Objectives  Identify appropriate usage of BMP  Evaluate UCI Medicine Ward teams on usage of daily BMP and determining how often residents over-order BMP.  Educate residents on the harmful effects of obtaining too many laboratory tests  Encourage UCI residents to obtain BMPs when indicated to prevent extraneous costs

Indications for BMP  Initial monitoring of electrolytes and renal function.  Trending electrolyte abnormalities  Medications that may alter electrolytes or cause renal dysfunction

Background  BMPs are routinely ordered at UCI – is it always necessary?  BMPs are rather costly to patients as each test is 22 dollars and can lead to physical pain, iatrogenic anemia, or infection with each blood draw

Study Design  10 patients admitted to UCI Internal Medicine ward service from 4/28/15 to 5/18/15 were selected in a cross-sectional study  Number of BMPs ordered per patient and reason for ordering the BMP was evaluated.

Results  In the 10 patients reviewed, there were 90 total hospital days. Total number of BMPs ordered was 110.  Daily BMPs were ordered on ALL patients  Total BMP to patient ratio was 1.22.

Results PtDxHD# of BMPs AKI (HD wnl) Electrolytes Abnormal VancoOther Nephrotoxins Why Extra BMPs? Through Chart Review 1Sepsis 2/2 UTI, UGIB 77Yes (3)Yes (2)No Daily monitoring 2Neck Abscess 910No Yes Monitor Cr while on Vancomycin 3R fibular fracture 77Yes (2) No Daily monitoring 4PNA77No Yes Monitor Cr while on Vancomycin 5R femur fracture 1011NoYes (3)No One episode of Hyperkalemia on HD2 and daily monitoring

Results PtDxHD# of BMPs AKI (HD wnl) Electrolytes Abnormal VancoOther Nephrotoxins Why Extra BMPs? Through Chart Review 6PBC711No Yes (ACE inhibitors) CMP monitoring 7Ascending Cholangitis 1117No CMP monitoring 8Empyema2125Yes Vancomycin 9COPD44NoYes (3)No Daily monitoring 10PNA711Yes (5)Yes (4)No Elevated Glucose while in house lead to extra BMPs ordered on HD2-3

Discussion  Basic Metabolic Panel $22  Liver Function Test $21  Comprehensive Metabolic Panel $27  22 Extraneous BMPs ordered, leading to $484 spent in 90 hospital days, NOT including physician interpretation fee.

Discussion  Observations:  Patients with any type of laboratory abnormality appear to have daily electrolyte monitoring, even after abnormalities have resolved.  Vancomycin leads to daily BMP monitoring.  Monitoring LFTs with CMP appears to confound the data as the BMP is normal while LFTs are abnormal.

Discussion  Daily BMP ordering continues to remain an area to improve in cost effectiveness.  2 patients had more BMPs ordered for acute electrolyte abnormalities which were promptly treated.  3 patients had daily BMPs for monitoring electrolytes as they had abnormalities on admission which subsequently improved and 2 patients had daily CMPs ordered when electrolytes and renal function were normal, leading to 22 extra daily BMPs  3 patients had daily BMPs ordered while on Vancomycin. What are the guidelines for Creatinine monitoring for Vancomycin usage?

Areas for Improvement  Think about the hospital bill the patient may have. Although the laboratory test for CMP is $27, the cost for physician interpretation will increase the patients bill to $1000.  No indications for daily BMP if Vanco levels are within range. Literature search revealed weak guidelines that Cr should be monitored for the first few days until Vanco trough is normal at least 2x and then BMP may be ordered weekly or if the trough is too high.