Background: Tests Pending at Discharge (TPAD) is a common patient safety concern at transitions of care due to provider discontinuity, suboptimal communication, and lack of ownership. A significant proportion of inpatients, up to 70%, are discharged with one or more TPAD. Recent studies show that 30-40% of resulted TPAD warrant a change in patient management. There is debate who is responsible for these test results; some argue primary care providers should assume responsibility, while others assign responsibility to the provider who ordered the test.
There is a similar issue for TPAD from the emergency department (ED). We are specifically interested in transition of care from ED to inpatient care and improving TPAD management within this population. Because the test result is not available at time of verbal report, it is often overlooked entirely, and patient care could be delayed or compromised because of unnoticed result.
Purpose: This project aims to create a systems solution to transitions of care through methodical TPAD evaluation and facilitation of care plans. Instead of relying on an uncertain hand-off, our project provides a process to provide timely TPAD clinical review and ensure safe care transitions. We strive to minimize the patient safety risks associated with tests at care transitions through an organized follow-up process.
Description: An electronic medical record query was created to isolate all abnormal test results which were ordered in the ED and resulted after the ED stay. The query was refined to isolate only test results which were likely to be influential to patient management or typically not repeated during admission. The TPADs are regularly reviewed by an acute care provider who by considering patient specific context determines if the test is significant or not. Significant tests are further acted upon by either paging inpatient team, paging PCP, or communicating via in-chart messaging. Test result is handed off with current recommendations for care management as appropriate.
Conclusions: During our five-month pilot phase (6/14/18 – 11/13/18), 580 tests pending at ED discharge met criteria be included in the query; 154 results (26%) were on admitted patients. Focusing only on patients transitioning from ED to inpatient care (n=154), 78 (51%) required no action (i.e. patient baseline, known diagnosis or trivial result). The remaining 76 (49%) were considered likely to influence care, thus requiring direct communication with current provider.
We believe that a coordinated process to TPAD follow-up facilitates improved transition of care from ED to inpatient care by ensuring timely review and direct hand-off of test results. Future directions include implementing a similar process for TPAD on transition from inpatient setting to outpatient care.