L ABORATORY S TEWARDSHIP : T AKING THE F IRST S TEPS TO D OWNSTREAM S AVINGS A NDREW F LETCHER MD CONSULTATIVE SERVICES │ LABORATORY STEWARDSHIP
Background 13 Billion test performed 70% decisions based 10-30% unnecessary CONSULTATIVE SERVICES │ LABORATORY STEWARDSHIP
Background 3 most significant causes of patient harm • Ordering the wrong test • Failing to retrieve a test result • Misinterpreting a test result CONSULTATIVE SERVICES │ LABORATORY STEWARDSHIP
their patients ask for an unnecessary test or procedure at 47 % least once a week the average medical doctor prescribes an unnecessary 72 % test or procedure at least once a week 53 % that even if they know a medical test is unnecessary, they order it if a patient insists the frequency of unnecessary 73 % tests and procedures is a very or somewhat serious problem CONSULTATIVE SERVICES │ LABORATORY STEWARDSHIP
Trends in Healthcare Radiology Utilization management Blood Utilization Laboratory Stewardship Antimicrobial Stewardship Pharmacy Utilization management CONSULTATIVE SERVICES │ LABORATORY STEWARDSHIP
Creating Successful Laboratory Stewardship 1/3 Success Factors of labs have a stewardship program Data Analysis 1/2 Formal Governance of those labs have a productive Evidence-Based Recommendations and progressing committee IT Engagement and Support Project Management Measurement and Reporting CONSULTATIVE SERVICES │ LABORATORY STEWARDSHIP
NCLS Publication CONSULTATIVE SERVICES │ LABORATORY STEWARDSHIP
Where to Start? Three Initial areas of Focus Test Consolidation How many reference labs do you use? Reference test formulary Creation & Implementation In-House Testing Daily recurring labs Inappropriate test intervals CONSULTATIVE SERVICES │ LABORATORY STEWARDSHIP
Test Consolidation How many reference laboratories do you use? 1. Is there a primary Vendor? 2. Why are tests sometimes not consolidated? -Physician Request -Patient Request -Insurance requirement -Easier process for lab staff Free Phenytoin at Lab X $106 Free Phenytoin at Primary Lab vendor $13 CONSULTATIVE SERVICES │ LABORATORY STEWARDSHIP
Where to Start? Three Initial areas of Focus Test Consolidation How many reference labs do you use? Reference test formulary Creation & Implementation In-House Testing Daily recurring labs Inappropriate test intervals CONSULTATIVE SERVICES │ LABORATORY STEWARDSHIP
Test Formulary Review Eliminate Review all send out test listing in remaining testing menu if test on menu performed ordered <4 to see if in 1 year times in 1 year reasonable CONSULTATIVE SERVICES │ LABORATORY STEWARDSHIP
POE Optimization Vitamin D Folate • 1,25-Dihydroxy vitamin D • Folate (RBC) • 25-Hydroxy vitamin D • Folate (serum) Flu Gonorrhea • Flu PCR • Gonorrhea culture • Flu respiratory viral panel • Gonorrhea DNA probe • Flu screen CONSULTATIVE SERVICES │ LABORATORY STEWARDSHIP
POE POE Optimization Optimization CONSULTATIVE SERVICES │ LABORATORY STEWARDSHIP
Inpatient Reference test cost Monthly average pre Formulary $31,054 Monthly average post Formulary $20,028 35% Percent decrease Average monthy savings $11,026 Projected yearly savings $132,309 CONSULTATIVE SERVICES │ LABORATORY STEWARDSHIP
Commonly Misordered Testing Test Removal & Reflex Path Implementation 18 16 14 12 85% 86% 10 8 6 4 2 0 MTHFR 2 Mutations Factor V Leiden APC w/reflex to Factor V Leiden CONSULTATIVE SERVICES │ LABORATORY STEWARDSHIP
Where to Start? Three Initial areas of Focus Test Consolidation How many reference laboratories do you use? Reference test formulary Creation & Implementation In-House Testing Daily recurring labs Inappropriate test intervals CONSULTATIVE SERVICES │ LABORATORY STEWARDSHIP
