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Sensible Test Ordering Practice
in an Emergency Department
The S.T.O.P. and think! Project at Tallaght Hospital’s Emergency Department:
How quality improvement tools can be used to support Sensible Test Ordering Practice
Coag Numbers by week
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350
Jan W
eek 2
Jan W
eek 4
Feb W
eek 2
Feb W
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March
Wee
k 2
March
Wee
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April W
eek 2
April W
eek 4
May W
eek 2
May W
eek 4
June
Wee
k 1
June
Wee
k 3
July
Wee
k 1
July
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July
Wee
k 5
2014 2013 Target 2014 Median 2013 Median
Appropriate requesting of Coag tests restated at education meeting for ED staff
New OCS profiles initiated
Briefing for new Medical staff at induction on misuse of Coag screens
TAT Sub-project results New NCHD staff
Gerard Boran, FRCPath FRCPI
Clinical Director of Diagnostics, Tallaght Hospital, Dublin Clinical Lead, HSE/RCPI National Clinical Programme in Pathology
Peter Gaffney, MSc FAMLS Chief Medical Scientist, Tallaght Hospital, Dublin
Sarah Condell, PhD Nursing & Midwifery Research & Development Lead, HSE
August 15, 2014
Sensible Test Ordering Practice in an Emergency Department
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Declaration We declare that this work has been completed in compliance with the RCPI Quality Improvement Project Guidelines and is our own work Signed:
1. 2.
3. Date of submission: 15th August 2014
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Consent for dissemination We consent to the dissemination of our project abstract. We understand that neither the institution or the project authors’ names or affiliations will be made available without prior contact from RCPI.
1. 2.
3. Date: 15th August 2014
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Table of Contents Declaration................................................................................................................. ii Consent for dissemination ......................................................................................... iii Table of Contents...................................................................................................... iv List of Tables..............................................................................................................v List of Photographs ....................................................................................................v List of Common Abbreviations....................................................................................v List of Figures............................................................................................................vi Abstract..................................................................................................................... 1
Aim........................................................................................................................ 1 Methods ................................................................................................................ 1 Results .................................................................................................................. 2 Conclusion ............................................................................................................ 2
Introduction ............................................................................................................... 3
Tools from the science of Quality Improvement ..................................................... 3 Demand Management in Laboratory Medicine ...................................................... 4 Sensible Test Ordering Practice ............................................................................ 6 Evidence for effectiveness of demand management interventions in pathology..... 8 The QI project site ............................................................................................... 11 Justification for this project .................................................................................. 12
Aim statement ......................................................................................................... 13 Drivers for Improvement.......................................................................................... 15 Measures for Quality Improvement.......................................................................... 16
Analysis of baseline data..................................................................................... 17 Other data measurement tools used during the project ....................................... 18 Arthur’s Day ........................................................................................................ 19
Project Implementation, Results and Discussion ..................................................... 21
Financial Modelling of Savings ............................................................................ 29 Patient Experience Time: Length of Stay in ED ................................................... 30
Conclusions............................................................................................................. 31 Future Recommendations ....................................................................................... 33
Spreading the improvements nationally ............................................................... 34 References.............................................................................................................. 35 Appendix A: Surveys ............................................................................................... 37 Appendix B: Team Membership and Acknowledgements........................................ 39
Sensible Test Ordering Practice in an Emergency Department
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List of Tables Table 1. Concepts, Methods and Tools for Quality Improvement (©RCPI 2012) ....... 4 Table 2. Lewandrowski’s 10 tools for demand management in laboratory medicine.. 5 Table 3. Ranking of interventions from weak to strong (adapted from Astion 2006)... 5 Table 4. RCPA/ACEM Guideline for Pathology Testing in Emergency Departments . 7 Table 5. Studies estimating or analysing cost savings of test ordering interventions 10 Table 6. SMART Aim Statement Checklist .............................................................. 13 Table 7. Stakeholder Analysis ................................................................................. 16 Table 8. Plan for PDSA Cycles................................................................................ 18 Table 9. Estimates of cost savings from reduced pathology tests............................ 29
List of Photographs Photo 1. Test Screen of the KEY Order Communications system used to request pathology tests. ....................................................................................................... 11 Photo 2. Arthur bleeds Harry, the patient................................................................. 19 Photo 3. Arthur sends Harry’s blood specimens to the Lab via the ED pneumatic chute system........................................................................................................... 19 Photo 4. Lab staff receive Harry’s blood specimens ................................................ 19 Photo 5. Arthur gets interrupted checking the results .............................................. 19 Photo 6. ED team demonstrating IT system at a meeting. ....................................... 21
List of Common Abbreviations CPOE Computerised Provider/Physician Order Entry System CRP C-reactive protein CTPA Computed Tomography Pulmonary Angiogram ED Emergency Department KEY The CPOE/OCS in use at Tallaght Hospital LIS Laboratory Information System MAU Medical Admissions Unit OCS Order Communication System (same as CPOE) PDSA Plan-Do-Study-Act Cycle
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List of Figures Figure 1. Relationships between improved pathology test ordering and satisfaction.10 Figure 2. Driver Diagram ......................................................................................... 14 Figure 3. Percentage of blood tests ordered per 8 hour shift ................................... 17 Figure 4. Flow Diagram ........................................................................................... 20 Figure 5. Hand-drawn visual from observation exercise - Arthurs Day..................... 20 Figure 6. Cycle 1 - Induction.................................................................................... 22 Figure 7. Cycle 2 - Reinforcement ........................................................................... 22 Figure 8. Guidance development incorporating Tallaght ED Top 20 presentations.. 23 Figure 9. Run chart on sample time to laboratory using PTS/chute system ............. 24 Figure 10. Cycle 4 - Maintaining Engagement. ........................................................ 25 Figure 11. Cycle 4 - Maintaining Engagement (survey). .......................................... 26 Figure 12. Effect of PTS/chute system changes. ..................................................... 26 Figure 13. Redesigned Profiles ............................................................................... 27 Figure 14. Cycle 5 - IT Profile redesign ................................................................... 27 Figure 15. Annotated run chart summarising all PDSA Cycles ................................ 28 Figure 16. Blood test orders post-profile change ..................................................... 28 Figure 17. Point of care testing of blood glucose in ED ........................................... 29 Figure 18. Patient experience time. ......................................................................... 30 Figure 19. Pareto Chart showing that the ICT change was the critical factor ........... 31 Figure 20. Ogrine and Shojania's conceptual map of PDSA. ................................... 33
Sensible Test Ordering Practice in an Emergency Department
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Abstract
Inappropriate use of diagnostic laboratory services, particularly over-ordering, can
result in diagnostic error, poor patient outcomes and experience, as well as
increased costs and waste of hospital resources.
