Department of Hospital Medicine, Northwestern University, Evanston, Illinois, USA.
Department of Medicine, Mount Sinai Beth Israel, New York City, New York, USA.
J Hosp Med. 2023 May;18(5):398-404. doi: 10.1002/jhm.13081. Epub 2023 Mar 28.
Unnecessary laboratory testing of hospitalized patients is prevalent.
We conducted a study focused on "mindful ordering" to decrease unnecessary laboratory ordering within an Internal Medicine residency program.
DESIGNS, SETTINGS AND PARTICIPANTS: We collected survey data on resident/faculty perceptions of laboratory ordering as well as order information from the electronic medical record (EMR).
Interventions focused on resident-identified barriers such as knowledge, EMR, habit and faculty expectations. Interventions were cumulative and included resident/faculty education and EMR optimization.
We assessed basic and complete metabolic panels (BMP, CMP) and complete blood counts with and without differential (CBC w/diff, w/o diff). Primary outcomes included: total labs ordered per week, lab and frequency, and resident perception of ordering practices. Secondary outcomes included: length-of stay (LOS) and venipuncture utilization.
Survey data demonstrated increased resident perception of both mindful ordering and team discussion. Total labs ordered per week decreased 20% in the first year (1944 to 1500 labs/week). Residents' use of the "one-time draw" option increased; use of "daily" frequency decreased. Trends showed an increase in BMP relative to CMP, and an increase in CBC w/o diff relative to CBC w/diff. These changes were sustained through 127 weeks. There was an approximately 10% decrease in monthly average of patients undergoing venipuncture each day (86.7% to 74.2%). The shifts in laboratory ordering in conjunction with increased discussion about labs suggest a sustained change in resident lab ordering behavior. This study shows the impact of focusing interventions on resident-identified barriers to mindful ordering to create a sustained decrease laboratory orders.
住院患者的实验室检查过度普遍。
我们开展了一项专注于“谨慎医嘱”的研究，旨在减少内科住院医师培训项目中不必要的实验室医嘱。
设计、地点和参与者：我们收集了关于住院医师/教师对实验室医嘱的看法以及电子病历（EMR）中的医嘱信息的调查数据。
干预措施主要针对住院医师确定的障碍，如知识、EMR、习惯和教师期望。干预措施是累积的，包括住院医师/教师教育和 EMR 优化。
我们评估了基本和完整代谢组学（BMP、CMP）以及有和无差异的全血细胞计数（CBC w/diff、w/o diff）。主要结果包括：每周医嘱的实验室检查总数、实验室检查次数和频率，以及住院医师对医嘱实践的看法。次要结果包括：住院时间（LOS）和静脉穿刺利用率。
调查数据显示，住院医师对谨慎医嘱和团队讨论的看法都有所增加。第一年每周医嘱总数减少了 20%（从 1944 次减少到 1500 次/周）。住院医师使用“一次性采血”选项的频率增加，使用“每日”频率的次数减少。趋势显示，BMP 相对 CMP 的比例增加，CBC w/o diff 相对 CBC w/diff 的比例增加。这些变化持续了 127 周。每天接受静脉穿刺的患者每月平均人数减少了约 10%（从 86.7%减少到 74.2%）。实验室医嘱的变化与关于实验室医嘱的讨论增加相结合，表明住院医师实验室医嘱行为发生了持续变化。本研究表明，关注住院医师确定的谨慎医嘱障碍的干预措施能够产生持续减少实验室医嘱的效果。
