laboratory stewardship-expanded slides for handout
TRANSCRIPT
CONSULTATIVE SERVICES │ LABORATORY STEWARDSHIP
LABORATORYSTEWARDSHIP:
TAKING THE FIRST STEPSTO DOWNSTREAM
SAVINGSANDREW FLETCHER MD
CONSULTATIVE SERVICES │ LABORATORY STEWARDSHIP
Background
13 Billion test performed70% decisions based10-30% unnecessary
CONSULTATIVE SERVICES │ LABORATORY STEWARDSHIP
Background
3 most significant causes of patient harm• Ordering the wrong test• Failing to retrieve a test
result• Misinterpreting a test result
CONSULTATIVE SERVICES │ LABORATORY STEWARDSHIP
73%
53%
72%
47%
the frequency of unnecessary tests and procedures is a very or somewhat serious problem
that even if they know a medical test is unnecessary, they order it if a patient insists
the average medical doctor prescribes an unnecessary
test or procedure at least once a week
their patients ask for an unnecessary test or procedure at
least once a week
CONSULTATIVE SERVICES │ LABORATORY STEWARDSHIP
Trends in Healthcare
Laboratory Stewardship
Pharmacy Utilization management
Antimicrobial Stewardship
Blood Utilization
Radiology Utilization management
CONSULTATIVE SERVICES │ LABORATORY STEWARDSHIP
of labs have a stewardship program
1/3
of those labs have a productive and progressing committee
1/2Data Analysis
Formal Governance
Evidence-Based Recommendations
IT Engagement and Support
Project Management
Measurement and Reporting
Success Factors
Creating Successful Laboratory Stewardship
CONSULTATIVE SERVICES │ LABORATORY STEWARDSHIP
NCLS Publication
CONSULTATIVE SERVICES │ LABORATORY STEWARDSHIP
Test ConsolidationHow many reference labs do you use?
Reference test formularyCreation & Implementation
In-House Testing Daily recurring labs Inappropriate test intervals
Three Initial areas of Focus
Where to Start?
CONSULTATIVE SERVICES │ LABORATORY STEWARDSHIP
Free Phenytoin at Lab X $106Free Phenytoin at Primary Lab vendor $13
Test ConsolidationHow many reference laboratories do you use?
1. Is there a primary Vendor?2. Why are tests sometimes not consolidated?
-Physician Request-Patient Request-Insurance requirement-Easier process for lab staff
CONSULTATIVE SERVICES │ LABORATORY STEWARDSHIP
Test ConsolidationHow many reference labs do you use?
Reference test formularyCreation & Implementation
In-House Testing Daily recurring labs Inappropriate test intervals
Three Initial areas of Focus
Where to Start?
CONSULTATIVE SERVICES │ LABORATORY STEWARDSHIP
Test Formulary
all send out testing performed in 1 year
test listing in menu if ordered <4 times in 1 year
remaining test on menu to see if reasonable
ReviewReview Eliminate
CONSULTATIVE SERVICES │ LABORATORY STEWARDSHIP
POE Optimization
Vitamin D• 1,25-Dihydroxy vitamin D• 25-Hydroxy vitamin D
Flu• Flu PCR• Flu respiratory viral panel• Flu screen
Folate• Folate (RBC)• Folate (serum)
Gonorrhea• Gonorrhea culture• Gonorrhea DNA probe
CONSULTATIVE SERVICES │ LABORATORY STEWARDSHIP
POE Optimization
POE Optimization
CONSULTATIVE SERVICES │ LABORATORY STEWARDSHIP
Inpatient Reference test cost
Monthly average pre Formulary $31,054 Monthly average post Formulary $20,028 Percent decrease 35% Average monthy savings $11,026 Projected yearly savings $132,309
CONSULTATIVE SERVICES │ LABORATORY STEWARDSHIP
Commonly Misordered TestingTest Removal & Reflex Path Implementation
0
2
4
6
8
10
12
14
16
18
MTHFR 2 Mutations Factor V Leiden APC w/reflex to Factor VLeiden
85% 86%
CONSULTATIVE SERVICES │ LABORATORY STEWARDSHIP
Test ConsolidationHow many reference laboratories do you use?
Reference test formularyCreation & Implementation
In-House Testing Daily recurring labs Inappropriate test intervals
Three Initial areas of Focus
Where to Start?
CONSULTATIVE SERVICES │ LABORATORY STEWARDSHIP
Don’t perform repetitive CBC and chemistry testing in the face of clinical and lab stability.
Don’t order diagnostic tests at regular intervals (such as every day), but rather in response to specific clinical questions.