Aim Our aim was to encourage Sensible Test Ordering Practice to reduce the requesting
of selected pathology tests by 50% in the Emergency Department of a large Irish
teaching hospital by the end of April 2014. We focused on a range of clinical
chemistry and haematology tests including coagulation screens, blood glucose, and
c-reactive protein.
Methods We used the “S.T.O.P. and think!” technique successfully developed in 2004 in
Sydney, Australia, and published in 2013 as the influential Guideline for Pathology
Testing in the Emergency Department by the Royal College of Pathologists of
Australasia and the Australasian College for Emergency Medicine.
Baseline data on tests ordered were collected and analysed. A working group that
included all stakeholders was established. Measurement commenced in January
2014 and consisted of an annotated run chart with results provided weekly to the
Emergency Department staff. Other measures included process mapping and
observation, a staff satisfaction survey, an analysis of cost savings achieved, and an
assessment for any changes in patient length of stay as a result of the interventions.
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Plan-Do-Study-Act cycles were conducted around five interventions; (1) education at
induction, (2) scheduled teaching sessions, (3) development of a visual aid for
guidance in test ordering, (4) improved test turnaround time, and finally (5) redesign
of the pathology test ordering panels on the electronic ordering system which turned
out to be the critical intervention.
Results Our aim was achieved after 4 months and 5 cycles, with a 50% reduction in
coagulation screens, 98% reduction in blood glucose tests, and significant reductions
in several other pathology tests. Savings due to the total reduction in pathology
testing were estimated at �94,500 per annum. We also confirmed that patient length
of stay was not adversely affected by the reduction in pathology testing.
Conclusion This project demonstrated that successfully reducing unnecessary pathology testing
in Emergency Departments is possible using the tools of quality improvement
following identification and careful selection of the optimal intervention.
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Introduction
Appropriate use and management of demand for scarce and costly healthcare
resources is a growing problem of international importance, not least for diagnostic
laboratory medicine services which have seen annualised workload increases of 10%
over the past decade. In Ireland, laboratory diagnostics account for up to 9% of
typical hospital budgets (HSE). Over-utilisation and unnecessary investigation is an
unintended but wasteful and risky consequence stemming from increases in
healthcare information technology and automation, major advances in medical
practice and patient turnover, as well as clinician and client/patient expectations.
This project applies the tools of quality improvement to enhance the practice of
demand management in laboratory medicine, specifically to support better test
ordering practice and to thoughtfully address over-utilization of laboratory medicine
services in an Emergency Department setting. We will also tell the story of “Arthur’s
Day” in the Emergency Department to illustrate the tools in action.
Tools from the science of Quality Improvement Throughout this project we applied tools, methods, and concepts from the science of
quality improvement which were taught on the Diploma course, are summarised in
Table 1 below and are described fully in Langley et al (2009), Provost et al (2011),
and Pfeffer et al (2000).
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Table 1. Concepts, Methods and Tools for Quality Improvement (©RCPI 2012)
Demand Management in Laboratory Medicine Techniques for demand (utilisation) management in laboratory medicine have been
refined into a scientific approach and have been recently reviewed by Huck and
Lewandrowski (USA, 2014) who described 10 commonly used tools (see Table 2),
and Smellie (UK, 2013).
The Four Quadrants of Profound Knowledge SMART Aim Checklist Driver Diagram Run Charts PDSA Cycle Defining Variation The difference between natural and artificial variation Defining Flow Process Mapping Demand versus Capacity Scheduling Care Defining Patient Safety Techniques to foster a culture of safety Care of the Caregiver Characteristics of high reliability organisations The importance of risk management Finding the balance between clinicians and management Leveraging hierarchies to better patient care Understanding just culture The role of leadership in changing culture Strategies for bringing about cultural change Techniques to build trust within a culture that does not appear trustworthy How to adopt to change for success Recognising the need for change Getting buy in for quality improvement Sending clear messages about QI How to spread [change; improvements] by mobilising frontline staff Defining healthcare value How to increase healthcare value How to reduce waste in healthcare
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Table 2. Lewandrowski’s 10 tools for demand management in laboratory medicine
The usual approach is to design “interventions” which, according to Astion’s concept
(2006) may be weak or strong. Examples of common interventions including
educational efforts, guidelines and prompts, modifications to request forms and
Computerised Physician Order Entry Systems (CPOE), and authorisation/traffic light
systems can be found in Table 3.
Table 3. Ranking of interventions from weak to strong (adapted from Astion 2006)
A recent review of decision-support modifications to CPOE/order entry systems
found that beneficial patient outcomes vary and may be absent depending on the
change implemented (Georgiu, Australia, 2006). Minimum re-testing intervals are
now well documented (Lang, 2013) though can be complicated to implement, and
1. Develop a multidisciplinary team for Utilisation Management 2. Develop and implement institutional protocols including reflex testing algorithms for lab use. 3. Provide reliable and readily available test information to clinicians and nurses 4. Get to know your Computerised Provider Order Entry (CPOE) system 5. Review your referrals to Reference Labs, and the budget. 6. Provide interpretive support to avoid unnecessary workups. 7. Use order entry or the LIS to prevent or trap unnecessary repeat orders (minimum re-testing intervals) 8. Make structural changes in your process. 9. Don’t ignore the cost management of blood products. 10. Measure thyself (repeat often).
Weaker Interventions
Intermediate
Stronger
Strongest
Interventions Guidelines Lectures and Educational events Computerised Reminders regarding utilisation
Utilisation Report Cards Changes to the request form Changes to the Computerised Provider (Order) Entry System
Utilisation Report Cards with Peer or Leadership Review Requirement for Higher Level Authorisation/ Traffic Light System (e.g. by pathologist, consultant)
Utilisation Report Card with Peer/Leadership Review and Financial Penalties for abuse or Incentives to encourage good behaviour Outright Banning
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clinical guidelines and protocols are under development in many countries, including
the Irish National Clinical Programme in Pathology.
Sensible Test Ordering Practice
Authorisation systems have proved popular tools for implementing strong
interventions to manage demand and promote appropriate use in many healthcare
domains including pathology testing in Emergency Departments. Also sometimes
known as “traffic light systems” they commonly use a 3-tiered system to identify
common open access tests as for example “Green” which may be ordered by junior
staff grades, with more complex or expensive tests in “Amber” or “Red” tiers requiring
escalation to increasingly senior staff grades (e.g., registrar or consultant) before the
test can be ordered. Mc Carthy et al implemented such a system at the Prince of
Wales Hospital Emergency Department in Sydney supported by the Australian
Governments Quality in Pathology Program (Mc Carthy et al 2009, Tan et al 2004,
Stuart et al 2002), and aptly nicknamed it the “S.T.O.P. and think!” project after its
aim to encourage junior doctors to think more about “Sensible Test Ordering
Practice”. Notably, this traffic-light authorisation system led to a decrease in many
pathology tests including a 50% decrease in coagulation screen ordering when
implemented because the frontline ED doctors had to decide whether their patients
really needed a coagulation screen and discuss with their seniors before ordering the
test. Total pathology costs fell by AUS $49,000 per month. Their pivotal work
contributed to the influential Australasian Guideline (Table 4) jointly published by the
Royal College of Pathologists of Australasia and the Australasian College for
Emergency Medicine (RCPA/ACEM 2013).
