In an era where the cost of healthcare in the United States is rising at an unsustainable rate, promoting high value care has never been more important. As highlighted by the Society of Hospital Medicine Choosing Wisely Campaign, routine inpatient lab draws, in the setting of clinical stability can lead to adverse health consequences and significantly contribute to unnecessary healthcare expenditure. As electronic medical records (EMR) are quickly becoming the standard format, order sets are increasingly being utilized to standardize practices, facilitate care, and increase efficiency. Admission order sets used for all inpatient admissions at our facility tend to default to routine daily blood work. We aim to evaluate the impact of modifying this order set on the frequency of lab orders and its potential impact on patient outcomes.
The admission order set was modified so that orders for routine blood work automatically stopped after 2 days of inpatient care prompting the provider to re-evaluate and order further blood work as needed. Labs that were part of the order set included CBC, CMP, BMP, Mg, Phos, PTT, and PT/INR. Residents were educated about the new order set and rationale behind it in a 30-minute educational session that preceded its implementation in February 2015. Our control group was patients admitted to two Internal Medicine resident services between January 1st and 31st. Patients admitted between February 16 and March 19th to the same services constituted the experimental group. Patients admitted with acute blood loss anemia or were on an anticoagulant that required frequent laboratory monitoring were excluded. Data regarding the number of daily lab orders, length of stay (LOS), 30-day readmissions and emergency visits, 30 and 90-day mortality, as well as laboratory expenditure were compared between the two groups using a student t-test.
46 patients were identified in each of the study groups with no significant difference in their case mix indices. The number of labs per patient per day ordered was significantly lower in the intervention arm (Mean: 9.3 vs 6.3; p= 0.016), which translated into a 13% lab cost reduction per patient. No significant differences were found in the average LOS in days (5.6 vs 5.2; p = 0.7), 30-day readmission (9 vs 6; p = 0.57), or 30-day emergency visits (3 vs 6; p =0.48). There were no mortalities in either group at 30 and 90 days.
In an era of EMR and increasing order set utilization, and in an effort to promote high value care, a simple intervention of adjusting the default daily lab order in the admission order set to stop after 2 admission days significantly reduced the number of ordered labs and lab cost expenditure without adversely affecting the length of stay or quality of care.
To cite this abstract:Mehdi, A; Garber, A; Nemeth, R; Azmat, S; Deshpande, A; Prabhakaran, A . DRAWING WISELY BEYOND EDUCATIONAL SESSIONS: THE IMPACT OF ADMISSION ORDER SET ADJUSTMENT ON INPATIENT LABORATORY ORDERING PRACTICES. Abstract published at Hospital Medicine 2017, May 1-4, 2017; Las Vegas, Nev. Abstract 305. Journal of Hospital Medicine. 2017; 12 (suppl 2). https://www.shmabstracts.com/abstract/drawing-wisely-beyond-educational-sessions-the-impact-of-admission-order-set-adjustment-on-inpatient-laboratory-ordering-practices/. Accessed April 6, 2020.