to-decision by improving the test interval

by up to 3 hours

TROPONIN I

0

500

1000

1500

2000

2500

3000

3500

00.

5 11.

5 22.

5 33.

5 44.

5 55.

5 66.

5 77.

5 88.

5 99.

5 1010

.5 1111

.5 12 12+

2,965

4,410

CONSULTATIVE SERVICES │ LABORATORY STEWARDSHIP

Identify order mechanisms that drive the repeat interval

Modify the repeat time to be 3-6 hours after

Improve the time-to-decision by improving the test interval

by up to 3 hours

TROPONIN I

0500

1000150020002500300035004000

0.0

0.5

1.0

1.5

2.0

2.5

3.0

3.5

4.0

4.5

5.0

5.5

6.0

6.5

7.0

7.5

8.0

8.5

9.0

9.5

10.0

10.5

11.0

11.5

12+

3,587

CONSULTATIVE SERVICES │ LABORATORY STEWARDSHIP

Downstream impact

• Length of stay

• Pharmacy

• Radiology

• Others……

CONSULTATIVE SERVICES │ LABORATORY STEWARDSHIP

Downstream Impact on Pharmacy

IVIGArgatrobanRemicade

CONSULTATIVE SERVICES │ LABORATORY STEWARDSHIP

Downstream impact

• Length of stay

• Pharmacy

• Radiology

• Others……

CONSULTATIVE SERVICES │ LABORATORY STEWARDSHIP

Radiology Services

CONSULTATIVE SERVICES │ LABORATORY STEWARDSHIP

CT PE Protocol

30

CONSULTATIVE SERVICES │ LABORATORY STEWARDSHIP

CONSULTATIVE SERVICES │ LABORATORY STEWARDSHIP

D-Dimer and CT PE Protocol

32

CONSULTATIVE SERVICES │ LABORATORY STEWARDSHIP 33

CONSULTATIVE SERVICES │ LABORATORY STEWARDSHIP

CONSULTATIVE SERVICES │ LABORATORY STEWARDSHIP

45,000chest x-rays

=

23%CT Scans

CONSULTATIVE SERVICES │ LABORATORY STEWARDSHIP

=

23%CT Scans

$34.20 per scan

CONSULTATIVE SERVICES │ LABORATORY STEWARDSHIP

=

23%CT Scans

$10,260 cost saving

CONSULTATIVE SERVICES │ LABORATORY STEWARDSHIP

=

23%CT Scans

$1,445,400 savings for patients

CONSULTATIVE SERVICES │ LABORATORY STEWARDSHIP

=

23%CT Scans

360 hrsreduction in LOS

CONSULTATIVE SERVICES │ LABORATORY STEWARDSHIP

Downstream impact

• Length of stay

• Pharmacy

• Radiology

• Others……

CONSULTATIVE SERVICES │ LABORATORY STEWARDSHIP

LABORATORYSTEWARDSHIP:

TAKING THE FIRST STEPSTO DOWNSTREAM

SAVINGSANDREW FLETCHER MD