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Table 4. RCPA/ACEM Guideline for Pathology Testing in Emergency Departments
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Evidence for effectiveness of demand management interventions in pathology Epner et al (2013) noted that inappropriate test ordering can result in false positive
findings resulting in diagnostic error and leading to a cascade of further unnecessary
investigations with additional inconvenience and anxiety for the patients concerned.
As in primary care, ED patients may have expectations (van Bokhoven et al, 2006)
that blood tests are performed as part of the healthcare visit. ED patient outcomes
from inappropriate test ordering are rarely reported in the literature and whilst
investigating this was not the aim of this project, concerns for patient safety and care
remains an important driver of this project (see driver diagram).
Most literature on inappropriate pathology testing concentrates on reducing the
increasing burden of over-requesting and associated costs. So, for example, Vegting
et al (2012) within a department of internal medicine used consultant commitment,
the unbundling of test profiles, increased awareness of national protocols,
information on test costs and six weekly feedback to effect change in laboratory
ordering patterns without impacting patient mortality or readmission rate but with
statistically significant cost reduction. Likewise, Calderon-Margalit et al (2005)
undertook a hospital wide initiative that included the development of a policy
restricting emergency blood test ordering and the frequency of repeat test orders,
including educational roll out and feedback on its impact. This reduced laboratory test
orders by 19% in the following 12 months.
Some studies have focused specifically on certain clinical settings within hospitals.
For example, Chu et al (2013) studied restricted intern and resident blood test
ordering in an adult tertiary-referral ED. On the basis of altering the blood test form
so as to reflect permissible test ordering (although any test could be ordered once
consultation with a registrar or consultant occurred), the mean number of tests
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ordered per 100 patients presenting fell significantly by 19%. Likewise, Hutton et al
(2009) in their university hospital ED and MAU setting used consultant only
requesting or agreed disease related protocols and produced an 85% reduction in
the number of c-reactive protein (CRP) requests and no evidence of subsequent
request shifting to ward areas. Similarly, Santos et al (2012) focused on ED ordering
of CRP in a medium-sized teaching hospital and showed that educational discussion
and departmental feedback with residents and medical students produced a 48%
reduction in adjusted annual CRP ordering rate. Additionally, Hughes et al (2009)
used the intervention of targeted education for ‘front door staff’ in a small district
hospital on the guidelines for coagulation screening to reduce test ordering in acute
medical admissions by 26% and without reducing the rate of appropriate screening.
These studies from the international literature suggest that blood test ordering is
amenable to interventions aimed at safely reducing blood test ordering and thus
eliminating waste.
All of the studies differ in size, methods, units of analysis, selected blood tests,
currencies, measurement timeframes and occurred over 8 years, rendering them
incomparable. However, almost all made either an estimate or analysis of cost
savings (see Table 5). Mostly, this was done using basic units of analysis, such as kit
costs. However, there can be other cost and value savings in reducing the number
of blood tests ordered. Fundamental change can improve several measures
concurrently (Langley et al, 2009) so improving laboratory efficiency through demand
management can potentially increase TAT and give faster, and possibly, safer
decisions for patient care, thereby improving the patient experience. It can also
reduce medical and laboratory staff workload. Figure 1 illustrates possible inter-
relationships.
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Table 5. Studies estimating or analysing cost savings of test ordering interventions
Figure 1. Relationships between improved pathology test ordering and satisfaction.
Author
Year
Country
Cost saving
Calderon-Margalit et al
2005
Israel
$247,000 p.a.
Hutton et al 2009 UK £10,000 p.a. Hughes et al 2009 UK £21,000 p.a. Vegting et al 2012 Netherlands �350,000 p.a. Chu et al 2013 Australia AUS$ 2633 /100 attendances
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The QI project site Tallaght Hospital is a 625-bedded facility in the South-West of Dublin, serving the
population of 6 Dublin suburbs, West Wicklow and parts of County Kildare. The
Emergency Department is the country’s largest, with over 77,000 patient attendances
per annum and approximately 50,000 patients had blood samples taken in 2013.
From a total staff of 50, 30 staff including doctors and some nurses had pathology
ordering rights.
Photo 1 shows a testscreen of the KEY Order Communications System (OCS) used
for requesting pathology investigations in the ED. It was state-of-the art when first
installed in 1998 but by December 2013 was on the “sunset” list of hospital
equipment needing replacement. An in-house team of systems analysts had
meticulously maintained the system, including re-programming of the inpatient
pathology ordering panels as required. However these had not been reviewed
substantively for over 5 years. The hospital also benefits from a networked
pneumatic tube system for transport of pathology specimens to the laboratory.
Details of each patient episode were recorded using the SYMPHONY database
management system in the ED, which was also due for an upgrade in the timeframe
of the project.
Photo 1. Test Screen of the KEY Order Communications system used to request pathology tests.
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Justification for this project The need for this project originated with an ED consultant (encouraged by the CEO)
who approached the Clinical Director of Diagnostics with the proposal to form a
group to improve pathology test ordering from ED. The same ED consultant had also
been familiar with the “STOP and think!” work of Mc Carthy et al in Australia during
his training there some years earlier. The justification for the project was two-fold.
First, we wanted to improve patient-centred care (including patient experience and
outcomes) as there was a high index of suspicion that over-ordering of pathology
tests was occurring, and secondly, cost-effectiveness would improve as a result. The
latter aim was particularly important as the ED was about to undergo a costly and
major expansion project itself.
Although this project is about Sensible Test Ordering Practice in the Emergency
Department, it is worth noting at the outset that the doctors and nurses who work in
our high-pressure ED are without doubt among the most dedicated and “sensible”
people we have ever met. Notwithstanding this, advances in ICT, laboratory
automation, imaging, and medical practice in general (“technology push”) have
conspired to make test ordering easier and more rapid, driving increases in workload
despite our best efforts. While we think about what is best for the patient, the tests
are already done. This project is more about making sense of the technology than
sensible doctors and nurses.
