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Session 5004-17
Improving Laboratory Test
Utilization: Opportunities,
Strategies and Successes
Stephen E. Kahn, PhD, DABCC, FACB
Elizabeth Schulwolf, MD, MA, FHA, FACP
Kate Bernhardt, MS, MLS(ASCP)CM, LSSGB
Marisa C. Saint Martin, MD
Loyola University Health System
A Member of Trinity Health
Maywood, Illinois USA
DISCLOSURE
In the past 12 months, I have not had any
significant financial interest or other relationship
with the manufacturers of the products or
providers of the services that will be discussed in
my presentation.
Symposium
Introduction
Stephen E. Kahn, Ph.D. DABCC, FACB
Professor and Vice Chair, Clinical Services,
Department of Pathology – Clinical Laboratories
skahn@lumc.edu
Session 5004-17
ASCP 2017 Annual Meeting
Chicago, Illinois
The imperative to improve laboratory test utilization
• U.S. healthcare’s paradigm has changed from volume to value
• According to the IOM, provision of healthcare must be safe, timely, efficient, effective, equitable and patient-centered (STEEEP)
• Top priorities for healthcare still remain increased patient safety and reduction in medical errors
• Yet, laboratory test ordering is all too often excessive, insufficient or inappropriate
• Utilization of the laboratory has become a critically important component of evidence-based laboratory medicine
Recently Available Evidence
The laboratory test value-based pyramid
Evidence must be translated into action to change outcomes
Improving Laboratory Utilization: A Single Academic Center Experience
Elizabeth Schulwolf, MD, MA, FACP, FHM
Associate Professor, Department of Medicine
Director, Division of Hospital Medicine
Co-Chair of Test Utilization Steering Committee
Disclosure
In the past 12 months, I have not had any significant financial
interest or other relationship with the manufacturers of the products
or providers of the services that will be discussed in my
presentation.
Objectives
• Define the problem at our institution
• Describe the clinical implication of lab overutilization in the
inpatient setting
• Examine literature on initiatives intended to reduce inpatient
laboratory utilization
• Discuss national campaigns for reducing laboratory utilization
• Summarize our initiatives to date and next steps
11
FY 17 Current = 62.6
FY 17 Threshold = 57
(14.9% reduction)
FY 17 Target = 53
(20.9% reduction)
Recent LUMC IP Utilization
What is the impact for patients?
• Increased risk of hospital-acquired anemia
• Studies demonstrate an associated decline in hemoglobin
relative to total volume of blood drawn during a hospital
stay
• Canadian study demonstrated every 100mL of
phlebotomy associated with 1.9% decrease hematocrit
• Similar findings in study of patients hospitalized with
acute myocardial infarction
• Potential improvement in patient satisfaction due to
reduction in venipunctures
Date of download: 1/26/2016Copyright © 2016 American Medical
Association. All rights reserved.
From: Diagnostic Blood Loss From Phlebotomy and Hospital-Acquired Anemia During Acute Myocardial
Infarction
Arch Intern Med. 2011;171(18):1646-1653. doi:10.1001/archinternmed.2011.361
Figure 1. Mean volume of diagnostic blood drawn on each day from hospital days 1 through 10. Mean blood drawn for laboratory
tests on each of the first 10 hospital days, comparing patients who developed moderate to severe hospital-acquired anemia (HAA)
with those who did not. The denominator on each hospital day included all patients who remained in the hospital on each respective
day hospital day (hospital day 1: 17 676; hospital day 2: 13 632; hospital day 3: 11 403; hospital day 4: 8261; hospital day 5: 5263;
hospital day 6: 3339; hospital day 7: 2183; hospital day 8: 1475; hospital day 9: 1060; hospital day 10: 753).
Figure Legend:
Initiatives to reduce lab utilization: Outpatient
• Study in primary care setting evaluating if displaying
laboratory costs would affect utilization
• One of four clinics passively displayed costs of 27 lab
tests at time of ordering
• Compared monthly lab ordering rate before and after
the intervention
• Labs selected based on high cost or high volume
• Four (19%) of lower cost tests and one (17%) higher
cost test showed significant reduction in the intervention
clinic
• 30% intervention physicians “always” or “usually”
considered the information in cost displays
Horn DM, et al. JGIM. 2013; 29(5): 708-14.
