BEDSIDE ASSESSMENT OF THE NECESSITY OF DAILY LAB TESTING FOR PATIENTS NEARING DISCHARGE

Purpose : While no clear criteria or guidelines exist to define clinical stability in the context of lab utilization, we argue that patients planned for discharge within 24-48 hours are clinically stable and less likely to need lab testing. Using this framework, we implemented a multifaceted, patient-centered initiative—the Necessity of Labs Assessed Bedside Initiative (NO LABS)—that focuses on reducing lab testing in patients 24-48 hours before discharge. 

Description : We targeted two inpatient hospitalist units. Both employed bedside, patient-centered interdisciplinary rounds (with the hospitalist, social worker, case manager, nurse, nurse manager, and medical director), and followed a script highlighting the daily plan and patient safety issues. We incorporated a prompt to identify clinically stable patients for next-day discharge, and to consider discontinuing labs when appropriate. This intervention was coupled with education and a robust awareness campaign targeting reduction in unnecessary lab testing. In the 2,877 discharges included (baseline June 2014-June 2015; post-intervention July 2015-July 2016) there was a significant decrease in the percentage of patients with lab orders 24 hours prior to discharge (baseline mean 56.2%; post-intervention mean 44.4%). A similar trend was seen for labs ordered 48 hours prior to discharge (77.8% vs. 69.7%). This corresponded with a significantly decreasing trend in the percentage of patients getting labs in the 24, 48 and 72 hours before discharge after the intervention (-1.87%, -1.47%, and -0.74% decrease per month, respectively; P<0.05; Figure). 

Conclusions : Our patient-centered, multifaceted approach effectively reduced unnecessary daily labs. Bedside rounding and the emphasis on discontinuing lab testing provided a unique opportunity to effectively communicate to the patient about necessary (or unnecessary) testing. Moreover, given the complexity of identifying clinical stability, our strategy focused on the onset of discharge planning, a more easily discernible and less obtrusive focal point to consider discontinuation of lab testing. We believe that our structured, multidimensional, patient-centered intervention can provide a strong framework for decreasing unnecessary testing beyond the last 48 hours of admission.