An Educational and Administrative Intervention to Promote Rational Laboratory Test Ordering on an Academic General Medicine Service.
BACKGROUND
Overuse of clinical laboratory testing in the inpatient setting is a common problem. The objective of this project was to develop an inexpensive and easily implemented intervention to promote rational laboratory use without compromising resident education or patient care.


METHODS
The study comprised of a cluster-randomized, controlled trial to assess the impact of a multifaceted intervention of education, guideline development, elimination of recurring laboratory orders, unbundling of laboratory panels, and redesign of the daily progress note on laboratory test ordering. The population included all patients hospitalized "general medicine" was duplicated during 2 consecutive months on a general medicine teaching service within a 999-bed tertiary care hospital in Boston, Massachusetts. The primary outcome was the total number of commonly used laboratory tests per patient day during 2 months in 2008. Secondary outcomes included a subgroup analysis of each individual test per patient day, adverse events, and resident and nursing satisfaction.


RESULTS
A total of 5392 patient days were captured. The intervention produced a 9% decrease in aggregate laboratory use (rate ratio, 0.91; P = .021; 95% confidence interval, 0.84-0.98). Six instances of delayed diagnosis of acute kidney injury and 11 near misses were reported in the intervention arm.


CONCLUSIONS
A bundled educational and administrative intervention promoting rational ordering of laboratory tests on a single academic general medicine service led to a modest but significant decrease in laboratory use. To our knowledge, this was the first study to examine the daily progress note as a tool to limit excessive test ordering. Unadjudicated near misses and possible harm were reported with this intervention. This finding warrants further study.
Department of Medicine, Massachusetts General Hospital, Boston; Harvard Medical School, Boston, Mass. Electronic address: bwertheim@partners.org.
Bradley M
BM
Wertheim
Department of Medicine, Massachusetts General Hospital, Boston; Harvard Medical School, Boston, Mass.
Andrew J
AJ
Aguirre
Harvard Medical School, Boston, Mass; Division of Infectious Diseases, Massachusetts General Hospital, Boston.
Roby P
RP
Bhattacharyya
Department of Medicine, Massachusetts General Hospital, Boston.
John
J
Chorba
Department of Medicine, Massachusetts General Hospital, Boston.
Ashutosh P
AP
Jadhav
Harvard Medical School, Boston, Mass; Division of Pulmonary and Critical Care Medicine, Massachusetts General Hospital, Boston.
Vanessa B
VB
Kerry
Biostatistics Center, Massachusetts General Hospital, Boston.
Eric A
EA
Macklin
Department of Medicine, Massachusetts General Hospital, Boston.
Gabriela
G
Motyckova
Department of Medicine, Massachusetts General Hospital, Boston; Georgia Regents University/Medical College of Georgia, Augusta.
Shveta
S
Raju
Harvard Medical School, Boston, Mass; Department of Pathology, Massachusetts General Hospital, Boston.
Kent
K
Lewandrowski
Department of Medicine, Massachusetts General Hospital, Boston; Emory University School of Medicine, Atlanta, Ga.
Daniel P
DP
Hunt
Department of Medicine, Massachusetts General Hospital, Boston; Harvard Medical School, Boston, Mass.
Douglas E
DE
Wright
D000046:Academic Medical Centers / Q000379:methods* / Q000458:organization & administration; D001900:Boston; D019411:Clinical Laboratory Techniques / Q000379:methods*; D005260:Female; D006801:Humans; D007318:Inservice Training / Q000379:methods*; D008297:Male; D050316:Medical Order Entry Systems / Q000458:organization & administration / Q000706:statistics & numerical data; D008875:Middle Aged; D016134:Organizational Policy; D062606:Tertiary Care Centers / Q000458:organization & administration; D019564:Unnecessary Procedures / Q000706:statistics & numerical data*
Diagnostic tests; Medical education; Resource use