Session 5004-17

Improving Laboratory Test

Utilization: Opportunities,

Strategies and Successes

Stephen E. Kahn, PhD, DABCC, FACB

Elizabeth Schulwolf, MD, MA, FHA, FACP

Kate Bernhardt, MS, MLS(ASCP)CM, LSSGB

Marisa C. Saint Martin, MD

Loyola University Health System

A Member of Trinity Health

Maywood, Illinois USA

DISCLOSURE

In the past 12 months, I have not had any

significant financial interest or other relationship

with the manufacturers of the products or

providers of the services that will be discussed in

my presentation.

Symposium

Introduction

Stephen E. Kahn, Ph.D. DABCC, FACB

Professor and Vice Chair, Clinical Services,

Department of Pathology – Clinical Laboratories

skahn@lumc.edu

Session 5004-17

ASCP 2017 Annual Meeting

Chicago, Illinois

The imperative to improve laboratory test utilization

• U.S. healthcare’s paradigm has changed from volume to value

• According to the IOM, provision of healthcare must be safe, timely, efficient, effective, equitable and patient-centered (STEEEP)

• Top priorities for healthcare still remain increased patient safety and reduction in medical errors

• Yet, laboratory test ordering is all too often excessive, insufficient or inappropriate

• Utilization of the laboratory has become a critically important component of evidence-based laboratory medicine

Recently Available Evidence

The laboratory test value-based pyramid

Evidence must be translated into action to change outcomes

Improving Laboratory Utilization: A Single Academic Center Experience

Elizabeth Schulwolf, MD, MA, FACP, FHM

Associate Professor, Department of Medicine

Director, Division of Hospital Medicine

Co-Chair of Test Utilization Steering Committee

Disclosure

In the past 12 months, I have not had any significant financial

interest or other relationship with the manufacturers of the products

or providers of the services that will be discussed in my

presentation.

Objectives

• Define the problem at our institution

• Describe the clinical implication of lab overutilization in the

inpatient setting

• Examine literature on initiatives intended to reduce inpatient

laboratory utilization

• Discuss national campaigns for reducing laboratory utilization

• Summarize our initiatives to date and next steps

11

FY 17 Current = 62.6

FY 17 Threshold = 57

(14.9% reduction)

FY 17 Target = 53

(20.9% reduction)

Recent LUMC IP Utilization

What is the impact for patients?

• Increased risk of hospital-acquired anemia

• Studies demonstrate an associated decline in hemoglobin

relative to total volume of blood drawn during a hospital

stay

• Canadian study demonstrated every 100mL of

phlebotomy associated with 1.9% decrease hematocrit

• Similar findings in study of patients hospitalized with

acute myocardial infarction

• Potential improvement in patient satisfaction due to

reduction in venipunctures

Date of download: 1/26/2016Copyright © 2016 American Medical

Association. All rights reserved.

From: Diagnostic Blood Loss From Phlebotomy and Hospital-Acquired Anemia During Acute Myocardial

Infarction

Arch Intern Med. 2011;171(18):1646-1653. doi:10.1001/archinternmed.2011.361

Figure 1. Mean volume of diagnostic blood drawn on each day from hospital days 1 through 10. Mean blood drawn for laboratory

tests on each of the first 10 hospital days, comparing patients who developed moderate to severe hospital-acquired anemia (HAA)

with those who did not. The denominator on each hospital day included all patients who remained in the hospital on each respective

day hospital day (hospital day 1: 17 676; hospital day 2: 13 632; hospital day 3: 11 403; hospital day 4: 8261; hospital day 5: 5263;

hospital day 6: 3339; hospital day 7: 2183; hospital day 8: 1475; hospital day 9: 1060; hospital day 10: 753).

Figure Legend:

Initiatives to reduce lab utilization: Outpatient

• Study in primary care setting evaluating if displaying

laboratory costs would affect utilization

• One of four clinics passively displayed costs of 27 lab

tests at time of ordering

• Compared monthly lab ordering rate before and after

the intervention

• Labs selected based on high cost or high volume

• Four (19%) of lower cost tests and one (17%) higher

cost test showed significant reduction in the intervention

clinic

• 30% intervention physicians “always” or “usually”

considered the information in cost displays

Horn DM, et al. JGIM. 2013; 29(5): 708-14.