Initiatives to reduce lab utilization: Inpatient
• Pragmatic Randomized Introduction of Cost data study
through the EHR, 1-year study
• 3 hospitals in Philadelphia
• Medicare allowable fee data displayed in randomized
fashion for 30 intervention labs and 30 control labs
• No significant change in overall test ordering behavior or
lab fees
Sedrak MS, et al. JAMA Intern Med. 2017; 177(7): 939-45.
Why do we order unnecessary tests?
• 2014 internal medicine and general surgery resident
survey at the University of Pennsylvania
• 116 respondents
• 82.8% reported ordering unnecessary routine labs
• 49.0% reported ordering unnecessary routine labs on
a daily frequency
• 90.5% ordered out of “habit”
• 86.2% cited lack of cost transparency
• 82.8% reported discomfort with uncertainty
• 75.9% concerned the attending will want the
information
• 67.2% report lack of role modeling of cost conscious
care
• 65.5% cited lack of cost conscious culture at the
institution
• 51.7% cited ease of ordering labs in EHR
Sedrak MS, et al. J Hosp Med. 2016; 11: 869-72.
Choosing Wisely®
• Launched in 2012 by ABIM
• In collaboration with Consumer Reports
• Provides patient-friendly information to participating organizations to disseminate to their audiences
• Accompanying videos for providers and patients
• Reduce unnecessary tests and treatments
• 86 societies provide recommendations
Our Story
Local Initiatives
• Formation of Test Utilization Steering Committee
• Grass roots efforts to increase awareness and create
change in practice
• Displaying lab charges passively at the time of order entry
• Resident engagement
• Unit-level and team-level projects focused on lab
utilization
• Resident champions
• High-Value Care initiative focused on lab utilization
• Leveraging EMR for clinical decision support
• Pocket card to promote adding on lab tests and provide
reference for tube colors
• Get in early with the rising third year medical students
Sedrak MS, et al. JAMA Intern Med. 2017; 177(7): 939-45.
The “Five Rights” of Clinical Decision Support (CDS)
• The right information
• Alert includes previous patient test results
• To the right person
• Requestor may be making a potentially misinformed decision about lab testing
• In the right CDS intervention format
• Interruptive alert
• Through the right channel
• CPOE
• At the right time in the workflow
• At the time of ordering
Sirajuddin AM et al. J Healthc Inf Manag 2009; 23: 38 – 45
Orientation in Action
Next Steps
• Constant evaluation of our processes and assessment of
impact of initiatives
• Leveraging EMR to aid the ordering provider in clinical
decision-making
• Limiting the frequency of how often higher volume lab
tests can be ordered
• Displaying previous results in the order view
• Changing the ordering frequency display to give less
options to ordering providers
• Engagement of our unit medical directors and quality
medical directors to champion change at their “local” level
• Resident and faculty survey to understand our local culture
• Share data, data and more data!
• Celebrate wins!
Sedrak MS, et al. JAMA Intern Med. 2017; 177(7): 939-45.
Thank You
eschulwolf@lumc.edu
A Test Utilization Initiative and Quality Improvement Model
Kate Bernhardt, MS, MLS(ASCP)CM, LSSGB
Regulatory Compliance Specialist
LUMC Department of Pathology
kabernhardt@lumc.edu
Urinalysis with Reflex Culture (UARC)
Disclosure Statement
In the past 12 months, I have not had any significant financial interest or other relationship with the manufacturers of the products or providers of the services that will be discussed in my presentation.
Objectives
• Utilize Project Management tools to more efficiently lead quality improvement projects
• Describe how LUMC successfully decreased urine culture volume by approximately 50%, through implementation of Urinalysis with Reflex Culture (UARC)
• Understand the importance of identifying your stakeholders early and forming a robust communication plan
Project Management Basics
• Project Management is using a set of tools to:
• Create a work plan
• Manage work
• Anticipate and solve problems
• Allocate resources
• Implement the plan
Fred Pryor Seminars, a division of PARK University Enterprises, Inc. Project Management Workshop Seminar Workbook. 2015.
Lean Six Sigma
• Lean• “Eliminate waste”
• Six Sigma• “Eliminate defects”
• Lean Six Sigma• Theory that reducing
variation & waste in a process, and producing output within customer-defined limits, will yield great returns
• Organized, specific, repeatable means of assessing and resolving challenges with “DMAIC”
Loyola Medicine, Operational Excellence. Lean Six Sigma Green Belt Training Material. 2015.
