Background: Inappropriate laboratory utilization in hospitalized patients is a significant contributing factor to health care expenditures, iatrogenic anemia, downstream testing, and poor patient satisfaction. For these reasons, the Society of Hospital Medicine has recommended through the Choosing Wisely Campaign to avoid repetitive complete blood counts (CBC) and chemistry testing in the face of clinical stability. Nationally, attempts to reduce over-testing have been addressed by academic and community institutions with varying success. We endeavored to better understand our institution’s ordering practices and attitudes surrounding routine CBCs, and to implement a brief pilot intervention aimed at decreasing inappropriate inpatient CBC ordering.
Methods: A retrospective six-month review of CBC ordering data at an academic medical center was performed for general medicine inpatient services between March and August 2016. To assess attitudes towards laboratory practices, a survey was electronically distributed to all Internal Medicine residents (n=134) and Medicine-Pediatrics residents (n=32). Concurrently, four resident general medicine inpatient teams (3 residents per team) were instructed to review daily CBC orders for all patients once daily for a seven-day period. Two signs were posted in each team room and each team member was paged daily to review the need for CBC orders. The number of CBCs per patient-day was calculated and compared to baseline data from 6-month review period.
Results: Analysis of baseline data demonstrated 1.37 CBCs per patient-day on the resident teams. During the intervention period, this decreased to 0.82 CBCs per patient-day (p = 0.01) as illustrated in Figure 1.
Survey response rate was 37% (61/167). The data revealed that residents did not perceive daily CBCs to substantially impact patient care, however most residents did order daily CBCs for their patients. Common reasons that residents ordered daily CBCs included attending preference (46%), clinical uncertainty (43%), and ease of ordering (64%). During the intervention, there were no perceived adverse events related to decreased CBC ordering. A variety of potential solutions were proposed for reducing inappropriate CBC ordering as detailed in Figure 2.
Conclusions: We demonstrated that routine ordering of daily CBCs is prevalent in our academic medical center and was driven by culture practice and expedience. While our intervention showed promise, further improvement in “routine daily lab” ordering practices will likely require education, ongoing feedback and clinical decision support (CDS) within the electronic medical record. Future directions include utilization of CDS and expanding this investigation to include other laboratory studies and clinical settings (e.g. ICUs).
