Empowering Residents to “Stop. Think. Does My Patient Need Those Labs”

From the 2019 HVPAA National Conference

Dr. Rachna Rawal (Saint Louis University), Dr. Paul Kunnath (Saint Louis University), Mr. Ara Vartanyan (Saint Louis University), Dr. Hala Saad (Saint Louis University), Dr. Alex Lane (Saint Louis University), Dr. Oluwasayo Adeyemo (Mount Sinai Baltimore), Dr. Jennifer Schmidt (Saint Louis University)

Background

The United States is in the midst of a health quality crisis; for this to resolve, we must transform our low-cost healthcare culture to high-value care. To achieve a culture change, trainees must learn high-value care habits. We developed a 127-week longitudinal study to promote mindful laboratory habits in an Internal Medicine residency program.

Objective

1. Promote and sustain mindful laboratory ordering habits in Internal Medicine residents

2. Develop a high-value care culture

Methods

Subjects were Internal Medicine residents and attending physicians rotating on the general Medicine inpatient service. The primary aim was to decrease total laboratory orders (BMP, CMP, CBC with and without differentials) and to promote ordering of more specific laboratory panels. Total duration was 127 weeks; 15 weeks of control, 80 weeks of interventions (divided into five 16-week phases), and 32 weeks assessing sustainability. Each intervention built on the previous and included resident education, electronic medical record changes, interactive case sessions, attending physician education, and night-float resident education. Aggregate data was obtained from the EMR; pre/post surveys assessed culture change. Primary outcomes were total labs ordered, type of laboratory panel, resident attitudes and money saved. Secondary outcomes included assessing trends of 30-day readmission rate, LOS, case-mix index and venipuncture utilization during the project.

Results

Survey data revealed increased resident perception of mindful lab ordering from 40% (32 weeks) to 85% (80 weeks) (statistically significant, p<0.05). Additionally, 85% of residents reported team discussion of laboratory ordering, increasing from 25% (p<0.05). Both perceptions sustained at 127 weeks. 100% of attending physicians reported a perception of decreased laboratory orders on resident teams at 95 weeks. EMR lab frequency utilization data demonstrated a 50% decrease in use of “daily” frequency and 50% increase of “one-time” option (sustained post-intervention) (Figure 1, p<0.05). Figure 2 (p<0.05) shows the number of labs ordered per 1000-patient days. Both BMP and CBC without differentials increased while CMP and CBC with differential decreased. Hepatic panels, a balancing measure, did not significantly change. These lab-ordering patterns sustained in the post-intervention period.

Secondary outcomes demonstrated a downtrend in 30-day readmission rate (1.23 to 1.0), unchanged LOS (1.02-1.0) and uptrend incase-mix index (CMI) (1.36 to 1.94). The percentage of patients on medicine service undergoing venipuncture also decreased by 10% (Figure 3, p<0.05).

Conclusions

We believe we have created and sustained a cultural change toward more mindful laboratory ordering. Residents not only perceive that they are more mindful, they have decreased the number of labs ordered and have changed how they order labs. They have shifted which lab frequency options they use and also order more specific laboratory panels. These changes in laboratory ordering did NOT result in an increased readmission rate or LOS and these new ordering patterns sustained decreased despite a rising CMI. Therefore, we know that the cultural change in laboratory ordering is not secondary to lower acuity patients. Patients benefit directly from the decrease in labs with less undergoing venipuncture. We believe that sustained results at 127 weeks indicates a true culture change within our program.

Clinical Implications

We initiated a grassroots movement in our program that has incited a sustainable high-value care culture through multi-faceted interventions such that our trainees can continue to propel this in their own future practices.

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