Sustained Reduction in Lab Ordering After Implementing Mindful Ordering Initiatives
Dr. Mohoney
Clinical question: Do perceptions of mindful laboratory test ordering and number of labs ordered change after resident-focused training and optimization of electronic medical record (EMR) ordering options?
Background: Multiple recommendations and guidelines have discouraged over-ordering laboratory tests to avoid iatrogenic anemia, improve cost savings, and reduce patient harm. In addition, a reduction in lab ordering has not been associated with missed diagnoses or increased mortality. Despite this information, survey results showed residents at the study site’s institution and elsewhere felt there was insufficient focus on mindful lab ordering. Moreover, the majority of faculty felt residents over-ordered labs.
Study design: Multiple quality-improvement interventions evaluated by surveys and general linear modeling for total lab ordering analysis
Setting: Inpatient general medicine teaching service at a 250-bed midwestern hospital from 2016 to 2019
Synopsis: This study included 86 to 92 residents and 17 to 20 faculty per year, rotating through a general-medicine inpatient teaching service between 2016 and 2019. Interventions were implemented in five phases, which included resident education, promotion of faculty-resident communication, optimization of EMR by expanding lab ordering frequency options, adjusting the medicine admission order set, and reducing the frequency of lab collection default settings.
Survey data showed an increase in the percentage of residents who perceived themselves as ordering labs mindfully from 40% at week 31 to 91% at week 127 (P <.05). Total lab orders per thousand patient days were increasing pre-intervention (beta=10.57, 95% CI: 2.97-18.18, P=.01) and the trend was suppressed during intervention (beta=-15.68, 95% CI: -23.67 to –7.68, P <.001). Additionally, there was no significant change from intervention to postintervention (beta=.38, 95% CI: -2.83 to 3.58, P=.82), suggesting sustainability of ordering habits.
Limitations include the cumulative nature of the interventions, therefore the effectiveness of each intervention could not be assessed.
Bottom line: Residents had an increased perception of mindful lab ordering and there was a reduction in total labs ordered after quality-improvement interventions targeting resident education and optimization of EMR lab ordering functions.
Citation: Rawal R, et al. Empowering medicine residents to order labs mindfully to improve patient-centered care. J Hosp Med. 2023;18:398-404.
Dr. Mohoney is an internal medicine resident, PGY-3, at Maine Medical Center, Tufts University School of Medicine in Portland, Maine.