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Aim statement The aim of our project was to reduce by 50%, the requesting of the selected
pathology tests in the ED of Tallaght Hospital, by the end of April 2014. This aim
followed the SMART acronym of Specific, Measureable, Actionable, Realistic, and
Timely (see Table 6). Whilst the Diploma team considered this a ‘stretch’ goal in
terms of the level of reduction within the given timeframe, the decision was still made
to adopt it.
Table 6. SMART Aim Statement Checklist
We initially selected coagulation screens and CRP tests for special focus, where
ordering averaged 1200 and 1500 tests per month respectively. However, we
monitored the effect of each intervention (PDSA cycle) on all tests requested
particularly as we were planning a major revision of the electronic test ordering
panels.
Specific
Our aim is precise, concise, with single focus and it means the same thing to all
Measurable We have a readily understandable measure of our aim. The measure is directly and quantitatively related to aim achievement, can be proceduralised, and various sampling intervals may be used.
Actionable Deliberate actions are required to make an improvement towards and achieve the aim, with team members capable and willing to make these actions
Realistic The aim is worthwhile, has leadership support with a good prospect of success, is within our control and influence with both time and resources available and is not limited by regulatory, legal, or ethical constraints.
Timely There is a target date, the time is ripe with a sense of urgency, and staff can be assigned with no competing initiatives
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As the project progressed a number of secondary objectives were identified (“side-
shows” or “sub-projects”) to encourage continued staff engagement and clinical buy-
in (i.e. winning their hearts and minds). One was to address a shared concern to
improve turnaround time (TAT) by reducing the percentage of samples taking more
than 20 minutes from OCS to the arrival at the laboratory. Another sub-project aimed
to reduce the movement of laboratory staff to collect samples from the chute system.
Figure 2. Driver Diagram
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Drivers for Improvement
The need for change and justification for this project was firstly, improving patient
centred care, and secondly, reducing waste by examining and improving the systems
involved. Of course, the ED clinicians had many concerns and suggestions for
improvement for us apart from the perceived indiscriminate ordering of tests and
demand management problem which was our primary concern. For example, the
turnaround time (TAT) was felt to be unacceptable and needed improvement. Also,
technical limitations and bugs in the out-dated electronic system for test ordering (e.g.
non-specificity of both the ordering clinician and allocated consultant for reporting
purposes) were causing frustration. These concerns correspond to the first three of
Singh et al’s (2009) taxonomy of diagnostic error dimensions, namely provider-
patient encounter, performance and interpretation of diagnostic tests, and follow-up
and tracking.
Given the timeframe for this project, the Diploma team decided to maintain focus on
the first concern – that of demand management of blood test orders from the ED.
Demand management centres on appropriate test ordering (Fryer and Smellie, 2013)
or as Smellie (2012; p323) states “the right test in the right patient at the right time”.
The team recognised that “big improvements can often be realised by making small
changes directed at the right places in the system” (Langley et al, 2009. p 114). The
team constructed a Driver Diagram (Figure 2) as a means of describing its theory for
improvement (Langley et al, 2009). Together with the driver diagram, the model for
improvement guided the project. The question of what we were trying to accomplish
was set in our aim statement, so the next question was how will we know if a change
was an improvement?
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Measures for Quality Improvement ‘The work before the work’: this is how Batalden (2014; p 7) describes the essential
prerequisites in preparing for a quality improvement change. In our project, there
were several steps involved including a series of small ‘start-up’ huddle meetings
over a two month timeframe (Nov-Dec 2013). Here, an important element was
listening to all the issues that were being raised by ED staff in relation to pathology
blood test ordering. Overwhelmingly, there was a sense of frustration with processes
and a degree of demoralisation from the waste they contained, both in relation to use
of professional’s time and the cost of the service. From this exercise, key time-points
were identified; stakeholders were assessed for their level of influence and reaction
to change (Table 7); project aims were clarified and feasibility and achievability of
requisite tasks was assessed.
Table 7. Stakeholder Analysis
Stakeholder
Initial
support
Level of
influence
Key concern
Steps to getting buy in
ED Consultant High High Wanting quick change to speedier process.
Non-follow up of inappropriate tests.
Examine PTS issues
ED NCHD High High Making right choice easy IT changes Examine PTS issues
ED CNMs Medium Medium IT system perceived as very slow
ED S/Ns High Medium IT system perceived as very slow
Phoning lab for out-of-hours
tests.
IT changes
Demo that bell sets off bleep
Laboratory High High Any gains would be short-lived Ensure changes processes are embedded
in the system and not reliant on individuals
IT services High Medium Not all suggestions of change could be incorporated into IT
system
Needed time for work to be negotiated
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Analysis of baseline data During start-up initial data from November 2013 was examined to set the baseline
and identify potential actions. For example, an analysis of the time of ordering blood
tests was undertaken to consider if variability between staff shifts was an issue. The
following chart (Figure 3) indicates that this would not be a fruitful issue to pursue
within the project.
Relative % ED Requests Across shifts
0.0%
5.0%
10.0%
15.0%
20.0%
25.0%
RPCRP
Gluc LPAMY
TropTox
2 BP CK MgBNP
TFT FeUrat
e
Test
% T
ests
00:00 to 08:00 08:00 to 17:00 17:00 to 00:00
Figure 3. Percentage of blood tests ordered per 8 hour shift Another measure that could have had potential use was a Box Plot by grade of
doctor or nurse ordering the tests. However, this data was not available from the
Symphony system. These start-up meetings and an initial walk-through of the test
ordering process allowed a PDSA cycle plan (Table 8) to be drawn up.
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Table 8. Plan for PDSA Cycles
Other data measurement tools used during the project The run chart of coagulation screen orders was commenced in January 2014. The
figures were collated weekly and consisted of total coagulation screen test orders
and as a percentage of haematology requests. The weekly updated chart was
circulated to all ED staff via the ED team. The charts were annotated and the runs
examined to interpret the data for shifts or trends. A retrospective Pareto chart was
developed to show the action with largest impact.
The project was further informed by a flow diagram from a detailed process mapping,
conducted by the Hospital’s Quality Manager with input provided by both a doctor
and nurse (Figure 4). An observation session (see “Arthur’s Day”) of ‘following the
patient” was carried out by the Diploma team. Staff satisfaction was measured by 2
short surveys (< 10 items) using the Survey Monkey system (Appendix A). We also
evaluated with the assistance of Tallaght Hospitals’ Business Intelligence Unit for any
Concept
Cycle #
Description of PDSA Cycle
Responsible
Demand Management
1 (induction)
ED Consultant gives introductory induction talk and an email on coagulation screen ordering to new doctors
ED consultant With team backup
Demand management
2 (reinforcement)
ED consultant gives scheduled teaching lecture to ED doctors
ED consultant + team
Demand management
3 (visual aid)
Provide visual aid (Chart) IT + team
Improve TAT 4a Additional canisters circulated Team (side-show) 4b Priority on PTS given to ED Team 4c New labelled canisters for ED Team Demand management
5 Major change in Ordering Panels IT + team
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changes in the Patient Length of Stay (LOS) as a patient outcomes marker. Changes
in pathology costs were also estimated, using three different financial models.
