Reducing Unnecessary CBCs on the Inpatient Resident Service at the Orlando VA Hospital

From the 2023 HVPA National Conference

Zara Bashir MD (University of Central Florida/HCA Healthcare GME, Orlando, FL), Feras Al-Moussally MD, Jorge Rodriguez MD, Ashlee Sidhu MD, Brian Murr MD, Liliana Franco MD, Jorge Restrepo DO, Ashwini Komarla MD

Background:
Physicians-in-training are important contributors to the burden of tests ordered, and it is acknowledged that this stems from a variety of factors, including a focus on reaching a definitive diagnosis regardless of care value, the practice of defensive medicine, which deviates from recommended medical practice to protect from litigations, and ignorance of the financial costs associated with testing. Currently on the inpatient service at the Orlando VA Healthcare System, there are complete blood counts (CBC) being drawn daily which are not clinically indicated. This increases costs and use of hospital resources, causes hospital acquired anemia, and impacts the patient experience. The relevance of this study remains universal among all healthcare systems, especially in teaching hospitals in which young doctors may not realize redundancy and harms of lab ordering. This project has been replicated at multiple institutions and is part of the SHM Choosing Wisely Campaign.

Objective:
We aimed to reduce the number of daily CBCs ordered that are not clinically indicated on the resident teaching service at the Orlando VA Health Care System to 25 % by 4/15/23. (From baseline of 41%) . We also wanted to to reduce the ratio of non-indicated CBCs/ day LOS by 0.2.

Methods:
Our team reached out to attendings who rotate on the teaching service to conduct interviews to identify reasons and elicit discussion regarding unnecessary repetitive CBC orders. Interviews were scheduled based on availability. Eight of nine attendings responded. We also surveyed Internal Medicine residents using an online survey sent to all residents in our program about their ordering habits and reasons for ordering daily labs. 

Results:
Based on our current in-progress data collection, on average patients have 6.6 CBCs ordered per admission. Our resident survey response rate was 66%. More than half of the residents indicated that they order daily labs “most of the time.” The two most common reasons were thinking that the attending wants it or not being sure if it was needed so the desire to be on the safe side.

Conclusions:
Based on the responses we have gathered through the questionnaire, attending physicians do not have the expectation for a daily lab value to be present for stable patients. There appears to be a discord between what is perceived to be the expectation from attending physicians and what the expectations truly are. Addressing this discord through different interventions such as lectures and reminders, as well as facilitating discussion between attendings and trainees, will be an important aspect to facilitate safe and high-quality medicine.

Clinical Implications:
Further work is needed to educate residents on the indications for CBC orders and to take time to consider them when on service. Our findings suggest a discord between attending physicians’ expectations and resident physicians’ beliefs.

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