Background: The ordering of unnecessary daily labs affects the safety of patients through hospital-acquired anemia, patient discomfort, and unnecessary downstream testing. This results in both additional financial and labor costs burdening the health system. As such, establishing effective interventions is warranted with necessary analysis of site-specific lab-ordering culture. We seek to perform this analysis to develop a sustainable quality improvement intervention that can both optimize lab ordering culture and improve patient care.
Methods: We used mixed methods to assess lab ordering behaviors and attitudes at Mount Sinai Hospital. We gathered data from the EHR on the number of daily labs (BMP, CMP, and CBC) performed on a general teaching medicine floor. In order to assess cross-professional beliefs and attitudes on daily lab testing as baseline for an Institute for Healthcare Improvement model, we surveyed attendings, resident physicians, physician assistants (PA), nurse practitioners (NP), registered nurses (RN), and patient care associates (PCA) on their beliefs on daily lab testing.
Results: An average of 2.2 labs were collected per patient day from June to October 2020, representing an increase over the previously found 1.3 labs per patient day found in a similar patient population at MSH from March 2016 to August 2017. 127 survey responses were received from 29 (22.8%) attending physicians, 43 (33.9%) resident physicians and fellows, 12 (9.4%) PAs, 10 (7.9%) NPs, 14 (11.0%) RNs, and 19 (15%) PCAs. Of the 94 respondents with ordering privileges (MD, DO, PA, NP), only 18% agreed that daily labs were necessary while 73% thought they were unnecessary. None of the attending physicians agreed daily lab testing was necessary, in contrast to 10% of NPs, 33% of PAs and 25% of residents. Only 29% of ordering providers agreed that daily testing improved patient care and safety; moreover, 89% believe it has potential harms. Of the residents, NP, and PAs, 68% cited worry over attending reaction and 97% cited training/habit as a reason for unnecessary labs. With regards to the non-ordering staff, a high percentage of RNs/PCAs agreed that daily labs improved patient care, 71.4% and 57.9% respectively.
Conclusions: Analysis of previously conducted interventions on unnecessary lab testing has demonstrated a strong need for sustainable interventions to improve patient care and reduce systemic costs. While most respondents agreed on the potential harms of daily labs over benefits, this multidisciplinary robust survey highlights a major discrepancy between attendings and other ordering providers on the necessity of daily tests. These results reveal the potential impact of planned PDSA (plan-do-study-act) cycle interventions including educational sessions, the initiation of monthly audit and feedback email, and attending-led rounding discussions on necessary labs.