Before   any   interven-ons   were   undertaken,   a   baseline   was   established   for   the   first   5   weeks   across   the   4  inpa-ent  service  teams.  Average  lab  orders  was  2.8  labs/pa-ent/day.  Following  the  first  interven-on  on  week  6,  a  non  random  decrease  in  lab  orders  was  witnessed  as  evidenced  by  a  shiE  of  more  than  6  data  points  below  the  established  mean,   reaching  a  new  mean  of  2.3   labs/pa-ent/day   (a  decrease  of  18%).   This  decrease  was  sustained  as   further   interven-ons  were   implemented  on  weeks  12  and  15,  although  no  measureable   further  decline  in  lab  orders  was  noted  (Fig.  1).  

The  decline  in  daily  orders  was  not  uniform  across  all  4  teams,  as  different  teams  responded  differently  to  our  interven-ons.   Team  2   showed   the  most   substan-al   decrease   in   lab   orders   from  2.6   labs/pa-ent/day   to   1.6  labs/pa-ent/day  -­‐  a  38.5%  decrease,  well  above  our  an-cipated  target  of  15%  (Fig.  2).  Similarly  Teams  1  &  3  showed  significant  decreases  in  lab  orders  of  30.5%  &  19.2%  respec-vely.  On  the  other  hand,  Team  4  showed  no  significant  improvement  maintaining  an  average  lab  order  of  2.3  labs/pa-ent/day.  

More   extensive   and   inclusive   data   obtained   from   BMC’s   data   warehouse   of   all   the   labs   ordered   by   all   6  inpa-ent  general  medicine  teams  was  analyzed.  A  baseline  was  also  obtained  and  a  decrease  of  daily  lab  orders  from  3.5  labs/pa-ent/day  pre-­‐interven-on  to  3.1  labs/pa-ent/day  post-­‐interven-on  was  observed.  This  was  a  decrease   of   11.4%.   However,   3   weeks   following   our   last   interven-on,   lab   orders   started   increasing   again  reaching  our  original  baseline  of  3.5  labs/pa-ent/day  (Fig.  3).    

 

Introduc)on  &  Background  

Aim  

Methods  

Our  aim  was  to  reduce  the  number  of  unnecessary  lab  orders  per  pa-ent  per  day  by  >15%  within  3  months  on  the  inpa-ent  internal  medicine  service  at  BMC.  

Measures:  To   measure   our   progress,   real   -me   data   was  recorded  of  the  number  of  rou-ne  labs  ordered  per  pa-ent   by   4   inpa-ent   general   medicine   teams   at  BMC.   This   was   performed   3   -mes   per   week   on   a  random  sample  of  5  pa-ents  per  team  each  day  and  the  averages  calculated  for  each  team  for  the  week  (a  total  of  15  pa-ents  per  team  per  week).    Data  was  recorded  con-nuously  for  23  weeks.      The   lab   tests   we  were   specifically  monitoring  were  CBC,  BMP,  CMP,  Magnesium  and    Phosphate.  These  labs  were   selected   as   they   are   the  most   frequently  ordered  labs  and  are  considered  rou-ne  tests.    Interven)ons:  In   order   to   accomplish   our   aim   of   reducing  unnecessary   lab  orders,   surveys  were  performed   to  develop   root   cause   analysis   driving   unnecessary  morning   orders.   Educa-onal   interven-ons   targe-ng  residents   involving   large   group   and   small   group  interac-ve   teaching   and   reflec-on   sessions   were  implemented.   This   provided   educa-on   about   the  financial   as   well   as   the   pa-ent   burden   of  unnecessary   labs.   Addi-onally,   residents’   habits   of  rou-nely   ordering   labs   without   necessarily  considering  pa-ent   impact,   treatment   strategy,   and  test  cost  were  addressed.      Our   second   interven-on  was   geared  more   towards  the  a`ending  physicians.  A`ending  physicians  were  encouraged   to   conduct   rounds   dedicated   to  discussing   daily   lab   orders   as   well   as   seang   their  expecta-ons  from  the  residents.    Our   third  and  final   interven-on  was  placing  posters  in   the   work   rooms   on   the   floors   to   remind   interns  and   residents   to   be   mindful   of   their   pa-ents’   best  interests   and   think   about   the   benefits   and   risks  before  ordering  morning  labs.    Interven-ons   were   spaced   about   a   month   apart   in  order   to   gauge   both   the   effects   of   individual  interven-ons,   in   addi-on   to   evalua-ng   the  compounded  effect.  

