Mindfulness based Laboratory ordering: a new quality control project
Example Case Mr. LAB admitted ~35 days ago. Declared incompetent and with no active issues after 5-6 days on the CTU. Complete blood count (CBC) and chemistry panels ordered on admission on a daily basis Daily bloodwork orders forgotten and never stopped Are those labs needed? What is the purpose? Daily labs stopped Cost: ~$6/day ---> $180/month saved on ONE patient!!
Rationale - 1 COST: RESIDENT EFFORT: Direct Costs: Indirect costs: Lab costs Materials for test (i.e. tubes, phlebotomy supplies) Indirect costs: Opportunity cost: there are only so many phlebotomists, nurses, residents to take the blood who could be doing something else Some specimens get delayed! Investigation Cascade: one unexpected abnormal test leads to cascade of investigations RESIDENT EFFORT: We lack a very good result management system. Reviewing results is time consuming and ordering too many tests dilutes the signal to noise ratio.
RATIONALE - 2 TEAM EFFORT: PATIENT: CANMEDS: Checking charts for new orders is time consuming for the unit clerk ---> task reduced if most orders are done at a predictable time. PATIENT: Blood taking HURTS! Can cause anemia (~1 g per week of “routines”) ---> can lead to a gastroscopy, colonoscopy or CT abdomen to rule out bleeds and blood transfusions for anemia. Phlebotomists can transmit nosocomial infection – its one more person going from room to room!! CANMEDS: Judicious use of labs falls under: Manager; Health Advocate; Scholar
Mindfulness Lab reduction Team CTU Faculty Senior Resident Junior Resident/ Student
Mindful time out plan Orders stored for one year in a binder on the floor (time stamped) Labs entered by coordinator into the computer system Labs requests returned to unit coordinator Value and necessity of proposed labs is discussed for each patient Laboratory time out occurs during daily signout Unit Coordinator prints up to date list of patients.
Plan Will not apply to stat labs needed during the day or therapeutic drug monitoring (ex. INR or tacrolimus levels) Lectures at QI rounds about importance of reducing unnecessary diagnostic testing.
Preliminary experience A quick trial on during period 3 added 5 minutes to sign-out ---> and resulted in, on average, a reduction of ~13 lab tests per patient. We will obtain your feedback regarding efficiency of daytime workflow from unit coordinators and residents. Tell us if this isn’t working!
What is the purpose? No more daily labs without reason Better patient care Less anemic patients! Fewer investigative cascades (avoid 30 complete blood counts -> leading to anemic patient -> leading to colonoscopy) Encourage residents to know their patients better and to improve clinical judgment when ordering labs.
Thank you for being mindful! For any suggestions please email: Dr. X http://www.bloodtestingservice.co.uk/wp-content/uploads/2015/07/private-blood-tests-uk.jpg