Do Non-Teaching Services Order Labs Mindfully?

From the 2018 HVPAA National Conference

Rachna Rawal (St. Louis University), Paul Kunnath (St. Louis University), Oluwasayo Adeyemo (St. Louis University), Hala Saad (St. Louis University), Ara Vartanyan (St. Louis University), Jennifer Schmidt (St. Louis University)

Background

A project on high-value lab ordering targeting residents prompted a look at the on-teaching services staffed by the same attending physicians. Did the high-value care education for our teaching teams influenced their ordering habits when on the non-teaching service?

Objectives

  1. Assess lab ordering habits of non-teaching Medicine service
  2. Determine leakage from resident QI project to non-teaching service
  3. Compare teaching and non-teaching Medicine team ordering practices

Methods

Participants were General Internal Medicine physicians attending on the non-teaching and teaching inpatient medicine service. Data collected from the electronic medical record (EMR) included labs ordered (CBC without differential, CBC with differential, BMP, CMP) and patient census. Pre and post-project surveys created by the project team assessed current lab ordering practices and barriers to cost-conscious care. Initial interventions occurred over 48 weeks and were targeted to residents on the Medicine teaching services. Interventions included high-value care education, new ordering lab frequencies in the EMR, and alterations to the Medicine admission order set. For the final 16 weeks, an attending physician project champion sent additional emails to teaching service attending physicians, and a member from our project team attended the monthly Medicine attending meetings. Data analysis looked at lab ordering overall as well as frequency of BMP vs CMP and CBC with differential vs CBC without differential.

Results

Of all CBC orders, the percentage of CBC without differentials increased from 5% to 30% over 48 weeks (Figure 1, statistically significant p<0.05). Additionally, of all metabolic panel orders, the percentage of BMPs increased from 58% to 69% (Figure 2). Overall, total labs decreased by 13% over 48 weeks (statistically significant p<0.05).

Surveys assessing knowledge of lab costs revealed that 55% of all attending physicians were aware of the costs of the labs.  Survey data showed that 83% of the attendings feel that they order labs mindfully on the non-teaching services and 92% believe that the project has influenced their ordering behaviors. 67% report using the new EMR lab frequency options (ex. MWF, TThS) instead of the “daily” option.

Conclusion

While our project was initially focused only our residents, its effects have been wider reaching. Residents received the initial educational interventions and EMR education, however the culture of mindful lab ordering has spread to the non-teaching services. We attribute this to increased resident awareness of high-value care on the teaching teams. We believe this change has continued to impact ordering practices when the attendings rotate on to the non-teaching service. The increased percentage of BMP and CBC without differential show a shift toward more specific lab panels. We believe that over time the culture will continue to shift toward high-value care.

Implications for the Patient

While our initial project was focused on promotion of mindful lab ordering on teaching teams, its effects have spread to the non-teaching Medicine service. This unintentional leakage demonstrates a true cultural shift toward high-value patient care.

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