Initiatives to reduce lab utilization: Inpatient

• Pragmatic Randomized Introduction of Cost data study

through the EHR, 1-year study

• 3 hospitals in Philadelphia

• Medicare allowable fee data displayed in randomized

fashion for 30 intervention labs and 30 control labs

• No significant change in overall test ordering behavior or

lab fees

Sedrak MS, et al. JAMA Intern Med. 2017; 177(7): 939-45.

Why do we order unnecessary tests?

• 2014 internal medicine and general surgery resident

survey at the University of Pennsylvania

• 116 respondents

• 82.8% reported ordering unnecessary routine labs

• 49.0% reported ordering unnecessary routine labs on

a daily frequency

• 90.5% ordered out of “habit”

• 86.2% cited lack of cost transparency

• 82.8% reported discomfort with uncertainty

• 75.9% concerned the attending will want the

information

• 67.2% report lack of role modeling of cost conscious

care

• 65.5% cited lack of cost conscious culture at the

institution

• 51.7% cited ease of ordering labs in EHR

Sedrak MS, et al. J Hosp Med. 2016; 11: 869-72.

Choosing Wisely®

• Launched in 2012 by ABIM

• In collaboration with Consumer Reports

• Provides patient-friendly information to participating organizations to disseminate to their audiences

• Accompanying videos for providers and patients

• Reduce unnecessary tests and treatments

• 86 societies provide recommendations

Our Story

Local Initiatives

• Formation of Test Utilization Steering Committee

• Grass roots efforts to increase awareness and create

change in practice

• Displaying lab charges passively at the time of order entry

• Resident engagement

• Unit-level and team-level projects focused on lab

utilization

• Resident champions

• High-Value Care initiative focused on lab utilization

• Leveraging EMR for clinical decision support

• Pocket card to promote adding on lab tests and provide

reference for tube colors

• Get in early with the rising third year medical students

Sedrak MS, et al. JAMA Intern Med. 2017; 177(7): 939-45.

The “Five Rights” of Clinical Decision Support (CDS)

• The right information

• Alert includes previous patient test results

• To the right person

• Requestor may be making a potentially misinformed decision about lab testing

• In the right CDS intervention format

• Interruptive alert

• Through the right channel

• CPOE

• At the right time in the workflow

• At the time of ordering

Sirajuddin AM et al. J Healthc Inf Manag 2009; 23: 38 – 45

Orientation in Action

Next Steps

• Constant evaluation of our processes and assessment of

impact of initiatives

• Leveraging EMR to aid the ordering provider in clinical

decision-making

• Limiting the frequency of how often higher volume lab

tests can be ordered

• Displaying previous results in the order view

• Changing the ordering frequency display to give less

options to ordering providers

• Engagement of our unit medical directors and quality

medical directors to champion change at their “local” level

• Resident and faculty survey to understand our local culture

• Share data, data and more data!

• Celebrate wins!

Sedrak MS, et al. JAMA Intern Med. 2017; 177(7): 939-45.

Thank You

eschulwolf@lumc.edu

A Test Utilization Initiative and Quality Improvement Model

Kate Bernhardt, MS, MLS(ASCP)CM, LSSGB

Regulatory Compliance Specialist

LUMC Department of Pathology

kabernhardt@lumc.edu

Urinalysis with Reflex Culture (UARC)

Disclosure Statement

In the past 12 months, I have not had any significant financial interest or other relationship with the manufacturers of the products or providers of the services that will be discussed in my presentation.

Objectives

• Utilize Project Management tools to more efficiently lead quality improvement projects

• Describe how LUMC successfully decreased urine culture volume by approximately 50%, through implementation of Urinalysis with Reflex Culture (UARC)

• Understand the importance of identifying your stakeholders early and forming a robust communication plan

Project Management Basics

• Project Management is using a set of tools to:

• Create a work plan

• Manage work

• Anticipate and solve problems

• Allocate resources

• Implement the plan

Fred Pryor Seminars, a division of PARK University Enterprises, Inc. Project Management Workshop Seminar Workbook. 2015.

Lean Six Sigma

• Lean• “Eliminate waste”

• Six Sigma• “Eliminate defects”

• Lean Six Sigma• Theory that reducing

variation & waste in a process, and producing output within customer-defined limits, will yield great returns

• Organized, specific, repeatable means of assessing and resolving challenges with “DMAIC”

Loyola Medicine, Operational Excellence. Lean Six Sigma Green Belt Training Material. 2015.

