Article title: Reducing Electrolyte Testing in Hospitalized Children by Using Quality Improvement Methods
Authors: Michael J. Tchou, MD, Sonya Tang Girdwood, MD, PhD, Benjamin Wormser, MD, Meifawn Poole, DO, Stephanie Davis-Rodriguez, MD, MSc, J. Timothy Caldwell, MD, PhD, Lauren Shannon, CNP, MSN, Philip A. Hagedorn, MD, Eric Biondi, MD, MSBA, Jeffrey Simmons, MD, MSc, Jeffrey Anderson, MD, MBA, Patrick W. Brady, MD, MSc
Key points
- Diagnostic testing can be a source of excess healthcare spending, and targeting its overuse can reduce unnecessary costs.
- Education about costs of laboratory tests and standardization of communication around diagnostic testing are powerful interventions that can reduce electrolyte testing in hospitalized children.
Context
With rising health care costs in pediatrics, there is a growing interest in reducing waste in the care of children. A significant proportion of diagnostic tests do not lead to changes in diagnosis, management or prognosis, and can be considered as overuse. Reducing the overuse of laboratory testing can not only decrease healthcare costs, but also avoid other negative effects of excess testing such as pain or anemia from frequent blood draws. We focused on electrolyte tests since they are frequently drawn and repeated in the inpatient pediatric setting, even when not clinically indicated. Using quality improvement methods, we sought to decrease the number of electrolyte laboratory draws per 10 patient days by 25%.
Results
Figure 1 - Prior to interventions, the average number of electrolyte lab draws per 10 patient days was 2.0, and decreased by 35% after 2 months of interventions, as demonstrated in the statistical process-control u-chart.
Electrolyte laboratory draws decreased from 2.0 per 10 patient days to 1.3, a 35% reduction within 2 months of initiation of interventions. The reduction occurred after provider education about study aims and the value of various electrolyte tests, and after individual provider feedback about their practice in ordering electrolytes. The lowest points in the statistical process-control u-chart (Figure 1) coincided with the introduction of cost reference cards, and with standardization of communication about laboratory testing, which included a laboratory plan template in patient notes and structured discussions on rounds. The reduction in electrolyte testing corresponded to >$292,000 in charge savings, and did not result in change in medical emergency team or readmission rates.
| Intervention Description | Intervention Start Date |
|---|---|
| Start Provider Education: Introductory lectures and meetings for providers |
9/12/16 |
| Start Provider Education: Introductory lectures and meetings for providers |
9/12/16 |
| Start Provider Education: Introductory lectures and meetings for providers |
9/12/16 |
| Start Provider Education: Introductory lectures and meetings for providers |
9/12/16 |
| Start Provider Education: Introductory lectures and meetings for providers |
9/12/16 |
| Start Provider Education: Introductory lectures and meetings for providers |
9/12/16 |
| Start Provider Education: Introductory lectures and meetings for providers |
9/12/16 |
| Start Provider Education: Introductory lectures and meetings for providers |
9/12/16 |
Implications
This study showed that education about costs of laboratory tests can be effective in changing the practice of providers, who often have limited knowledge about specific healthcare costs. In addition, engaging residents, who are often the front-line providers who order tests, in the development of interventions, and targeting them in provider feedback were crucial in the reduction of laboratory testing. Using a multifaceted approach that included education of providers, individualized feedback, standardization of communication about laboratory testing, and use of the electronic medical record to limit testing, allowed for sustainability.
The immediate next steps are to identify methods to promote sustainability, such as focusing on specific diagnoses for which electrolyte testing is frequently ordered. Additional research would be required to determine rates of electrolyte testing rates and the factors that affect the rates for specific diagnoses.
About the blog post author
Sonya Tang-Girdwood, MD, PhD
Dr. Tang Girdwood is a fellow in Pediatric Hospital Medicine at Cincinnati Children’s Hospital Medical Center. She has a PhD in Biochemistry, Cellular and Molecular Biology & Pharmacology. Sonya co-led a multidisciplinary team in improving the timely transition of intravenous to enteral antibiotics in hospitalized children as part of a high-value care initiative. As a clinical pharmacology fellow, she is currently conducting a study evaluating beta-lactam concentrations during different stages of sepsis in critically ill children.
Twitter: @STangGirdwood