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Mindfulness-Based Laboratory Reduction: Reducing Utilization Through Trainee-Led Daily ‘Time Outs’

  • Author Footnotes
    1 For the purposes of authorship, EGM and RRS share credit as first named author.
    Emily G. McDonald
    Correspondence
    Requests for reprints should be addressed to Emily G. McDonald, MD, MSc, Royal Victoria Hospital, 1001 Boulevard Decarie D5.5842, Montreal, QC H4A 3J1, Canada.
    Footnotes
    1 For the purposes of authorship, EGM and RRS share credit as first named author.
    Affiliations
    Department of Medicine, McGill University, Montreal, Quebec, Canada

    Clinical Practice Assessment Unit, McGill University Health Centre, Montreal, Quebec, Canada
    Search for articles by this author
  • Author Footnotes
    1 For the purposes of authorship, EGM and RRS share credit as first named author.
    Ramy R. Saleh
    Footnotes
    1 For the purposes of authorship, EGM and RRS share credit as first named author.
    Affiliations
    Department of Medicine, McGill University, Montreal, Quebec, Canada
    Search for articles by this author
  • Todd C. Lee
    Affiliations
    Department of Medicine, McGill University, Montreal, Quebec, Canada

    Clinical Practice Assessment Unit, McGill University Health Centre, Montreal, Quebec, Canada
    Search for articles by this author
  • Author Footnotes
    1 For the purposes of authorship, EGM and RRS share credit as first named author.
Published:February 01, 2017DOI:https://doi.org/10.1016/j.amjmed.2017.01.011

      Abstract

      Background

      Overuse of laboratory investigations is widely prevalent in hospitalized patients, leads to discomfort, and increases direct and indirect costs.

      Objective

      We implemented a simple, inexpensive, mindfulness strategy on our inpatient medical clinical teaching unit to reduce unnecessary laboratory orders through education, a forcing function, and daily structured laboratory “time outs.”

      Methods

      On a 26-bed unit in an academic hospital center, the per-period laboratory costs per patient were compared pre- and postintervention using segmented regression analysis of an interrupted time series.

      Results

      The average cost per admitted patient decreased from $117 to $66, with an estimated savings of $50,657 over 985 admissions. After adjusting for fiscal period and the presence of our intervention, there was a significant reduction in the per-patient number of total tests, complete blood counts, and electrolyte panels performed (P <.001 for all level and time trend changes).

      Conclusion

      This trainee-designed and -led intervention, centered around structured, mindfulness-based laboratory test ordering, was successful at decreasing the overuse of common daily blood work in hospitalized patients.

      Keywords

      Clinical Significance
      • Overuse of routine laboratory tests in hospitalized patients is common, but seldom impacts clinical practice significantly.
      • Daily blood work can lead to patient discomfort in addition to increased direct and indirect costs, investigative cascades, and inefficient care.
      • In being medically mindful, combining education with regular “time outs,” the physician removes themselves from “autopilot,” and specific thought is applied to an area of overuse in need of focused attention.
      The systematic overuse of laboratory investigations in hospitalized patients has been decried for over 2 decades.
      • van Walraven C.
      • Naylor C.D.
      Do we know what inappropriate laboratory utilization is? A systematic review of laboratory clinical audits.
      Drivers of overuse vary across and between institutions, physicians, and levels of training, and may include uncertainty of the diagnosis, lack of experience, adherence to hospital protocol or established routines, and lack of attention to, or knowledge of, associated costs.
      • Nardella A.
      • Farrell M.
      • Pechet L.
      • Snyder L.M.
      Continuous improvement, quality control, and cost containment in clinical laboratory testing. Enhancement of physicians' laboratory-ordering practices.
      • Bloomgarden Z.
      • Sidel V.W.
      Evaluation of utilization of laboratory tests in a hospital emergency room.
      Indiscriminate testing reduces the quality of patient care through increased patient discomfort,
      • Detsky A.S.
      • Krumholz H.M.
      Reducing the trauma of hospitalization.
      direct and indirect costs of care (test tubes, phlebotomy, and analysis time), creating a “needle in haystack” phenomenon where important results are buried amongst the unimportant, generating false-positive results with associated diagnostic cascades, and contributing to hospital-acquired anemia.
      • Thavendiranathan P.
      • Bagai A.
      • Ebidia A.
      • Detsky A.S.
      • Choudhry N.K.
      Do blood tests cause anemia in hospitalized patients? The effect of diagnostic phlebotomy on hemoglobin and hematocrit levels.
      Routine repeated testing, particularly for common tests such as the complete blood count, is seldom helpful in clinical management.
      • Rajkomar A.
      • McCulloch C.E.
      • Fang M.C.
      Low diagnostic utility of rechecking hemoglobins within 24 hours in hospitalized patients.
      For these reasons, several professional societies recommend the avoidance of routine laboratories in stable patients.
      Choosing Wisely CanadaCanadian Society of Internal Medicine
      Internal medicine: five things physicians and patients should question.
      This trainee-designed and -led initiative sought to translate such recommendations into action by implementing and evaluating a simple strategy on our inpatient clinical teaching units designed to reduce unnecessary laboratory testing.