Arthur’s Day
On Monday 31st March 2014, the Diploma team went to the ED for an observational
visit to see test ordering in practice (see Photos 2-5). Our host that day was Dr.
Arthur and one of his patients who agreed to our intrusion who we will call “Harry” to
protect his anonymity. Proceedings were minuted and recorded on video as well as
in a hand-drawn visual (see Figure 5). Harry was about 70, had come in to ED in the
ambulance that morning clearly short of breath and had been on warfarin. No way
was it the first time for Harry to be phlebotomised so Arthur prepared the bottles and
got on with it. The samples were placed in the chute (PTS) after innumerable clicks
on the computer to order the tests. Harry then went for a Chest XRay and we went to
the lab to follow the coagulation screen, blood count, CRP, and chemistry tests.
Harry’s INR was in the region of 4 so the lab phoned it back to Arthur who was
interrupted a few times as he picked up the phone. As there was a risk of pulmonary
embolus, Harry proceeded to a CTPA and Arthur didn’t waste time doing a d-dimer
assay.
Photo 2. Arthur bleeds Harry, the patient
Photo 3. Arthur sends Harry’s blood specimens to the Lab via the ED pneumatic chute system
Photo 4. Lab staff receive Harry’s blood specimens
Photo 5. Arthur gets interrupted checking the results
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Figure 4. Flow Diagram
Figure 5. Hand-drawn visual from observation exercise - Arthurs Day
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Project Implementation, Results and Discussion
The working group was established with both core (ED consultant, Diploma
participants) and an invited membership including clinical staff representatives,
quality manager, the laboratory IT officer, technical services staff, and pharmacy (see
appendix B). Meetings were then held either weekly or fortnightly in the ED. The
invited membership attended if and when there were pertinent issues for discussion
so that all attendees contributed at the meetings. Meetings lasted between 25 to 40
minutes. The question for the working group was what changes could we make that
would result in an improvement? With this question and using the tools outlined in
our measures for quality improvement (above) we commenced our PDSA cycles.
Photo 6. ED team demonstrating IT system at a meeting.
The first PDSA cycle (Figure 6) focused on providing information (verbal and
introductory email) on appropriate blood test ordering of coagulation screens to
NCHDs at their induction. We predicted that this might be a key moment when they
would be receptive to this information and the data showed the predicted response.
Sensible Test Ordering Practice in an Emergency Department
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Coag Num bers by w eek
100
150
200
250
300
350
Jan W
eek 2
Jan W
eek 4
Feb W
eek 2
20142013Target
Figure 6. Cycle 1 - Induction
The second cycle (Figure 7) was whether the reduction in coagulation screen
requesting could be maintained by reiteration of the information using weekly
teaching sessions and feedback. Our data analysis for this cycle showed that whilst
reinforcement might maintain the reduction, the ‘Consultant as Champion’ might be a
required presence; such that when the individual concerned was on holidays,
coagulation screen requests rose.
Coag Numbers by week
100
150
200
250
300
350
Jan
Wee
k2
Jan
Wee
k3
Jan
Wee
k4
Feb
Wee
k1
Feb
Wee
k2
Feb
Wee
k3
Feb
Wee
k4 M
arch
Wee
k 1
Mar
chW
eek
2M
arch
Wee
k 3
2014 2013 Target 2014 Median 2013 Median
Figure 7. Cycle 2 - Reinforcement
Question: Will reinforcement of message at education meetings maintain reduction? Prediction: ‘Consultant as Champion’ presence required
Question: Can induction talk reduce coag screen requesting? Prediction: Yes by ~ 20%
Sensible Test Ordering Practice in an Emergency Department
23
The burden that reinforcement placed on key staff was recognised and so for our
next cycle of change we decided to develop a quick visual aid for appropriate blood
test ordering. Using the 2013 top 20 ED presentations to Tallaght, the Diploma team
in conjunction with the ED Specialist Registrar, SHO and nurse team members
adapted the RCPA/ACEM 2013 Guideline (Table 4) to correspond to Tallaght ED’s
top 20 presentations and associated tests (Figure 8)
Figure 8. Guidance development incorporating Tallaght ED Top 20 presentations This further highlighted what we knew already, that the ED profiles on the Key OCS
electronic ordering system were in need of urgent review. In addition, the process
mapping highlighted problematic and redundant steps within the IT ordering system.
A case was made to release an IT staff member to undertake the work though this
could not be scheduled for at least 8 weeks.
At this stage the project had been running for a number of weeks and the clinical staff
were reluctant to test the visual aid without concomitant changes in the IT system;
however the projected date for IT changes was a further 8 weeks away. While we
were waiting, we had time to focus on the “side-show” sub-projects to help maintain
clinical buy-in. Our fourth cycle of change was therefore directed to the TAT sub-
Sensible Test Ordering Practice in an Emergency Department
24
project to test if supporting other initiatives around blood test ordering would help
maintain clinical staff support for the project aim. In start-up meetings staff had
complaints about the pneumatic chute system (PTS) for transporting samples from
ED to the Laboratory (Photo 3): problems identified included insufficient canisters in
the system, canister hoarding by some departments, and variable time for sample
transport depending on pneumatic line usage. Small tests of change were conducted
within this cycle including commencing monitoring of canisters, the addition and
labelling of 24 extra canisters for ED, and priority for ED over other departments on
PTS (Figure 9).
% > 20 mins from OCS to Lab
0%
10%
20%
30%
40%
50%
60%
70%
80%
90%
100%
3012
13 to
0501
14
0601
14 to
1201
14
1301
14 to
1901
14
2001
14 to
2601
14
2701
14 to
0202
14
0302
14 to
0902
14
1002
14 to
1602
14
1702
14 to
2302
14
2402
14 to
0203
14
0303
14 to
0903
14
1003
14 to
1603
14
1703
14 to
2303
14
2403
14 to
3003
14
3103
14 to
0604
14
0704
14 to
1304
14
1404
14 to
2004
14
2104
14 to
2704
14
2804
14 to
0405
14
0505
14 to
1105
14
1205
14 to
1805
14
1905
14 to
2505
14
2605
14 to
0106
14
0206
14 to
0806
15
0906
14 to
1506
14
% > 20minsTarget> 20mins Median
Monitoring Started Additional canisters
put into circulation
New canisters labelled for Adult ED
Priority on PTS given to ED
PTS line 1 down twice this week
Figure 9. Run chart on sample time to laboratory using PTS/chute system
As it initially showed some promise (Figure 10), the decision was made to continue
this initiative alongside the original aim in an effort to maintain ‘hearts and minds’ of
the ED clinical staff.