Project Charter
PROBLEM STATEMENT: In an effort to reduce the number of unnecessary urine cultures and decrease
CAUTI rates within Loyola, the Department of Pathology will implement Urinalysis w/ Reflex to Culture (UARC). Each month, Microbiology receives an
average of +3,000 urine cultures; in December 2015, Microbiology received 3,243 urine cultures.
GOAL:After implementation of UARC, we would like to reduce the number of urine
cultures by one-third, with a stretch goal of a 50% reduction.
SCOPE:In: Inpatient and Outpatient Urine Cultures at LUMC & GMH
Out: Measuring reported CAUTIs (Infectious Disease)
Project CharterTEAM:
Project Champion : Dr. Stephen Kahn, Professor & Vice Chair of Clinical Services LUMC,Dr. Marisa Saint Martin, Laboratory Director of GMH
Project Manager: Kate Bernhardt, Regulatory Compliance Specialist
Team Members: Dr. Paul Schreckenberger, Dr. Jeanine Walenga, Michael Azzano, Cindy Blakemore, Roman Golash, Ann Del Bene, Jo Ann Molnar, Dr. Marisa Saint Martin (Project Champion GMH), Jean Wojtanek (GMH)
Special Thanks: Dr. Josh Lee, Mary Cashin, Jennifer Rodriguez, Violeta Rekasius, Debra Paris, Erin Ley, Beth Hoelting, Alex Castator, Colleen Jarosz, Kathy McKenna, Core Lab, Central Processing & Microbiology Colleagues
MILESTONES: LUMC Launch Date: April 12, 2016GMH Launch Date: August 11, 2016
Business Case
• Best practice of ordering urinalysis with reflex to culture
• Decrease unnecessary urine cultures
• Improve test utilization
• Increase efficiency in laboratory
• Improve antimicrobial stewardship
• CAUTI rate• Institutional efforts to decrease
number of CAUTIs
• Project may help contribute to less reported CAUTIs (false positives)
• Urine cultures ordered unnecessarily and come back positive, but not truly infection (contaminants)
• Published LUMC study showed 97% of patients without pyuria are shown to be negative for urinary tract infection; similar studies support absence of pyuria suggests diagnosis other than CAUTI
Order Change
• Urinalysis with Reflex Culture (UARC)
• Urinalysis is performed prior to all urine cultures
• Reflex cultures performed only when criteria for pyuria (≥6 WBC/hpf) is met, unless pre-determined exceptions are met*
• URIN (urine culture) no longer orderable to clinician
• Patient Exceptions• Neutropenic patients with WBC
<1.0 K/UL
• Pregnancy
• Patient scheduled for transurethral resection of prostate
• Patient scheduled for urologic procedures for which mucosal bleeding is anticipated
• Neonatal status
• Pediatric patients with known congenital anomalies of the urinary tract**
*Clinician orders UARC and select the applicable exception in Epic at time of order. The culture
will be performed even if the urinalysis is negative for pyuria.
**6th Patient Exception was added in March 2017 after clinician feedback.
Ordering in EMR
Ordering in EMR - Continued
Communication Plan
Results – First 30 Days
• Baseline Data• 3,243 urine cultures in
December 2015
• Average +3,000 / month (+100 / day)
• Many contaminated samples
• First 30 Days• 1,713 urine cultures
• Average 57 / day
• No longer receiving as many “junky” urines
• 47% Reduction in urine cultures
A 47% reduction exceeded our target of 33% and
almost reached our stretch goal of 50%.
Results – Monthly Volume of Urine Cultures (Figure 1)
UARC Go-Live on
4/12/16
Results - ContinuedTable 1. Ordering Patterns
Before and After UARCTable 2. Leukocyte esterase in UA by
Reflex Criteria (WBC > 6)*
Table 3. Urine Culture Positivity Rates
a. URID1 serves as a marker for “positivity”
because it is a lab entered charge code for
identification. The code would not be added if
the culture was contaminated or negative.
b. URID2 is a charge code for a second organism
identification. There is little difference between
the pre and post UARC data in URID2, so
additional analysis was not performed.