Daily  labs  are  ordered  rou-nely  everyday  by  residents  out  of  habit.  Few  wait  to  think  about  the  benefit  of  these  labs  and  whether  it  would  have  input  on  the  pa-ent’s  care.  Our  simple  educa-onal  interven-ons  and  reminders  have   had   a   significant   impact   on   reducing   unnecessary   lab   orders.   Our   interven-ons   did   not   seem   to   have   a  cumula-ve   effect;   rather   each   subsequent   interven-on   maintained   the   same   effect   produced   by   the   first  educa-onal  ini-a-ve.  However,  this  effect  was  only  sustainable  for  a  few  weeks  following  the  final  interven-on,  aEer  which  daily  lab  orders  returned  to  our  original  baseline.      

This   suggests   that   subsequent   interven-ons   acted   as   reminders   to   our   ini-al   educa-onal   ini-a-ve,   and   once  reminder  ceased,  residents  returned  back  to  usual  habits.      

We  conclude  that   to  be  able   to  effec-vely   reduce  unnecessary  daily   lab  orders,  con-nuous  reminders  must  be  implemented  following  ini-al  educa-on  about  the  cost  and  poten-al  harm  of  unnecessary  lab  tests.    

Results  

Conclusion  

Excessive   laboratory   tes-ng   contributes   to   the  increasing   cost   of   healthcare   without   enhancing  pa-ent   care.   Studies   have   demonstrated   increased  adverse  outcomes  and  decreased  pa-ent  sa-sfac-on  associated   with   excessive   daily   blood   draws.  Furthermore,   unnecessary   laboratory   tests   may  contribute   to   errors,   lower   pa-ent   sa-sfac-on,  pa-ent   debt   burden,   hospital   acquired   anemia,  physician   informa-on   overload,   ignorance   of   crucial  data,   and   need   for   further   tes-ng   to   follow   up   on  anomalous  or  incidental  results.  

Reducing  Unnecessary  Lab  Orders  on  the  Inpa-ent  General  Internal  Medicine  Service  

Sherif  Aly,  BS;  Faisal  Rahman,  MD;  Alexandra  Wong,  MD;  Mayank  Sardana,  MD;  Tom  Peteet,  MD;  Dane  Miller,  MPH;  Karin  Sloan,  MD;  James  Moses  MD  MPH  

Boston  Medical  Center,  General  Internal  Medicine,  Boston  MA    

Fig.  1:  Number  of  lab  tests  ordered  per  pa)ent  per  day  averaged  over  the  week  for  the  4  inpa)ent  internal  medical  service  teams  

1

1.5

2

2.5

3

3.5

4

1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23

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orde

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Subgroup Center Target

0 0.5

1 1.5

2 2.5

3 3.5

4

1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23

Lab

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Subgroup Center Target

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1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30

Lab

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Week

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Educa-onal  interven-on  

A`ending's  interven-on  

Posters  Posted  

Fig.  2:  Number  of  lab  tests  ordered  per  pa)ent  per  day  averaged  over  the  week  for  internal  medicine  team  2  (the  highest  achieving  team  in  lowering  unnecessary  lab  orders).  

Fig.  3:  Total  number  of  lab  tests  ordered  per  pa)ent  per  day  averaged  over  the  week  and  obtained  from  BMC’s  data  warehouse  for  all  of  the  inpa)ent  general  internal  medicine  service  teams.  

References  

Educa-onal  interven-on  

A`ending's  interven-on  

Posters  Posted  

Educa-onal  interven-on  

A`ending's  interven-on  

Posters  Posted  

Labs Mean

Labs Mean

Labs Mean

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3.  Thavendiranathan,  P.  et  al.  Do  Blood  Tests  Cause  Anemia  in  Hospitalized  Pa-ents?  Journal  of  General  Internal  Medicine  20,  520–524  (2005).