Daily Orders
CONSULTATIVE SERVICES │ LABORATORY STEWARDSHIP
Intervention Methods
Proactive
Appropriate order setsOrder management
Preference list managementPhysician education
Physician report cards
Reactive
Duplicate alertsFormulary restriction alerts
Best Practice AlertsPhysician education
CONSULTATIVE SERVICES │ LABORATORY STEWARDSHIP
76548965
Zyne Cotopaxi, MD09/04/2016 15:47
76548965
09/04/2016 13:00
Thyroid Stimulating Hormone 4.0 IU/mL
CONSULTATIVE SERVICES │ LABORATORY STEWARDSHIP
Test ConsolidationHow many reference labs do you use?
Reference test formularyCreation & Implementation
In-House Testing Daily recurring labs Inappropriate test intervals
Justification for StewardshipNCLS RecommendationsThree Initial areas of Focus:
Summary
CONSULTATIVE SERVICES │ LABORATORY STEWARDSHIP
13 Billion
laboratory tests performed annually
in the U.S.3%
of U.S. healthcare expenditures spent on Laboratory Services
70%of medical decisions are influenced by laboratory
data
CONSULTATIVE SERVICES │ LABORATORY STEWARDSHIP
Downstream impact
• Length of stay
• Pharmacy
• Radiology
• Others……
CONSULTATIVE SERVICES │ LABORATORY STEWARDSHIP
Troponin orders and Chest Pain LOS
23
CONSULTATIVE SERVICES │ LABORATORY STEWARDSHIP
Identify order mechanisms that drive the repeat interval
Modify the repeat time to be 3-6 hours after
Improve the time-to-decision by improving the test interval
by up to 3 hours
TROPONIN I
0
500
1000
1500
2000
2500
3000
3500
00.
5 11.
5 22.
5 33.
5 44.
5 55.
5 66.
5 77.
5 88.
5 99.
5 1010
.5 1111
.5 12 12+
2,965
4,410
CONSULTATIVE SERVICES │ LABORATORY STEWARDSHIP
Identify order mechanisms that drive the repeat interval
Modify the repeat time to be 3-6 hours after
Improve the time-to-decision by improving the test interval
by up to 3 hours
TROPONIN I
0500
1000150020002500300035004000
0.0
0.5
1.0
1.5
2.0
2.5
3.0
3.5
4.0
4.5
5.0
5.5
6.0
6.5
7.0
7.5
8.0
8.5
9.0
9.5
10.0
10.5
11.0
11.5
12+
3,587
CONSULTATIVE SERVICES │ LABORATORY STEWARDSHIP
Downstream impact
• Length of stay
• Pharmacy
• Radiology
• Others……
CONSULTATIVE SERVICES │ LABORATORY STEWARDSHIP
Downstream Impact on Pharmacy
IVIGArgatrobanRemicade
CONSULTATIVE SERVICES │ LABORATORY STEWARDSHIP
Downstream impact
• Length of stay
• Pharmacy
• Radiology
• Others……
CONSULTATIVE SERVICES │ LABORATORY STEWARDSHIP
Radiology Services
CONSULTATIVE SERVICES │ LABORATORY STEWARDSHIP
CT PE Protocol
30
CONSULTATIVE SERVICES │ LABORATORY STEWARDSHIP
CONSULTATIVE SERVICES │ LABORATORY STEWARDSHIP
D-Dimer and CT PE Protocol
32
CONSULTATIVE SERVICES │ LABORATORY STEWARDSHIP 33
CONSULTATIVE SERVICES │ LABORATORY STEWARDSHIP
CONSULTATIVE SERVICES │ LABORATORY STEWARDSHIP
45,000chest x-rays
=
23%CT Scans
CONSULTATIVE SERVICES │ LABORATORY STEWARDSHIP
=
23%CT Scans
$34.20 per scan
CONSULTATIVE SERVICES │ LABORATORY STEWARDSHIP
=
23%CT Scans
$10,260 cost saving
CONSULTATIVE SERVICES │ LABORATORY STEWARDSHIP
=
23%CT Scans
$1,445,400 savings for patients
CONSULTATIVE SERVICES │ LABORATORY STEWARDSHIP
=
23%CT Scans
360 hrsreduction in LOS
CONSULTATIVE SERVICES │ LABORATORY STEWARDSHIP
Downstream impact
• Length of stay
• Pharmacy
• Radiology
• Others……
CONSULTATIVE SERVICES │ LABORATORY STEWARDSHIP
LABORATORYSTEWARDSHIP:
TAKING THE FIRST STEPSTO DOWNSTREAM
SAVINGSANDREW FLETCHER MD