Altering standard admission order sets to promote clinical laboratory stewardship: a cohort quality improvement study

Abstract

BackgroundCareful design of preprinted order sets is needed to prevent medical overuse. Recent work suggests that removing a single checkbox from an order set changes physicians’ clinical decision-making.Local problemDuring a 2-month period, our coronary care unit (CCU) ordered almost eight times as many serum thyroid-stimulating hormone (TSH) tests as our neighbouring intensive care unit, many without a reasonable clinical basis. We postulated that we could reduce inappropriate testing and improve clinical laboratory stewardship by removing the TSH checkbox from the CCU admission order set.MethodsAfter we retrospectively evaluated CCU TSH ordering before intervention, the checkbox was removed from the CCU admission order set. Twelve weeks later, we commenced a prospective 2-month assessment of TSH testing and clinical sequelae of thyroid disease among all CCU admissions. If clinical indications were absent or testing had occurred within 6 weeks, TSH requests were labelled as ‘inappropriate’.ResultsPhysician ordering and, specifically, inappropriate ordering decreased substantially after the intervention. In 2016 among physician-ordered TSH tests, 60.6% (66/109) were inappropriate; in 2017 this decreased to 20% (2/10, p=0.01). Overall, the net effect of checkbox removal saw the decrease in TSH testing without clinical indication outweigh an increase in missed testing where indications appear to exist.ConclusionsProvision of an optional checkbox for a laboratory test in an admission order set can promote overuse of laboratory resources. Simple removal of a checkbox may dramatically change test ordering patterns and promote clinical laboratory stewardship. Given our reliance on order sets, particularly by trainees, changes to order sets must be cautious to assure guideline-directed care is maintained.

Does admission order form design really matter? A reduction in urea blood test ordering

“…We found that the updated admission form enables a sustainable reduction in laboratory tests seen in previous studies translated to BUN blood tests at these Canadian teaching hospitals. [11][12][13][14][15][16][17] Additionally, because of the simplicity of the intervention implementation where the physician leaders communicated the rationale for the form update, the common pitfalls of completing a physician led QI project, that requires several hours of dedicated time for physicians to review the shortcomings of the current processes while simultaneously focusing on their clinical duties was avoided. 31 The greater reductions experienced at hospital A compared with hospital B indicate that the additional interventions such as the targeted resident education, unit process changes alerting physicians of lab test order frequency and posted BUN clinical indication job aides that were in place at hospital A had a compounding effect.…”

“…8 9 Significant reductions in laboratory ordering have been reported through interventions of education and job aides, to redesigning standard admission order sets, laboratory forms or software as well as multimodal approaches. [10][11][12][13][14][15][16][17] There can be risks associated with these interventions that target reductions in laboratory test order such as physicians under ordering when clinically required and missing possibly relevant information for the patients diagnosis or management. 18 The blood urea nitrogen (BUN) test or the urea test is commonly ordered with creatinine, often adding little value to patient management at significant cost.…”

Reducing Unnecessary Noninvasive Testing for Inpatients With Unstable Angina: The RUNIT Protocol

“…Indeed, the fact that RUNIT negative patients also experienced a lower rate of duplicate studies suggests that the change in ordering J o u r n a l P r e -p r o o f pattern was adopted and applied outside the protocol, a feature associated with other successful initiatives. 22,23 This culture change was likely the main cause of the reduction in TTE ordering, highlighting the importance of not only the intervention, but also education endeavors including our audit, feedback, and grand rounds.…”

The Impact of Changes to an Electronic Admission Order Set on Prescribing and Clinical Outcomes in the Intensive Care Unit

“…28 Furthermore, Leis et al showed that simple removal of a check box for a thyroid-stimulating hormone (TSH) order from a critical care unit admission order set significantly decreased inappropriately ordered TSH tests from 60.6 to 20%. 29 This study is unique in that it sought to assess the effects of several different types of order sets changes outside of modifying the default settings of an order. Order set design is an important area of study as computerized provider order entry (CPOE) with CDS can lead to unintended consequences that need to be monitored for after implementation.…”