Sensible Test Ordering Practice in an Emergency Department
25
C o a g N u m b e r s b y w e e k
1 0 0
1 5 0
2 0 0
2 5 0
3 0 0
3 5 0
Jan
Wee
k 2
Jan
Wee
k 3
Jan
Wee
k 4
Feb
Wee
k 1
Feb
Wee
k 2
Feb
Wee
k 3
Feb
Wee
k 4
Mar
ch W
eek
1
Mar
ch W
eek
2
Mar
ch W
eek
3
Mar
ch W
eek
4
Apr
il W
eek
1
Apr
il W
eek
2
Apr
il W
eek
3
2014 2013 T arget
Figure 10. Cycle 4 - Maintaining Engagement.
Prior to the IT changes being implemented, we measured staff satisfaction using a
short survey (Appendix A). The Survey Monkey link was circulated by the clinical
members of the working group. Pre-intervention, eight nurses but no doctors
responded. The nurses were highly experienced with 6 having worked more than 5
years in Tallaght ED and 2 having worked between 2 and 5 years in the ED. Seven
reported high confidence levels in their knowledge on the types of patients requiring
coagulation screen tests. They reported the IT system as slow to use and there was
a mixed response on its ease of use (Figure 11). Whilst 5 reported the PTS/Chute
system changes as being for the better with 2 unsure and 1 reporting no change,
there was greater variation in their perceptions of the effect that this might have on
clinical decision making (Figure 12). Four used the open question at the end of the
survey to make further suggestions such as increasing the number of computer
points where sample labels could be printed.
Question: Will supporting other initiatives help maintain ED support? Prediction: Yes but perhaps not sustainable, yet critical to retain
Sensible Test Ordering Practice in an Emergency Department
26
Current IT system
0
1
2
3
4
5
easy 1quick
2 3 4 difficult5 slow
level of usage factor
num
ber
pace of use
ease of use
Figure 11. Cycle 4 - Maintaining Engagement (survey).
Effect of POD/chute system changes on timeliness of clinical decision
making
quicker
no change
unsure
Figure 12. Effect of PTS/chute system changes. Up to this point our run chart had shown that whilst there was an initial trend (5+
consecutive points) in reducing numbers of coagulation screen orders, this had not
been maintained with cycle 3 and 4 tests of change. Our fifth test PDSA cycle was
the IT system change of redesigned profiles (Figure 13) adapted from the
Australasian guideline.
The team considered that this was the intervention that would make the right choice
easy and could have additional benefits by reducing the orders for other pathology
tests. Figure 14 shows achievement of target with the redesigned IT profiles within
two weeks of target date. Figure 15 shows an annotated run chart summarising all
PDSA cycles.
Sensible Test Ordering Practice in an Emergency Department
27
Figure 13. Redesigned Profiles Figure 14. Cycle 5 - IT Profile redesign
Question: Will new profiles reflect appropriate testing & reduce unnecessary testing? Prediction: Additional 25% drop in coag screen orders as minimum +
Coag Numbers by week
100
150
200
250
300
350
Jan
Wee
k 2
Jan
Wee
k 3
Jan
Wee
k 4
Feb
Wee
k 1
Feb
Wee
k 2
Feb
Wee
k 3
Feb
Wee
k 4
Mar
ch W
eek
1M
arch
Wee
k 2
Mar
ch W
eek
3M
arch
Wee
k 4
Apr
il W
eek
1A
pril
Wee
k 2
Apr
il W
eek
3A
pril
Wee
k 4
May
Wee
k 1
May
Wee
k 2
May
Wee
k 3
May
Wee
k 4
May
Wee
k 5
June
Wee
k 1
June
Wee
k 2
June
Wee
k 3
June
Wee
k 4
July
Wee
k 1
2014 2013 Target 2014 Median 2013 Median
Cycle 5: IT system changes
Plan
Study
Act
Do
Sensible Test Ordering Practice in an Emergency Department
28
Coag Numbers by week
100
150
200
250
300
350
Jan W
eek 2
Jan W
eek 4
Feb W
eek 2
Feb W
eek 4
March
Wee
k 2
March
Wee
k 4
April W
eek 2
April W
eek 4
May W
eek 2
May W
eek 4
June
Wee
k 1
June
Wee
k 3
July
Wee
k 1
July
Wee
k 3
July
Wee
k 5
2014 2013 Target 2014 Median 2013 Median
Appropriate requesting of Coag tests restated at education meeting for ED staff
New OCS profiles initiated
Briefing for new Medical staff at induction on misuse of Coag screens
TAT Sub-project results New NCHD staff
Figure 15. Annotated run chart summarising all PDSA Cycles
In addition, and as predicted, the redesigned profiles showed a reduction in other test
ordering (Figure 16). Two elements were unexpected though. Firstly, the 98 %
reduction in laboratory glucose testing was startling. However, glucose testing in the
ED by point of care glucometry was maintained in the 4 weeks before and after the IT
change (Figure 17), also implying that the laboratory glucoses were superfluous.
Post Profile Changes CC Tests Requested from ED 2014 - 2013 (M ay Week 1 to June Week 2)
0%
-9%
0%
-15%
-51%
16%
-19%
-98%-100%
-80%
-60%
-40%
-20%
0%
20%
40%
Total CRP RP LP BP Trop Amy Gluc
Figure 16. Blood test orders post-profile change
Sensible Test Ordering Practice in an Emergency Department
29
POCT Glucose 2014
0
50
100
150
200
250
300
AprilWeek 1
AprilWeek 2
AprilWeek 3
AprilWeek 4
MayWeek 1
MayWeek 2
MayWeek 3
MayWeek 4
New OCS profiles initiated
Figure 17. Point of care testing of blood glucose in ED
Secondly, the additional 16% increase in Troponins was unanticipated. The profiles
were then re-examined by the Diploma team and ED Specialist Registrar and a
decision made to remove Troponin from the Sepsis profile. This test of change
resulted in Troponin test orders at +9% after 6 weeks
Financial Modelling of Savings We used three laboratory test costing financial models (see Table 9) to estimate the
savings resulting from fewer pathology tests being ordered. Model 1 used a
commercial pathology test tariff to calculate a saving of �286,000 per annum saving.
Model 2 also used a commercial tariff but based on marginal pricing, and this gave
an estimate of �159,000 per annum. Model 3 used a minimal costing approach,
giving the lowest estimate of �94,500 per annum, which most closely reflects the
expected savings in a large publicly funded teaching hospital environment.