UARC Conclusions
1. Approximately 40 - 50% decrease in the monthly volume of total urine cultures performed by the Clinical Microbiology Laboratory (See Figure 1)
This general level of decrease in monthly urine cultures continues to be observed. While it is to be expected, the magnitude of this decrease is also reflected in the audit that was done on Epic orders for urinalysis leading to culture, pre and post UARC, in November of 2015 and 2016 (Table 1).
2. Sustained decrease in CAUTI Standardized Infection Ratio and improved quality metrics for incidence of CAUTI at our institution
According to institutional quality program leaders and the CAUTI Committee, the sustained decrease in the CAUTI SIR and improved quality metrics used for incidence of CAUTI in our institution can also be correlated with the timing in the implementation of UARC (data not shown).
3. Use of > 6 WBC per hpf only is an effective criterion for improving lab test utilization in establishing a process for reflexing urinalysis (UA) to culture. But others could be considered.
Other institutions have reported additional criteria in combination with a WBC per hpf level or as a standalone criterion such as positive leukocyte esterase and positive nitrites. While all stakeholders in our project supported the use of a WBC criterion alone, our data indicate that use of additional criteria such as a positive leukocyte esterase would increase the number of specimens reflexed to culture although the extent of this increase would depend on the semi-quantitative threshold used for the leukocyte esterase result (Table 2).
4. Implementing UARC increased the urine culture positivity rate (at least one organism) by ~ 4.5% (Table 3).
The LIS test codes shown are ones that are used in the lab as a charge code for identification of an organism (or organisms) in culture specimens. This code is not used if a culture specimen has been contaminated or is negative. Although we audited only a single month of results, there does not appear to be much difference in the frequency of culture specimens positive for two organisms, pre and post UARC, unlike the changed culture positivity rate for one organism only.
5. After UARC was implemented at our institution, a comparable process to UARC was implemented at a second institution in our system which is a neighboring community hospital.
Similar results in the impact of urinalysis reflexed to culture and improvements in lab test utilization were, and continue to be, observed at this second hospital in our health system.
Project Management Recommendations• Project Charter
• Define the problem and risk of not addressing it
• Set clear, measurable goals
• Eliminate scope creep
• Establish formal roles• Project Champion, Project Manager, Team Members
• Communication Plan• Identify all stakeholders
• Keep stakeholders informed throughout project
• Continual Improvement• Listen and look for additional opportunities
Thank You
kabernhardt@lumc.edu
Patient Blood Management in the Academic and Community Hospital Settings:Our Experience
Marisa Saint Martin, MD
Assistant Professor
Medical Director Pathology and Laboratory
Services Gottlieb Memorial Hospital
Associate Director Blood Bank and Apheresis
Services
Associate Director Pathology Residency Program
Loyola University Health System
Disclosure Statement
In the past 12 months, I have not had any significant financial interest or other relationship with the manufacturers of the products or providers of the services that will be discussed in my presentation.
Objectives
To recognize different ways of designing and
strengthening a plan for PBM in the academic
hospital and community setting, using team effort
and collaboration with other departments
Patient Blood Management
Definition
Facts
Accreditation and regulations
PBM culture at Loyola University Medical Center
and Gottlieb Memorial Hospital
PBM Definition
Evidence based, multi-disciplinary approach to
optimizing the care of patients that may need
transfusion
Encompasses all aspects of patient evaluation
and clinical management surrounding the
transfusion decision making process
Decreases the need for unnecessary blood
transfusion, decreases cost, ensures availability
of products for patients who need them
PBM: Why?
