THE TRICKLE DOWN EFFECT: NON-COVERED HOSPITALIST TEAMS LAB ORDERING CULTURAL SHIFT

Rachna Rawal, MD, Paul Kunnath, MD, Ara Vartanyan, BS, Hala Saad, MD, Oluwasayo Adeyemo, Jennifer Schmidt, St. Louis University, Brentwood, MO

Meeting: Hospital Medicine 2019, March 24-27, National Harbor, Md.

Abstract number: 347

Categories: Hospital Medicine 2019, Innovations, Quality Improvement

Keywords: , ,

Background: A previous project targeting Medicine residents’ high-value care practices prompted evaluation of the non-resident hospitalist teams ordering practices. Would exposure to residents (receiving education on high-value care) translate to changes in attending physician ordering on hospitalist-only teams?

Purpose: Participants included Medicine physicians attending on the non-resident and resident inpatient services. Data collected from the electronic medical record (EMR) included labs ordered (CBC without differential, CBC with differential, BMP, CMP) and patient census. Pre and post-project surveys created by the project team assessed lab ordering practices and cost-conscious care barriers. Initial interventions, targeting residents, occurred over 95 weeks. They included education, additional EMR lab frequencies, order set changes and a hospitalist physician champion.

Description: While the non-resident service census increased during the course of this project (from 8 to 45 patients), the total labs ordered/week is unchanged. Additionally, attending physicians ordered more specific laboratory panels (Figure 1)–increased BMP with decreased CMP, no change to hepatic panels (balancing measure)(p<0.05). CBC with differential also decreased while CBC without differential increased (p<0.05). Figure 2 shows that the frequency of standing orders (daily) decreased with increased use of one-time orders (Am draw) (p<0.05).
55% of attending physicians reported awareness of labs’ costs. 83% of attendings feel they order labs mindfully on the non-resident services and 50% report that the resident-focused high-value care project has influenced their own ordering behaviors. 67% report using the new EMR lab frequency options instead of the “daily” option. 15% reported that the EMR ordering default change from “daily” to “AM draw” made them more mindful of laboratory orders.

Conclusions: While our initial project focused on residents, its effects have been wider reaching. Residents received initial education, however mindful lab ordering has spread to the non-resident services. We believe that the high-value care practices encountered by the attendings on the resident teams continue to impact the ordering practices of the attendings when they rotate on the non-resident hospitalist service. This unintentional leakage demonstrates a true cultural shift toward high-value patient care.

IMAGE 1: Figure 1: Total Labs Ordered Per Thousand-Patient Days

IMAGE 2: Epic Lab Frequency Utilization

To cite this abstract:

Rawal, R; Kunnath, P; Vartanyan, A; Saad, H; Adeyemo, O; Schmidt, J. THE TRICKLE DOWN EFFECT: NON-COVERED HOSPITALIST TEAMS LAB ORDERING CULTURAL SHIFT. Abstract published at Hospital Medicine 2019, March 24-27, National Harbor, Md. Abstract 347. https://www.shmabstracts.com/abstract/the-trickle-down-effect-non-covered-hospitalist-teams-lab-ordering-cultural-shift/. Accessed December 6, 2019.

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