Project Charter

PROBLEM STATEMENT: In an effort to reduce the number of unnecessary urine cultures and decrease

CAUTI rates within Loyola, the Department of Pathology will implement Urinalysis w/ Reflex to Culture (UARC). Each month, Microbiology receives an

average of +3,000 urine cultures; in December 2015, Microbiology received 3,243 urine cultures.

GOAL:After implementation of UARC, we would like to reduce the number of urine

cultures by one-third, with a stretch goal of a 50% reduction.

SCOPE:In: Inpatient and Outpatient Urine Cultures at LUMC & GMH

Out: Measuring reported CAUTIs (Infectious Disease)

Project CharterTEAM:

Project Champion : Dr. Stephen Kahn, Professor & Vice Chair of Clinical Services LUMC,Dr. Marisa Saint Martin, Laboratory Director of GMH

Project Manager: Kate Bernhardt, Regulatory Compliance Specialist

Team Members: Dr. Paul Schreckenberger, Dr. Jeanine Walenga, Michael Azzano, Cindy Blakemore, Roman Golash, Ann Del Bene, Jo Ann Molnar, Dr. Marisa Saint Martin (Project Champion GMH), Jean Wojtanek (GMH)

Special Thanks: Dr. Josh Lee, Mary Cashin, Jennifer Rodriguez, Violeta Rekasius, Debra Paris, Erin Ley, Beth Hoelting, Alex Castator, Colleen Jarosz, Kathy McKenna, Core Lab, Central Processing & Microbiology Colleagues

MILESTONES: LUMC Launch Date: April 12, 2016GMH Launch Date: August 11, 2016

Business Case

• Best practice of ordering urinalysis with reflex to culture

• Decrease unnecessary urine cultures

• Improve test utilization

• Increase efficiency in laboratory

• Improve antimicrobial stewardship

• CAUTI rate• Institutional efforts to decrease

number of CAUTIs

• Project may help contribute to less reported CAUTIs (false positives)

• Urine cultures ordered unnecessarily and come back positive, but not truly infection (contaminants)

• Published LUMC study showed 97% of patients without pyuria are shown to be negative for urinary tract infection; similar studies support absence of pyuria suggests diagnosis other than CAUTI

Order Change

• Urinalysis with Reflex Culture (UARC)

• Urinalysis is performed prior to all urine cultures

• Reflex cultures performed only when criteria for pyuria (≥6 WBC/hpf) is met, unless pre-determined exceptions are met*

• URIN (urine culture) no longer orderable to clinician

• Patient Exceptions• Neutropenic patients with WBC

<1.0 K/UL

• Pregnancy

• Patient scheduled for transurethral resection of prostate

• Patient scheduled for urologic procedures for which mucosal bleeding is anticipated

• Neonatal status

• Pediatric patients with known congenital anomalies of the urinary tract**

*Clinician orders UARC and select the applicable exception in Epic at time of order. The culture

will be performed even if the urinalysis is negative for pyuria.

**6th Patient Exception was added in March 2017 after clinician feedback.

Ordering in EMR

Ordering in EMR - Continued

Communication Plan

Results – First 30 Days

• Baseline Data• 3,243 urine cultures in

December 2015

• Average +3,000 / month (+100 / day)

• Many contaminated samples

• First 30 Days• 1,713 urine cultures

• Average 57 / day

• No longer receiving as many “junky” urines

• 47% Reduction in urine cultures

A 47% reduction exceeded our target of 33% and

almost reached our stretch goal of 50%.

Results – Monthly Volume of Urine Cultures (Figure 1)

UARC Go-Live on

4/12/16

Results - ContinuedTable 1. Ordering Patterns

Before and After UARCTable 2. Leukocyte esterase in UA by

Reflex Criteria (WBC > 6)*

Table 3. Urine Culture Positivity Rates

a. URID1 serves as a marker for “positivity”

because it is a lab entered charge code for

identification. The code would not be added if

the culture was contaminated or negative.

b. URID2 is a charge code for a second organism

identification. There is little difference between

the pre and post UARC data in URID2, so

additional analysis was not performed.

