Background: Healthcare costs in the United States are exorbitant and excessive lab utilization contributes significantly1. Daily labs (DL), typically consisting of basic metabolic panels (BMPs) and complete blood counts (CBC) are often over-ordered for hospital inpatients2. This leads to increased costs, limits phlebotomy resources, iatrogenic anemia, patient discomfort and interruption of sleep3. The Choosing Wisely® campaign recommends against checking DL in patients who have clinical and lab stability. Our hospital has two teams which are staffed by a hospitalist and third year internal medicine resident (PGY3). Each serves as the primary caregiver of seven inpatients, with the hospitalist supervising the care of the PGY3’s patients. The aim of our study is to assess the extent to which inappropriate DL and labs on the day of discharge (LOD) are ordered for patients who are ultimately discharged to skilled nursing facilities (SNF) on these services. We additionally aimed to understand any difference in ordering practices for these patients between attending and resident providers.

Methods: This study was conducted at an urban academic tertiary medical center. Only general medicine and cardiology patients from the dates of February 2021-June 2021 were included. Only patients who were discharged to SNFs were included as they contained a population who were typically stable and awaiting delays in placement. Five physicians in the section of hospital medicine all who had rotated on the service, served as reviewers, and assessed when DL and LOD were present. DL was defined as either a BMP, CBC or both present every day of hospitalization. Physician reviewers assessed appropriateness of DL by review of documentation present and lab abnormalities. General adjudication guidelines were agreed upon by reviewers. Inappropriate labs were considered when patients were clinically stable and daily surveillance was not needed and unlikely to change management. Lab utilization appropriateness was compared between attendings and residents. Categorical variables were assessed with chi square and continuous variables with T tests.

Results: A total of 111 encounters met inclusion criteria. 75% (83/111) of the patients had DL and 75% (83/111) had LOD. DL overall were deemed inappropriate in 31% (26/83) of cases, and LOD were deemed to be inappropriate in 39% (32/83) of cases. Among charts reviewed, 64% (70/111) had attendings as the primary provider and 36% (41/111) had residents. Among attending patients, 52/70 (74%) had DL ordered, and 53/70 (76%) had LOD ordered. Among resident patients, 31/40 (77.5%) had DL ordered, and 30/40 (75%) had LOD ordered. Of attending patients with DL, 35% (18/52) were deemed inappropriate, compared to 26% (8/31) of those seen by a resident (p = 0.47). Among those with LOD, 42% (22/53) of attending patients were deemed inappropriate, compared to 33% (10/30) of resident patients (p = 0.49). The overall proportions of lab orders between residents and attendings for both DL and LOD were not statistically significant (Figure 1).

Conclusions: For patients discharged to SNF, use of DL and LOD was high, and deemed inappropriate in up to a third of hospitalizations. Lab utilization remains an area in need of improvement at our institution. Stable patients awaiting discharge are a prime target for intervention towards reduction in overuse. Interestingly, senior residents rotating on with a high degree of autonomy demonstrated similar practice patterns for both DL and LOD.

IMAGE 1: Lab Utilization by Attendings and Residents