Table 9. Estimates of cost savings from reduced pathology tests
Model 1
Commercial charges (based on a published commercial tariff)
168221831-6393057199138321105475Annualised decrease/increase
1414141414141414Number of weeks counted
4529493-17282353610356814742013-2014 Difference
GlucAmyTropBPLPRPCRPCoag
�100,932�14,649-�9,583�33,625�21,899�4,208�27,426�93,073Savings
�6.00�8.00�15.00�11.00�11.00�11.00�13.00�17.00Profile cost (SJH price list)
GlucAmyTropBPLPRPCRPCoag
�286,230.29
Total Savings
Model 2
Marginal pricing (public hospital)
168221831-6393057199138321105475Annualised decrease/increase
1414141414141414Number of weeks counted
4529493-17282353610356814742013-2014 Difference
GlucAmyTropBPLPRPCRPCoag
�33,644�7,325-�4,472�18,341�13,936�1,913�6,329�82,123Savings
�2.00�4.00�7.00�6.00�7.00�5.00�3.00�15.00Profile cost
GlucAmyTropBPLPRPCRPCoag*
*Coag costs are greater than Clinical Chemistry test costs as they require a
separate sample and additional hardware and staffing input
�159,138.57
Total Savings
Model 3
Minimal Cost Pricing (Tallaght costs for reagents, staff, overheads)
168221831-6393057199138321105475Annualised decrease/increase
1414141414141414Number of weeks counted
4529493-17282353610356814742013-2014 Difference
GlucAmyTropBPLPRPCRPCoag
�16,822�3,662-�3,194�9,171�7,963�1,148�4,219�54,749Savings
�1.00�2.00�5.00�3.00�4.00�3.00�2.00�10.00Profile cost (Minimal Tallaght Costs)
GlucAmyTropBPLPRPCRPCoag*
*Coag costs are greater than Clinical Chemistry test costs as they require a
separate sample and additional hardware and staffing input
�94,539.71
Total Savings
Sensible Test Ordering Practice in an Emergency Department
30
Patient Experience Time: Length of Stay in ED In order to evaluate whether the reduced pathology testing might adversely impact on
patient outcomes, we chose one particular metric and examined the patient
experience time (PET) assisted by the hospital’s Business Intelligence Unit who
routinely collect and analyse PET data. Figure 18 shows when selected weeks in
May 2013 and May 2014 were compared, the median Length of Stay (LOS) time in
ED (in hours) decreased, as did the average time spent in ED. The number and
percentage of patients spending less than 6 hours in ED also improved. The May
2014 data would have been after the critical intervention (the changes in the Ordering
Panels). Although the reasons for this improvement are clearly multi-factorial (due to
ongoing improvements in the ED unrelated to our project), it is reassuring to assume
that the reduced pathology testing may assist with a better and shorter PET as
hypothetically there would be fewer unnecessary pathology tests to follow-up.
Figure 18. Patient experience time.
Median Time in ED (hrs)
0.00
2.00
4.00
6.00
8.00
10.00
May Wk 2, 2013 (Pre) May Wk 2, 2014 (Post)
Average Time in ED (hrs)
0.00
2.00
4.00
6.00
8.00
10.00
12.00
14.00
16.00
May Wk 2, 2013 (Pre) May Wk 2, 2014 (Post)
Number of patients < 6 hrs in ED
0
20
40
60
80
100
120
140
May Wk 2, 2013 (Pre) May Wk 2, 2014 (Post)
% of Patients < 6 hrs in ED
0%
5%
10%
15%
20%
25%
30%
May Wk 2, 2013 (Pre) May Wk 2, 2014 (Post)
Sensible Test Ordering Practice in an Emergency Department
31
Pareto Chart for the Impact of each Improvement Cycle
0
50
100
150
200
250
300
350
ICT change (Cycle 5) Induction (Cycle 1) Engagement (Cycle 4) Inclusion (Cycle 3) Reinforcement (Cycle 2)
Weekly Reduction in Coag Requests
Cumulative Reduction
Figure 19. Pareto Chart showing that the ICT change was the critical factor
Conclusions
The STOP and think! Project at Tallaght Hospital’s ED confirms that demand
management of pathology test ordering in the ED is possible. We achieved our
SMART aim of reducing coagulation screens within a four month timeframe, and
achieved significant other reductions due to re-design of the ordering panels. The
slight delay while an IT staff member was released to undertake the necessary ICT
changes was worth waiting for. A retrospective Pareto Chart (Figure 19) showed that
the most successful PDSA cycle (the critical factor) in effecting a reduction in
coagulation screens was the ICT change, followed by the education at induction.
In addition, we reduced other inappropriate pathology test orders with estimated
savings of �94,500 per annum to the hospital. Whilst there has been some
improvement in TAT by July 2014, changes have yet to reach target or be sustained.
Sensible Test Ordering Practice in an Emergency Department
32
A number of lessons were learnt from the project. The inclusion of multidisciplinary
stakeholders in the working group meant that the approach to the project was one of
facilitation or collaboration rather than ownership by the Diploma team. This was
critical to successful ‘buy in’ by all required to make the necessary changes. As
frontline staff working with the processes of blood test ordering, it was essential to
listen to clinical working group members regarding project implementation and hear
their solutions to potential problems. It meant that they determined the timing of tests
of change and all communication was through their working group members. This
led to moments of frustration where meetings were cancelled due to clinical
precedence, delayed communication, or staff leave.
Induction of NCHD’s was viewed by clinical working group members as an excellent
opportunity to implement change. This meant that PDSA cycles (1 and future cycle
6) were scheduled to coincide with induction hence altering our potential project
timelines. So ‘buy in’ involved a ‘trade off’ in terms of meeting project interests for
Diploma purposes; affirming Langley & Denis’ (2011:pi45) “different but equally
legitimate value sets”. As noted elsewhere, PDSA cycles are not as clear as they
look, or as easy to execute (Tomolo, 2009) or applied with rigour (Taylor et al, 2014).
Ogrine and Shojania (2014) show a more realistic concept that, at times, reflected
our experience (Figure 19) within a busy ED department.
Sensible Test Ordering Practice in an Emergency Department
33
Figure 20. Ogrine and Shojania's conceptual map of PDSA.
Future Recommendations The STOP and think project at Tallaght Hospital ED is ongoing with the intention of
maintaining optimal local sustainability. PDSA cycles are being developed for
appropriate testing and improving TAT. With regard to the former the next cycle is
another IT change - that of single log-on to the ED blood test profiles. This will be
tested with the new NCHDs in mid-July. In addition, the guidance document will be
utilised at their induction. Since this completes all possible IT system redesign, the
post-intervention survey will then be circulated. We believe that these are the final
actions required to embed our innovation into routine practice at Tallaght’s ED.