      Methods

      Study Population

      The intervention was conducted on our 26-bed medical clinical teaching unit at the Royal Victoria Hospital in Montreal, Quebec (517 total beds). This unit has an established culture of quality improvement, with twice-monthly dedicated academic rounds attended by the ward team.

      Intervention and Implementation Data Sources

      At baseline, doctors would write admission orders for daily blood tests, as was the prevailing culture. Orders were written on paper and transcribed into the computer by administrative personnel. The computer system did not have a forced end date; once ordered, daily laboratories would continue without any formal oversight, in perpetuity, unless specifically cancelled. Individual workarounds to avoid over-testing were put in place by some teams but were not systematic or formalized.
      Spurred by the absence of a viable technological solution, 2 residents and one faculty member developed the concept of “mindfulness based laboratory reduction.” Regular physician education was combined with a forcing function, and a change in ordering culture was encouraged. Firstly, at monthly quality improvement rounds, a simple resident-led curriculum (Appendix, available online) addressed the potential harms of over testing and outlined the intervention. Secondly, the ability to order daily laboratories beyond 2 days was removed, by implementing a unit policy universally applied at the level of transcription into the computer. Finally, daily afternoon sign-out was modified to include a “time out” briefly addressing any required laboratory testing for the following day. Junior residents and medical students would propose tests to the senior residents and faculty who would, in turn, discuss both value and necessity. Orders for the next day were recorded by the senior resident and submitted as a batch order for transcription into the computer. Emergency laboratory tests and those requiring advanced scheduling (ie, therapeutic drug monitoring) were not subject to these restrictions.

      Data Sources

      A complete list of laboratory tests processed from our unit was available for 2 years prior to and 1 year after the intervention. Data were grouped by fiscal period and attending physician. Costs for each test were estimated based on provincial insurance reimbursement values (in Canadian dollars). Costs did not include the collection tubes or the labor required to collect and transport the blood. The number of admissions, deaths, length of stay, and intensive care transfers per fiscal period were obtained from admitting records.

      Statistical Methods

      The per-period laboratory costs per patient were compared pre- and postintervention using segmented regression analysis of an interrupted time-series as previously described.
      • McDonald E.G.
      • Jones J.
      • Green L.
      • Jayaraman D.
      • Lee T.C.
      Reduction of inappropriate exit prescriptions for proton pump inhibitors: a before-after study using education paired with a web-based quality-improvement tool.
      Estimated savings were calculated by comparing actual costs postintervention with those predicted if we assumed no change from the preintervention average.
      To evaluate for potential safety signals, the proportion of admitted patients who died on the unit was compared pre- and postintervention using chi-squared. Before-and-after comparisons in the length of stay and monthly number of intensive care unit transfers used the Wilcoxon rank-sum test.
      All comparisons were performed by using Stata version 13 (StataCorp LLP, College Station, Texas).

      Role of the Funding Source

      This project was completed without any internal or external funding.

      Ethics

      The McGill University Health Centre Research Ethics Board approved this study.

