From the 2018 HVPAA National Conference
Raj Amin (Johns Hopkins School of Medicine), Erik Hasenboehler (Johns Hopkins School of Medicine), Adam Levin (Johns Hopkins School of Medicine), Greg Osgood (Johns Hopkins School of Medicine), Robert Sterling (Johns Hopkins School of Medicine), Steven Frank (Johns Hopkins School of Medicine), Peter Pronovost (UnitedHealthcare), Babar Shafiq (Johns Hopkins School of Medicine)
Daily laboratory testing is one of the five most overused tests in hospitalized medical care. Despite 8 of the top 15 operating room procedures with inpatient stays involving the musculoskeletal system, a campaign which prospectively implements, and evaluates, limited laboratory testing has not been performed in any orthopaedic surgery population.
We report the outcomes of a resident-led initiative aimed at appropriate laboratory test utilization in orthopaedic trauma surgery patients.
Over an 8-month period, a restrictive laboratory testing protocol (one CBC and BMP on postoperative day 2) was evaluated. Patients presenting with operative fractures (including or below the elbow and knee) at two trauma centers within our hospital system were included. The campaign was designed utilizing the four-pronged preventable harm framework of intervention, and a prospective quality improvement registry was kept for all patients. Post-operative outcomes recorded included: number/timing of CBC/BMP, length of stay, transfusion status, in-hospital major organ system morbidity, mortality, and 30-day same-hospital unplanned readmission for any etiology. Patients were compared in three groups: protocol compliant, protocol noncompliant due to provider error, and protocol noncompliant due to medical necessity. All statistical analyses were performed using JMP version 12.1.0 software (SAS Institute, Cary, NC).
182 patients met inclusion criteria, of which 82% successfully received their first set of post-operative laboratory testing on POD 2 (protocol compliant patients). Of the patients who had POD 1 testing (protocol noncompliant patients), 45% were due to provider error, and 55% were due to medical necessity. Those patients had POD 1 testing due to medical need were significantly older (45y v. 38y. v. 63y, p=0.0002), and had a higher comorbidity burden as measured by ASA score (2.2 v. 2.1 v. 2.8, p<0.0001) compared to protocol compliant patients and those excluded due to provider error. There was no difference between the three groups with respect to fracture morphology. 49% of patients were treated for high-severity tibia fractures.
There was a 70% reduction in the use of CBC or BMP testing. A total of 572 CBCs or BMPs were avoided (Figure 1). There was also strong physician adherence as the number of provider errors sharply declined during the intervention (Figure 2). In each of the final four months, the number of patients excluded due to provider error was <5%. There were eight all-cause 30-day complications and six unexpected 30-day readmissions amongst all 182 patients. None of the 30-day complications in the protocol compliant patients were attributable to less frequent laboratory testing.
To our knowledge, our house-staff led choosing wisely initiative is the first to prospectively implement a restrictive laboratory ordering protocol in orthopaedic surgery. We demonstrate that reduction of daily laboratory tests in select orthopaedic trauma surgery patients reduces daily laboratory testing by 70% while resulting in no attributable 30-day adverse outcomes. Given that trauma patients are amongst the least pre-operatively optimized orthopaedic surgery patients, our initiative suggests that other surgical subspecialties (including non-trauma orthopaedics) may also be able to reduce the need for daily laboratory testing in their patient populations.
Implications for the Patient
The practice of unnecessary daily laboratory testing is associated with patient harm including technical errors, pain, and phlebotomy-associated anemia, and substantial resource utilization. Our initiative improved the quality of patient care by reducing the underlying cause of the aforementioned harms.