Ongoing weekly data collection will be required to confirm this before evolving into
regular audit.
Sensible Test Ordering Practice in an Emergency Department
34
With regard to further improving TAT, the Head of Technical Services has agreed to
take the lead on the PTS/chute system issues and a strategy for canister
replacement is to be developed. The observation session revealed how samples
delivered by chute have to be ‘walked’ between laboratories. A business case has
been accepted and funding acquired to build a single point of chute entry accessible
by both laboratories, so reducing time and potential ‘loss’ of samples.
Spreading the improvements nationally This project has potential for replication to other hospital EDs, either as direct
adoption or with some adaptation, depending on local context (Ibanez de Opacua,
2013). In our case, the critical change factor was a re-design of out-dated Ordering
Panels. Different interventions may work better in other EDs, as was the case in the
Prince of Wales Hospital ED in Sydney. As a minimum, we would suggest that all
EDs discuss their pathology test ordering patterns with their local pathologists with a
view to identifying areas for improvement and reduction in unnecessary testing. Too
often these discussions focus only on TAT which, like laboratory automation and IT,
may even be a driver for unnecessary testing.
Details of the project will be published in guidelines being produced by the National
Clinical Programme in Pathology, which will be disseminated nationally by the HSE
and RCPI. The ED Specialist Registrar will also be presenting the project on behalf of
the team at the annual Irish Association of Emergency Medicine scientific meeting in
Autumn 2014, as part of a series of anticipated presentations by the Diploma team. A
number of journal articles are also planned.
Sensible Test Ordering Practice in an Emergency Department
35
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Sensible Test Ordering Practice in an Emergency Department
37
Appendix A: Surveys
Survey 1 – Pre-intervention As part of a quality improvement project, we are making some changes to blood test ordering from adult ED. We would like to know if this will improve staff satisfaction and so invite you to participate in this small voluntary, survey. The survey takes approximately 5 minutes to complete. All responses are anonymous and will be collated by the extern (Sarah) on the project team. A second short survey will be circulated once further changes occur. You are not obliged to complete either survey, but doing so will help us to demonstrate the worth of quality improvement and can help us to plan future actions. Gerard, Peter & Sarah 1. What is your current job?
Staff nurse Clinical Nurse Manager Intern Senior House Officer Reg/SpReg Consultant
2. How long have you worked in this ED?
< 6 months 6-12 months 1-2 years 2-5 years >5 years
3. How confident do you feel about your knowledge on the types of patient that require coagulation screens?
1 2 3 4 5 Not confident Very confident
4. How confident do you feel about your knowledge on the types of patient that require CRPs?
1 2 3 4 5 Not confident Very confident
5. We will be undertaking some changes to the IT blood test ordering system. Please rate how do you find the current system?
1 2 3 4 5 Easy to use Difficult to use 1 2 3 4 5 Time consuming Quick
6. We have recently made some changes to the pod/chute system. How do you find these?
A change for the better No change A change for the worst Unsure
7. In your opinion, what effect has changes to the pod/chute system had on clinical decision making?
Enabled quicker decisions about patient treatment No change in decision timeframe about patient treatment Unsure
8. If you have any ideas about how we could improve blood test ordering from ED that could improve patient care please tell us
Sensible Test Ordering Practice in an Emergency Department
38
Survey 2 – Post-intervention As part of a quality improvement project, we made some changes to blood test ordering from adult ED. We would like to know if this will improve staff satisfaction and so invite you to participate in this small voluntary, survey. The survey takes approximately 5 minutes to complete. All responses are anonymous and will be collated by the extern (Sarah) on the project team. You are not obliged to complete the survey, but doing so will help us to demonstrate the worth of quality improvement. We’d also like to take this opportunity to thank you for all your support on this project. Gerard, Peter & Sarah 1. What is your current job?
Staff nurse Clinical Nurse Manager Intern Senior House Officer Reg/SpReg Consultant
2. How long have you worked in this ED?
< 6 months 6-12 months 1-2 years 2-5 years >5 years
3. How confident do you feel about your knowledge on the types of patient that require coagulation screens?
1 2 3 4 5 Not confident Very confident
4. How confident do you feel about your knowledge on the types of patient that require CRPs?
1 2 3 4 5 Not confident Very confident
5. We have made all possible changes to the IT blood test ordering system that we can. Please rate how do you find the system now?
1 2 3 4 5 Easy to use Difficult to use 1 2 3 4 5 Slow to use Quick to use
6. In your opinion, has the effect of the IT and POD system changes improved efficiency of blood test ordering? 1 Yes, the system is now very efficient 2 Yes, efficiency has improved but more can be done 3 There has been no change 4 No, the process has become more inefficient. 7. In your opinion, has the effect of the IT and POD system changes improved timeliness of clinical decision making? 1. No, there has been no change in the timeliness of clinical decision making 2. Yes, clinical decision making has become quicker with the system changes 3. I am unsure if the changes have had any effect on clinical decision making. 8. Did you complete survey 1? Yes No Thank you.
Sensible Test Ordering Practice in an Emergency Department
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Appendix B: Team Membership and Acknowledgements
Word Count (excluding references, diagrams, cover pages and appendices): 5410
Team Membership showing multidisciplinary stakeholders Department
Team Member
(* denotes Diploma participant)
Role
Emergency Department Dr. Martin Rochford Lead ED Consultant for project Dr. SiobhanMcArdle ED SPR/lead NCHD for project Dr. Arthur Hennessy ED SPR Dr. Catriona Tiernan ED NCHD Marguarita O’Brien ED Nursing staff Laboratory Medicine Dr. Gerard Boran* Lead Consultant Pathologist for
project Clinical Director of Diagnostics
Peter Gaffney* Chief Medical Scientist – clinical chemistry
Dr Johnny McHugh Consultant haematologist Dymnpna Murphy Chief Medical Scientist -
haematology Nursing Executive (external)
Dr Sarah Condell* Representing nursing executive
ICT Department Brendan Carr Director of ICT Meliosa Moran IT systems analyst Tony Moulton Pathology IT officer Business Intelligence Unit
Deaglan MagFhloinn Business Intelligence Manager
Executive Management Team sponsors
Eilish Hardiman CEO (now former CEO); originator and sponsor for this project in 2012
David Slevin Director of Finance (now CEO) Process Improvement Office
Mary Hickey Process Improvement Manager
Pharmacy Niamh Kilcullen Pharmacist Technical services Gary Keane Technical services Seamus Foran Technical services We also acknowledge and thank all the patients and staff in the ED and the Pathology
Laboratory, particularly on the day of our observational visit (Arthur’s Day)