About 14 million units of RBC are transfused in
the US each year
Transfusion is the most common procedure a
physician will order in his/her career
Medical school education on transfusion
medicine is inadequate
WHO has been officially urging member states
to implement PBM since 2010
Accreditation/RegulationsThe Joint Commission 2011
Transfusion consent
RBC, plasma, and platelet transfusion
indications
Blood administration documentation
Preoperative anemia screening
Preoperative blood type and antibody screening
Accreditation/RegulationsAABB 2012 – Choosing Wisely Statements
Don't transfuse more units than needed
Don't transfuse RBC's for iron deficiency
Don't transfuse blood products for warfarin
reversal
Don't perform serial blood counts on stable
patients
Don't transfuse O negative blood except to O
negative patients and (in emergencies) women
of child-bearing age
Accreditation/RegulationsAHA 2013 – Top 5 Hospital Based Procedures
Blood management
Antibiotic stewardship
Reducing admissions for ambulatory sensitive
conditions
Appropriate use of elective percutaneous
coronary procedures
Appropriate use of ICU for terminal illness
Accreditation/RegulationsePBM 2015 – Joint Commission
Preoperative anemia
Preoperative hemoglobin
Preoperative type and x-match/type and screen
Initial transfusion threshold
Outcomes of PBM
Accreditation/RegulationsAABB and Joint Commission 2016 – Voluntary PBM Certification
Define credentials of transfusion ordering
individuals
Define PBM guidelines
Pre and post-transfusion patient care
Preoperative/pre-transfusion patient care
intervention/anemia management
Management of massive blood loss
Reporting
Accreditation/RegulationsAABB and Joint Commission 2016 – Voluntary PBM Certification
ReportingEffectiveness and opportunities for improvement
Allogeneic transfusion rates by service line and procedure type
Preoperative anemia intervention use and efficacy
Component use and discard
Appropriateness of transfusions
PBM techniques
Customer satisfaction
Compliance
Suspected transfusion associated events and under transfusion
Trinity : 93 Hospitals-One PBM
Monitoring of transfusion rates
Units ordered in non-bleeding patients
Pre-transfusion hemoglobin: >7 (or 8)
Discharge hemoglobin: >8 (or 9)
Trinity : 93 Hospitals-One PBM
EMR Data: Compiled and reviewed by
multidisciplinary team
Daily report
pRBC orders
pRBC indications
CRIT rule
Trinity : 93 Hospitals-One PBM
Daily report: Alert does not fire if
Patient is bleeding (>25% of BV or ongoing GI
bleed with Hgb <7, or high risk OB case)
Patient is not an adult
Patient has an excluded code in the problem list
Hemoglobin is <7
Patient is hemodynamically unstable: Systolic
Blood pressure changes of 20%
Trinity : 93 Hospitals-One PBM
Monthly summary report
By medical specialty
By DRG
Transfusion rate (# of patients transfused /total
# of patients)
# of patients transfused
Average units ordered/average units given
Average pre-transfusion hemoglobin
Average discharge hemoglobin
Trinity : 93 Hospitals-One PBM
Daily report
Monthly report
Quarterly Meeting
Educational activities
*93 hospitals and 121 continuing care facilities,
home care agencies and outpatient centers
* in 22 states
*131,000 colleagues
Trinity : LUMC
547 Beds
Trauma level I
Yearly pRBCs: ~17,000 units
Blood Utilization Review Committee:
Improvement of all dimensions of performance in
blood and blood component usage in addition to
serving as an educational resource for the health
care team
Trinity : LUMC
Blood Utilization Review Committee Members: Administration
Chair (medical staff member)
Nursing
Center for clinical excellence
Pharmacy
Risk management/ Patient safety
Blood bank director/staff
Laboratory
Cardio-thoracic surgery and General surgery
ED
OBGYN
Pediatrics
Medicine
Trinity : LUMC
Blood Utilization Review Committee
Improvement of all dimensions of performance in blood and
blood component usage
Responsible for policies and procedures concerning blood
usage
Administrative oversight concerning policies and protocols
dealing with patient safety and quality of patient care
Reports to Medical Executive Committee
Educational materials in our web site with guidelines, tools and
educational materials for easy access for all staff members
Educational material/announcements distribution
Trinity: GMH
254 Beds
Yearly pRBCs: ~1,700 units
Blood Utilization Review functions within the
Pharmacy and Therapeutics Committee
July 2015 PBM implemented lowering
hemoglobin trigger to 7
Trinity: GMH
Monitoring Transfusion practices following Trinity
parameters
Communication
Medical Executive Committee, Nursing and Specialty
Committees
News letter
General and Departmental Medical Staff Meetings
Success of 25% reduction of pRBC usage
Take Home Points
Implementation of PBM requires a
multidisciplinary approach with input from all
representative members throughout the hospital
The BUC or transfusion committee should be the
responsible entity for overseeing practice
changes and monitoring outcomes of transfusion
Education and gathering necessary tools and
materials with easy access and distribution
Take Home Points
Analyze
Discuss
DecideImplement
Measure
Take Home Points
Analytics: Data
Governance
Development
Education/Communication
Implement
Educate again
Measure
Communicate feedback with successes
Communicate additional opportunities for
improvement
Thank You
marisa.saintmartin@lumc.edu
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Symposium Panel
Q & A
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