Reduction of urea test ordering in the emergency department: multicomponent intervention including education, electronic ordering, and data feedback

Abstract

Introduction In the emergency department (ED), laboratory testing accounts for a significant portion of the medical assessment. Although excess laboratory test ordering has been proven to be prevalent, different types of interventions have been used to encourage a behavioural change in how physicians order tests. In one western Canadian hospital medicine program, a quality improvement project aimed to reduce the total monthly blood urea nitrogen (BUN) test ordered by physicians was found to be successful. The objective of this project was to evaluate a similar multicomponent intervention aimed at ED physician ordering, with the primary goal of reducing the number of monthly BUN tests ordered per ED visit. Methods A pre post intervention design was conducted over 12-months. The first intervention component was an educational presentation conducted by physician leaders. Second, a regularly used order panel within the ED electronic order system was modified, removing the BUN test. The third component involved audit and feedback; the total monthly BUN test ordered for the ED department post intervention start was shared with all ED physicians twice (at 5 and 12 months).An interrupted time series analysis was completed to evaluate the multicomponent intervention effect. Results The total monthly ordered BUN test declined from an average of 1905 pre-intervention to 448 post-intervention, and the total monthly BUN test to total ED visit ratio declined from 0.46 to 0.1. These results were a statistically significant reduction in physician BUN test ordering. Conclusions Targeted education, order panel design and data feedback interventions can impact physician ordering behaviour in the emergent healthcare context, where diagnostic tests are often over used.

What works for and what hinders deimplementation of low-value care in emergency medicine practice? A scoping review

“…Of the included studies, 60% (12/20) of quantitative randomised,82 102 108 110 118 124–130 16.3% (20/123) of quantitative non-randomised,84 85 90 121 131–146 62.5% (5/8) of quantitative descriptive,61 62 64–66 100% (12/12) of qualitative48–57 and 25% (1/4) of mixed methods studies68 were assessed as being of higher quality. Among studies evaluating interventions, 21% (30/143) were of higher quality.…”

When evidence-based medicine and quality improvement collide

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The paper by Mathura et al describes an effective quality assurance (QI) program to reduce the frequency of blood urea nitrogen (BUN) ordering within the emergency department (ED) [1]. The project was based upon a multifaceted three-phased QI intervention that yielded impressive results in a pre-post observational design.

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