From the 2019 HVPAA National Conference
Dr. Natalie Tapaskar (University of Chicago), Ms. Megha Kilaru (University of Chicago), Dr. Tipu Puri (University of Chicago), Mr. Edward Leung (Children’s Hospital Los Angeles), Ms. Farah Ahmed (University of Chicago), Ms. Allison Norenberg (University of Chicago), Ms. Eve Estrom (University of Chicago), Dr. Elizabeth Poli (University of Chicago), Dr. Shannon Martin (University of Chicago), Dr. Vineet Arora (University of Chicago)
Background
Excessive daily routine laboratory testing for hospitalized patients is a contributor to poor hospital sleep, iatrogenic anemia, and excessive costs. Recommendations from the Choosing Wisely™ campaign specifically state to avoid sleep interruptions for routine care and to avoid routine labs for stable patients.
Objectives
The purpose of this resident-led initiative was to reduce indefinitely recurring daily labs in clinically stable patients and promote sleep-friendly ordering.
Methods
Using the COST (Culture, Oversight, Systems, Training) framework of value improvement, the Order S.M.A.R.T.T. (Sleep: Making Appropriate Reductions in Testing and Timing) campaign was launched at UChicago Medicine in March 2018. The committee included a multi-disciplinary panel of representatives. A baseline survey assessed attitudes towards phlebotomy (Culture) and was used to inform the creation of a q48h 6AM phlebotomy option to “step down” from daily labs. We created two electronic medical record (System) interventions: 1) “Order Sleep” phlebotomy shortcut which provided 3 sleep-friendly options: 6 AM draw, 6 AM q48 hours draw, 10 PM draw and 2) A “4 AM Labs” icon on the patient lists to passively nudge providers that 4 AM labs were ordered. Training included lectures to Internal Medicine residents and Hospitalists. A single interrupted time series analysis was used to determine the changes in ordering practices (labs per patient per day) of sleep-friendly labs post-intervention while controlling for pre-intervention secular trends.
Results
Using a 6 month-time window, there was a significant decrease in mean labs ordered per month post-intervention versus pre-intervention (754.1 vs 977; p=0.0017). The Order Sleep tool was associated with a significant increase in sleep-friendly lab orders per patient encounter per week at the launch (0.49, p=0.001) with a significant continuous upward trend towards the 4 AM labs column launch which was associated with a significant increase in sleep-friendly lab orders per encounter per week (0.32, p=0.017). Figure 1. At baseline, hospitalist services were more likely to order sleep-friendly labs than general medicine resident services (1.26, p<0.001). The Order Sleep tool was associated with a significant increase in sleep friendly lab orders per patient encounter per week at the launch (1.03, p=0.0009) on the resident services, but with a significant decrease over time in each period afterwards (-0.100, p=0.02). There was no change found with sleep friendly orders on the hospitalist service. The 4 AM labs column was associated with a significant increase in sleep friendly lab orders per patient encounter per week at the launch for the hospitalist service (1.17, p=0.02) and an increase over time in the subsequent periods (0.11, p=0.01). The resident service also saw an increase in sleep-friendly orders per encounter over time in the subsequent periods following launch of the 4 AM Labs column (0.11, p=0.01) Figure 2.
Conclusion
An initiative using the COST value improvement framework can reduce daily labs while improving sleep-friendly ordering via an educational campaign and novel EMR tools on hospitalist and resident general medicine services.
Clinical Implications
This initiative served to reduce unnecessary and potentially harmful excessive laboratory testing on patients as well as promote sleep-friendly practices in the in-patient setting.
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