Daily Orders Don’t perform repetitive CBC and chemistry testing in the face of clinical and lab stability. Don’t order diagnostic tests at regular intervals (such as every day), but rather in response to specific clinical questions. CONSULTATIVE SERVICES │ LABORATORY STEWARDSHIP
Intervention Methods Proactive Reactive Appropriate order sets Duplicate alerts Order management Formulary restriction alerts Preference list management Best Practice Alerts Physician education Physician education Physician report cards CONSULTATIVE SERVICES │ LABORATORY STEWARDSHIP
76548965 76548965 Zyne Cotopaxi, MD 09/04/2016 15:47 09/04/2016 13:00 IU/mL Thyroid Stimulating Hormone 4.0 CONSULTATIVE SERVICES │ LABORATORY STEWARDSHIP
Summary Justification for Stewardship NCLS Recommendations Three Initial areas of Focus: Test Consolidation How many reference labs do you use? Reference test formulary Creation & Implementation In-House Testing Daily recurring labs Inappropriate test intervals CONSULTATIVE SERVICES │ LABORATORY STEWARDSHIP
70% of medical decisions are influenced by laboratory 13 Billion data laboratory tests 3% performed annually in the U.S. of U.S. healthcare expenditures spent on Laboratory Services CONSULTATIVE SERVICES │ LABORATORY STEWARDSHIP
Downstream impact • Length of stay • Pharmacy • Radiology • Others…… CONSULTATIVE SERVICES │ LABORATORY STEWARDSHIP
Troponin orders and Chest Pain LOS 23 CONSULTATIVE SERVICES │ LABORATORY STEWARDSHIP
T ROPONIN I 3500 2,965 3000 2500 2000 1500 4,410 1000 500 0 0 0.5 1 1.5 2 2.5 3 3.5 4 4.5 5 5.5 6 6.5 7 7.5 8 8.5 9 9.5 10 10.5 11 11.5 12 12+ Improve the time-to-decision Identify order Modify the repeat time mechanisms that by improving the test interval to be 3-6 hours after drive the repeat by up to 3 hours interval CONSULTATIVE SERVICES │ LABORATORY STEWARDSHIP
T ROPONIN I 4000 3,587 3500 3000 2500 2000 1500 1000 500 0 0.0 0.5 1.0 1.5 2.0 2.5 3.0 3.5 4.0 4.5 5.0 5.5 6.0 6.5 7.0 7.5 8.0 8.5 9.0 9.5 10.0 10.5 11.0 11.5 12+ Improve the time-to-decision Identify order Modify the repeat time mechanisms that by improving the test interval to be 3-6 hours after drive the repeat by up to 3 hours interval CONSULTATIVE SERVICES │ LABORATORY STEWARDSHIP
Downstream impact • Length of stay • Pharmacy • Radiology • Others…… CONSULTATIVE SERVICES │ LABORATORY STEWARDSHIP
Downstream Impact on Pharmacy IVIG Argatroban Remicade CONSULTATIVE SERVICES │ LABORATORY STEWARDSHIP
Downstream impact • Length of stay • Pharmacy • Radiology • Others…… CONSULTATIVE SERVICES │ LABORATORY STEWARDSHIP
Radiology Services CONSULTATIVE SERVICES │ LABORATORY STEWARDSHIP
CT PE Protocol 30 CONSULTATIVE SERVICES │ LABORATORY STEWARDSHIP
CONSULTATIVE SERVICES │ LABORATORY STEWARDSHIP
D-Dimer and CT PE Protocol 32 CONSULTATIVE SERVICES │ LABORATORY STEWARDSHIP
33 CONSULTATIVE SERVICES │ LABORATORY STEWARDSHIP
CONSULTATIVE SERVICES │ LABORATORY STEWARDSHIP
23% CT Scans = 45,000 chest x-rays CONSULTATIVE SERVICES │ LABORATORY STEWARDSHIP
23% CT Scans = $34.20 per scan CONSULTATIVE SERVICES │ LABORATORY STEWARDSHIP
23% CT Scans = $10,260 cost saving CONSULTATIVE SERVICES │ LABORATORY STEWARDSHIP
23% CT Scans = $1,445,400 savings for patients CONSULTATIVE SERVICES │ LABORATORY STEWARDSHIP
23% CT Scans = 360 hrs reduction in LOS CONSULTATIVE SERVICES │ LABORATORY STEWARDSHIP
Downstream impact • Length of stay • Pharmacy • Radiology • Others…… CONSULTATIVE SERVICES │ LABORATORY STEWARDSHIP
L ABORATORY S TEWARDSHIP : T AKING THE F IRST S TEPS TO D OWNSTREAM S AVINGS A NDREW F LETCHER MD CONSULTATIVE SERVICES │ LABORATORY STEWARDSHIP
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