UARC Conclusions

1. Approximately 40 - 50% decrease in the monthly volume of total urine cultures performed by the Clinical Microbiology Laboratory (See Figure 1)

This general level of decrease in monthly urine cultures continues to be observed. While it is to be expected, the magnitude of this decrease is also reflected in the audit that was done on Epic orders for urinalysis leading to culture, pre and post UARC, in November of 2015 and 2016 (Table 1).

2. Sustained decrease in CAUTI Standardized Infection Ratio and improved quality metrics for incidence of CAUTI at our institution

According to institutional quality program leaders and the CAUTI Committee, the sustained decrease in the CAUTI SIR and improved quality metrics used for incidence of CAUTI in our institution can also be correlated with the timing in the implementation of UARC (data not shown).

3. Use of > 6 WBC per hpf only is an effective criterion for improving lab test utilization in establishing a process for reflexing urinalysis (UA) to culture. But others could be considered.

Other institutions have reported additional criteria in combination with a WBC per hpf level or as a standalone criterion such as positive leukocyte esterase and positive nitrites. While all stakeholders in our project supported the use of a WBC criterion alone, our data indicate that use of additional criteria such as a positive leukocyte esterase would increase the number of specimens reflexed to culture although the extent of this increase would depend on the semi-quantitative threshold used for the leukocyte esterase result (Table 2).

4. Implementing UARC increased the urine culture positivity rate (at least one organism) by ~ 4.5% (Table 3).

The LIS test codes shown are ones that are used in the lab as a charge code for identification of an organism (or organisms) in culture specimens. This code is not used if a culture specimen has been contaminated or is negative. Although we audited only a single month of results, there does not appear to be much difference in the frequency of culture specimens positive for two organisms, pre and post UARC, unlike the changed culture positivity rate for one organism only.

5. After UARC was implemented at our institution, a comparable process to UARC was implemented at a second institution in our system which is a neighboring community hospital.

Similar results in the impact of urinalysis reflexed to culture and improvements in lab test utilization were, and continue to be, observed at this second hospital in our health system.

Project Management Recommendations• Project Charter

• Define the problem and risk of not addressing it

• Set clear, measurable goals

• Eliminate scope creep

• Establish formal roles• Project Champion, Project Manager, Team Members

• Communication Plan• Identify all stakeholders

• Keep stakeholders informed throughout project

• Continual Improvement• Listen and look for additional opportunities

Thank You

kabernhardt@lumc.edu

Patient Blood Management in the Academic and Community Hospital Settings:Our Experience

Marisa Saint Martin, MD

Assistant Professor

Medical Director Pathology and Laboratory

Services Gottlieb Memorial Hospital

Associate Director Blood Bank and Apheresis

Services

Associate Director Pathology Residency Program

Loyola University Health System

Disclosure Statement

In the past 12 months, I have not had any significant financial interest or other relationship with the manufacturers of the products or providers of the services that will be discussed in my presentation.

Objectives

To recognize different ways of designing and

strengthening a plan for PBM in the academic

hospital and community setting, using team effort

and collaboration with other departments

Patient Blood Management

Definition

Facts

Accreditation and regulations

PBM culture at Loyola University Medical Center

and Gottlieb Memorial Hospital

PBM Definition

Evidence based, multi-disciplinary approach to

optimizing the care of patients that may need

transfusion

Encompasses all aspects of patient evaluation

and clinical management surrounding the

transfusion decision making process

Decreases the need for unnecessary blood

transfusion, decreases cost, ensures availability

of products for patients who need them

PBM: Why?

About 14 million units of RBC are transfused in

the US each year

Transfusion is the most common procedure a

physician will order in his/her career

Medical school education on transfusion

medicine is inadequate

WHO has been officially urging member states

to implement PBM since 2010

Accreditation/RegulationsThe Joint Commission 2011

Transfusion consent

RBC, plasma, and platelet transfusion

indications

Blood administration documentation

Preoperative anemia screening

Preoperative blood type and antibody screening

Accreditation/RegulationsAABB 2012 – Choosing Wisely Statements

Don't transfuse more units than needed

Don't transfuse RBC's for iron deficiency

Don't transfuse blood products for warfarin

reversal

Don't perform serial blood counts on stable

patients

Don't transfuse O negative blood except to O

negative patients and (in emergencies) women

of child-bearing age

Accreditation/RegulationsAHA 2013 – Top 5 Hospital Based Procedures

Blood management

Antibiotic stewardship

Reducing admissions for ambulatory sensitive

conditions

Appropriate use of elective percutaneous

coronary procedures

Appropriate use of ICU for terminal illness

Accreditation/RegulationsePBM 2015 – Joint Commission

Preoperative anemia

Preoperative hemoglobin

Preoperative type and x-match/type and screen

Initial transfusion threshold

Outcomes of PBM

Accreditation/RegulationsAABB and Joint Commission 2016 – Voluntary PBM Certification

