Background: The Society of Hospital Medicine and the ABIM Foundation‘s Choosing Wisely Campaign have made tackling overutilization of routine labs part of their mission. Based on the literature, 30-50% of routine labs ordered for hospitalized patients every morning may be unnecessary. Aside from pain, discomfort and sleep disturbance, these daily labs predispose patients to iatrogenic anemia. Furthermore, incidental findings may lead to unnecessary downstream testing and waste of nursing and phlebotomy time – all of which comes to a financial loss for the hospital and patients. The aim of our project was to decrease overutilization of daily CBCs, BMPs and CMPs in a 36-bed teaching medicine unit.
Methods: We implemented a bundled intervention to decrease unnecessary lab ordering. Our educational and local publicity campaign included a presentation at each intern/resident block orientation as well as placing educational posters on the unit. These posters featured pictures of senior faculty encouraging housestaff to ‘THINK before you order’; the letters of mnemonic ‘THINK’ spelling out common indications for CBC and chemistry testing. “Does this patient need daily labs?” was added to the patient safety checklist that hospitalist teaching teams use during daily attending rounds. Interns were encouraged to discuss the need for continued daily labs for each of their patients during these rounds. To gamify this process for housestaff, we sent biweekly group emails with a scorecard based on their number of lab orders and announced the winner. Finally, we also developed a nursing driven pathway to decrease routine lab tests on patient’s day of discharge and to decrease ordering of recurring consecutive lab orders for multiple days in a row (Figure 1).
Results: 7-months of pre-intervention baseline data (August 2015-February 2016) was compared with 7-months of post-intervention data (March 2016-September 2016). We used Mann-Whitney-test for statistical analysis. All lab tests were normalized per-patient-day (Figure 2). Compared to baseline data, there was 6.44% (p = 0.026) decrease in total number of labs (CBCs, BMPs, CMPs) and 8.32% (p = 0.002) decrease in CBCs. Chemistry testing deceased by 2.88% (p=0.209) however it was not significant. Lab tests that were part of a recurring order (> 3 consecutive labs on the same order) also decreased by 13.59% (p = 0.018).
Conclusions: Our multidisciplinary bundled intervention with education, local publicity, gamification and nurse driven pathway has demonstrated success in reducing unnecessary daily labs.
