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August 17th, 2015

First-year residents rethink daily labs, improve patient care

By Amy Olson

Sometimes, it’s the simplest things that make the biggest differences in a patient’s care.

Fresh out of medical school at the University of North Dakota and weeks into his first year of residency, Joel Beachey, M.D., found himself contemplating a challenge from his attending physicians and chief residents: Just how frequently do hospital patients need certain blood tests?

Not as often as one might think.

Dr. Beachey and seven other residents – Drs. Urshila Durani, Elsie Mensah, Priya Joel Beachey, M.D.Vijayvargiya, Gaya Acharya, Kalie Kebed, Megha Prasad, and Matthew Thoendel – embarked on a quality improvement project to see if something as simple as talking through expectations could reduce two tests: Electrolyte panels and complete blood counts. Those tests are among those most commonly ordered, Beachey said.

“Dr. Beachey and the team looked at the literature and found close to 70 percent of lab tests done in the hospital on patients were unnecessary,” said Amy Oxentenko, M.D., director for the Internal Medicine Residency program.

The two tests – complete blood count and electrolyte panel – have important uses: Complete blood counts can help a physician assess whether a patient is fighting an infection or has internal bleeding. An electrolyte panel can help monitor for kidney function.

Having the tests may not change overall management of patients’ conditions. In some cases, it can harm patients, said Dr. John Ratelle, Internal Medicine, co-coordinator of the Quality Improvement curriculum during which Dr. Beachey and the team completed the project.

“We kind of assume if you’re in the hospital, you’ve got to have your blood drawn, right? That’s just something that needs to be done,” Dr. Ratelle said. “But maybe that’s not the case. Maybe things have been stable and it’s not really influencing day-to-day care.”

A number of factors play into physicians ordering the tests.

“A lot of it is lack of provider comfort and lack of knowledge what the cost of testing is,” Dr. Beachey said. “It’s also a lack of knowing what consultant expectations are for daily labs.”

Dr. Beachey and his team collaborated with other stakeholders across several departments and work areas. Based upon their analysis, they put together a short education session and then compared the number of the two tests ordered per patient for three days before the session and three days after the session. The number of tests ordered per patient per day dropped by 33 percent following the education session.

“We were kind of surprised that within that short period of time that we had that significant of a result,” Dr. Beachey said. “It really showed us that just a simple intervention, such as providing education and encouraging providers to think about their daily ordering, can make a really large difference.”

For Dr. Oxentenko, it highlighted the need for faculty to set clear expectations as well as a cultural shift in medicine.

“We need to give trainees permission to not order things. When I think back to when I was a resident, more was better. You felt that you were a better resident if you thought of everything and ordered all these laboratory tests while someone was in the hospital,” Dr. Oxentenko said. “The culture is completely different now.”

For Dr. Sara Bonnes, General Internal Medicine, the project demonstrates the power of small changes and the need to teach quality improvement methodology.

“It’s not necessarily the big things that make the greatest difference,” said Dr. Bonnes, co-coordinator of the Quality Improvement curriculum  in which Dr. Beachey and the team completed the project. “A lot of times, they like to focus on changing the electronic orders or other things. Sometimes, it’s just communication that is key.”

Dr. Bonnes said it’s important to share findings of quality improvement projects, both within and outside Mayo. In November, Dr. Beachey presented their findings at the Minnesota American College of Physicians meeting and won the quality improvement poster competition. In April, he was able to share their findings with a larger audience at the national American College of Physicians conference.

Dr. Beachey is interested in continuing the improvement efforts to see how the results might be sustained.

Watch Drs. Beachey, Bonnes, Oxentenko and Ratelle describe the project:

Tags: #FutureofHealthCare, Affordable Care Act, Arizona, Dr. John Noseworthy, Dr. Robert Nesse, Dr. William Rupp, Uncategorized

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