      Results

      The total, per-period, and per-admission laboratory costs are shown in Table 1. Crudely, the average cost per admitted patient decreased from $117 to $66, with an estimated savings based on 985 admissions of $50,657. In the time series analysis, after adjusting for fiscal period and the presence of our intervention, there was a significant reduction in the overall number of per-patient tests, complete blood counts, and electrolyte panels (Figures 1 and 2; P <.001 for all level and time trend changes).
      Table 1Comparison Pre- and Postintervention
      Total Cost ($)Per-Period Average Cost ($)No. AdmissionsPer-Admission Average Cost ($)
      Preintervention (25 Periods)
       154,55061691326117
      Postintervention (14 Periods)
       64,588448998566
      Figure thumbnail gr1
      Figure 1Average number of tests per patient by fiscal period.
      Figure thumbnail gr2
      Figure 2Average number of complete blood count and chemistry panels per patient by fiscal period. CBC = complete blood count.
      When attending physicians were compared, all of those who worked both prior to and following the intervention demonstrated a decrease in the number of tests performed per patient and in associated per-patient costs (Table 2), culminating in an average 32% reduction in per-patient cost. Moreover, the variability between the attending physicians with the lowest and highest per-patient costs was reduced from $50.05 to $17.73.
      Table 2Laboratory Utilization and Associated Costs by Attending Physician and Intervention Status
      Change was calculated as the proportion of reduction from preintervention cost per patient.
      AttendingPreintervention (25 Months)Postintervention (14 Months)Change (%)
      CostTestsPatientsCost Per Patient ($)Tests Per PatientCostTestsPatientsCost Per Patient ($)Tests Per Patient
      A12,748489713495.1336.5426315278152.6218.945
      B21,039818425781.8631.8375123846.8815.443
      C13,202481417575.4427.5539517819954.5018.028
      D9357352212972.5327.3330410686253.2917.227
      E20,737809328872.0028.18414276415454.6417.924
      F354814045169.5627.5427714799047.5216.432
      G13,180518219467.9426.73754126710037.5412.745
      H9488364014465.8925.3507315469155.7517.015
      I291610754663.3923.4
      J11,573455219260.2823.7
      K10,574384418357.7821.05032167711344.5314.823
      M287010745255.1920.7
      N12,932485623754.5620.513,425454734738.6913.129
      O20938194151.0420.07175246716044.8515.412
      P20618224446.8518.720916735538.0212.219
      Q271710676045.2817.820117044841.8914.77
      R351612777845.0816.4
      Summary154,55059,122230567.0525.664,54421,623140745.8715.432
      Change was calculated as the proportion of reduction from preintervention cost per patient.
      Length of stay decreased during the intervention to a median of 5 days (interquartile range 3-11) from 7 (interquartile range 3-13) days (P <.001). There was no difference in the median number of intensive care unit transfers per month (2 vs 2, P = .78). In-patient mortality decreased from 10.5% to 7.2% (P = .007).

      Discussion

      Providing tertiary care has become increasingly complex, and the pressure for residents to accomplish multiple competing tasks throughout the day has likely influenced routine ordering practices on the clinical teaching unit. The concept of mindfulness involves removing oneself from autopilot; the pairing of regular education sessions with periodically mandated reassessment of tests or medications is a type of “medical mindfulness,” which successfully cultivated attention directed at an area of frequent overuse on our unit.
      We demonstrated that a trainee-designed and -led intervention consisting of resident physician education, a forcing function preventing routine daily labs, and a systematically employed “time out” to review each patient's need for daily laboratory testing was effective at reducing cost without adversely impacting length of stay, inpatient critical care utilization, or in-hospital mortality. Change was immediate and sustained over the calendar year. The practice of all attending physicians benefitted, even those who were already conscious of over-testing. Importantly, this system built upon existing infrastructure, and at no incremental financial cost, saved an estimated $50,657 in direct laboratory costs on a 26-bed unit.
      Limitations include the involvement of one clinical teaching unit at a single Canadian academic center. Such a system may not be feasible in the absence of daily team sign-out, where issues of laboratory testing can be efficiently reviewed. Additionally, it may be less practical in a system where order entry practices preclude ordering during the daily sign-out. While we demonstrated an effect lasting over a year, long-term sustainability will remain a challenge. Encouragingly, similar interventions at our center combining monthly education with the use of structured “time outs” to reassess processes of care, have been successful in reducing Foley and central venous catheters,
      • Schwartz B.C.
      • Frenette C.
      • Lee T.C.
      • Green L.
      • Jayaraman D.
      Novel low-resource intervention reduces urinary catheter use and associated urinary tract infections: role of outcome measure bias?.
      • McDonald E.G.
      • Lee T.C.
      Reduction of central venous catheter use in medical inpatients through regular physician audits using an online tool.
      proton pump inhibitors,
      • McDonald E.G.
      • Jones J.
      • Green L.
      • Jayaraman D.
      • Lee T.C.
      Reduction of inappropriate exit prescriptions for proton pump inhibitors: a before-after study using education paired with a web-based quality-improvement tool.
      and antibiotic use.
      • Lee T.C.
      • Frenette C.
      • Jayaraman D.
      • Green L.
      • Pilote L.
      Antibiotic self-stewardship: trainee-led structured antibiotic time-outs to improve antimicrobial use.

      Conclusion

      We reduced routine laboratory testing on our clinical teaching unit using daily structured laboratory “time outs.” Fewer blood draws translate to less patient discomfort and increased efficiency of phlebotomists, nurses, and physicians. Laboratory timeouts lend themselves well to a changing culture toward a more mindful medical practice, addressing many of the drivers of test overuse for hospitalized patients. This is the type of inexpensive focused intervention that is fundamental to moving incrementally toward a higher-value health care system.

      Acknowledgment

      We are especially grateful to George Christodoulou for his help in designing the intervention. We would like to thank the McGill University Health Centre's Department of Quality, Patient Safety & Performance for providing the laboratory data. We also thank all faculty and residents who participated in the project, made it a success, and took it to other units.

      Supplementary Data

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