Define credentials of transfusion ordering

individuals

Define PBM guidelines

Pre and post-transfusion patient care

Preoperative/pre-transfusion patient care

intervention/anemia management

Management of massive blood loss

Reporting

Accreditation/RegulationsAABB and Joint Commission 2016 – Voluntary PBM Certification

ReportingEffectiveness and opportunities for improvement

Allogeneic transfusion rates by service line and procedure type

Preoperative anemia intervention use and efficacy

Component use and discard

Appropriateness of transfusions

PBM techniques

Customer satisfaction

Compliance

Suspected transfusion associated events and under transfusion

Trinity : 93 Hospitals-One PBM

Monitoring of transfusion rates

Units ordered in non-bleeding patients

Pre-transfusion hemoglobin: >7 (or 8)

Discharge hemoglobin: >8 (or 9)

Trinity : 93 Hospitals-One PBM

EMR Data: Compiled and reviewed by

multidisciplinary team

Daily report

pRBC orders

pRBC indications

CRIT rule

Trinity : 93 Hospitals-One PBM

Daily report: Alert does not fire if

Patient is bleeding (>25% of BV or ongoing GI

bleed with Hgb <7, or high risk OB case)

Patient is not an adult

Patient has an excluded code in the problem list

Hemoglobin is <7

Patient is hemodynamically unstable: Systolic

Blood pressure changes of 20%

Trinity : 93 Hospitals-One PBM

Monthly summary report

By medical specialty

By DRG

Transfusion rate (# of patients transfused /total

# of patients)

# of patients transfused

Average units ordered/average units given

Average pre-transfusion hemoglobin

Average discharge hemoglobin

Trinity : 93 Hospitals-One PBM

Daily report

Monthly report

Quarterly Meeting

Educational activities

*93 hospitals and 121 continuing care facilities,

home care agencies and outpatient centers

* in 22 states

*131,000 colleagues

Trinity : LUMC

547 Beds

Trauma level I

Yearly pRBCs: ~17,000 units

Blood Utilization Review Committee:

Improvement of all dimensions of performance in

blood and blood component usage in addition to

serving as an educational resource for the health

care team

Trinity : LUMC

Blood Utilization Review Committee Members: Administration

Chair (medical staff member)

Nursing

Center for clinical excellence

Pharmacy

Risk management/ Patient safety

Blood bank director/staff

Laboratory

Cardio-thoracic surgery and General surgery

ED

OBGYN

Pediatrics

Medicine

Trinity : LUMC

Blood Utilization Review Committee

Improvement of all dimensions of performance in blood and

blood component usage

Responsible for policies and procedures concerning blood

usage

Administrative oversight concerning policies and protocols

dealing with patient safety and quality of patient care

Reports to Medical Executive Committee

Educational materials in our web site with guidelines, tools and

educational materials for easy access for all staff members

Educational material/announcements distribution

Trinity: GMH

254 Beds

Yearly pRBCs: ~1,700 units

Blood Utilization Review functions within the

Pharmacy and Therapeutics Committee

July 2015 PBM implemented lowering

hemoglobin trigger to 7

Trinity: GMH

Monitoring Transfusion practices following Trinity

parameters

Communication

Medical Executive Committee, Nursing and Specialty

Committees

News letter

General and Departmental Medical Staff Meetings

Success of 25% reduction of pRBC usage

Take Home Points

Implementation of PBM requires a

multidisciplinary approach with input from all

representative members throughout the hospital

The BUC or transfusion committee should be the

responsible entity for overseeing practice

changes and monitoring outcomes of transfusion

Education and gathering necessary tools and

materials with easy access and distribution

Take Home Points

Analyze

Discuss

DecideImplement

Measure

Take Home Points

Analytics: Data

Governance

Development

Education/Communication

Implement

Educate again

Measure

Communicate feedback with successes

Communicate additional opportunities for

improvement

Thank You

marisa.saintmartin@lumc.edu

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Symposium Panel

Q & A