Reducing Unnecessary Phlebotomy Testing Using a Clinical Decision Support System

Overuse of phlebotomy testing offers little to improve patient outcomes but may subject patients to additional morbidity. Low-cost, high-frequency tests are ordered recurrently, unnecessarily, and contribute to the high cost of health care. Reducing unnecessary phlebotomy tests can cut costs without compromising quality. Type and screen tests are active for three days from the date the specimen is collected, yet our blood bank laboratory observed type and screen tests were often unnecessarily ordered in our organization. We set out to determine the effectiveness of a clinical decision support system (CDSS) on reducing unnecessary type and screen tests, estimate the cost saved by the CDSS implementation, and describe the unnecessary ordering practices by provider type. Adoption of CDSSs has been successful in reducing unnecessary radiologic imaging, overutilization of antibiotics, and Clostridium dificile testing. Our value improvement initiative was a separate-sample pretest posttest design at a mid-Atlantic academic health system. A CDSS was embedded in our computerized order entry (COPE) system to promote appropriate test ordering. The CDSS appears when a type and screen is ordered informing the provider of the date and time the current test expires. Our study demonstrated that CDSSs impacted a variety of provider types, reduced unnecessary phlebotomy tests, and achieved yearly cost savings. Unnecessary testing continues in health care and contributes to excessive health spending without adding value. Phlebotomy testing is one example of how providers can reduce waste and control healthcare costs for low-cost, high-frequency tests. To further improve test ordering practices of all provider types, we recommend additional interventions such as organizational support, education, audits, and feedback. In this era of precision medicine, ordering the right test, at the right time, for the right reason can reduce cost, reduce waste, and improve quality, outcomes, and satisfaction for patients. Until the establishment of national quality measures aimed to control the number of low-cost, high-frequency tests, health systems must find a way to reduce unnecessary health services. CPOE is widely used in a variety of health care settings and can incorporate CDSS to guide all provider types to make judicious decisions at the time of care

Impact of Implementing the Geriatric Resource Nurse Model on Fall and Hospital Acquired Pressure Ulcer Rates, and Length of Stay in Older Adults in an Acute Care Hospital

Background.Older adults are at high risk for adverse care outcomes, such as injuries from falls, hospital acquired pressure ulcers (HAPUs), and prolonged length of stay (LOS). Available evidence suggests outcomes may improve when older adults are cared for by healthcare providers with competence in geriatrics. To improve outcomes, an acute care not-for-profit teaching hospital in Washington DC area implemented a Geriatric Resource Nurse (GRN) model that prepares registered nurses (RNs) as clinical experts on core geriatric principles on four general care wards (three medical-surgical and one cardiac). Objectives. Toexamine the effects of GRN model implementation on fall and HAPU rates, and LOS in older adults in medical-surgical and cardiac units in an acute care hospital. Methods.A retrospective chart review was conducted to measure fall and HAPU rates, and LOS before and after implementation of the GRN model. Data from 1176 charts (609 in before and 567 in after intervention group) was reviewed. Data analysis was performed in SPSS 22. Results. Total number of falls was 24 (2.0%) with 13 (2.1%) before and 11 (1.9%) after intervention group. Total number of HAPUs was 26 (2.2%) including 18 (3.0%) before and 8 (1.4%) after intervention group. LOS ranged from 1-71 days. LOS mean for total population was 5.14 (SD=5.10), with a mean of 4.88 (SD=4.71) before and a mean of 5.41 (SD=5.49) after intervention. There were no statistically significant differences in fall (x2=0.06, p=0.81) and HAPU (x2=3.24, p=0.07) rates or LOS (t=-1.78, p=0.07) before and after the intervention. Conclusions. Our findingsdid not identify significant differences in fall and HAPU rates, and LOS before and after the intervention. These findings may be a result of inconsistencies in the institutional application of a systematic approach to geriatric care

Effects of a comprehensive bariatric program implementation on 30-day readmission and 30-day ER/infusion clinic visit rates due to dehydration

Background: Program accreditation requires adherence to MBSAQIP standards to assist patient in making needed changes to his/her diet and lifestyle. However, literature provides conflicting information regarding the value of a comprehensive bariatric program accreditation and its effects on 30-day readmission and 30-day ER/infusion clinic visit due to dehydration development. Objectives: To examine the effects of implementing a comprehensive bariatric surgical program on 30-day readmission rates, and 30-day emergency room (ER) and infusion clinic visit rates due to dehydration for bariatric surgical patients. Methods: Our study was a retrospective separate sample pre-post intervention chart review. The data were collected before and after implementing a comprehensive bariatric program using a convenience sample of 180 adult patients (age ≥18) that had bariatric surgery at an acute care hospital. We conducted Chi-square analyses with significance levels set at 0.05. Results: Among the 180 patients, majority had laparoscopic gastric bypass (n=112, 62.2%). Among the 180 patients, 55 (31%) were in the pre-intervention and 125 (69%) were in the post-intervention group. A total of 7 (3.9%) had 30-day readmission. Significantly more patients (n=5, 9.1%) in the pre-intervention group had 30-day readmission compared to those in the post-intervention group (n=2, 1.6%; X2=5.73, p=0.03). Among the 180 patients, 8 (4.4%) had 30-day ER/infusion clinic visit due to dehydration. No difference was found in 30-day ER/infusion clinic visit between the pre-intervention (n=5, 9.1%) and the post-intervention groups (n=3, 2.4%; X2=4.03, p=0.06). Conclusion: Implementation of comprehensive bariatric program was effective in lowering 30-day readmission rates

Disparities in Cardiac Rehabilitation Referral for Patients with Myocardial Infarction in the United States

Background: Each year an estimated 635,000 Americans experience a myocardial infarction (MI) and a treatment that has been shown to decrease mortality is cardiac rehabilitation. Proposed federal legislation, S.488, supports nurse practitioners and clinical nurse specialists to meet direct supervision requirements for cardiac rehabilitation programs. If passed, nurse leaders will need to work closely with hospitals to ensure all eligible MI patients are referred. Objective: To identify demographic and clinical characteristics of MI patients associated with lower cardiac rehabilitation referral rates in a national U.S. cohort. Methods: This was a retrospective cohort analysis using 2011-2015 data from the American College of Cardiology’s ACTION Registry-GWTGs. The cohort included 507,793 MI patients from 851 U.S. hospitals. Patients were stratified by referral versus non-referral and patient demographics and clinical characteristics were compared using χ2 tests (p\u3c.05). Results: A total of 78% (n=395,948) of patients were referral for cardiac rehabilitation. Patients aged ≥80 years (70.9%, n=44,918, p≤.001) had the lowest rate of age groups. Women (75.2%, n= 123,191) had significantly lower referral rates compared to men (79.3%, n= 272,757) (χ2 = 1110.168, p ≤ .001). Hispanic patients (65.5%, n=19,149) had the lowest referral rate of all race/ethnicity groups. Referral rates were significantly lower for patients without PCI (64.4%, n=99,364) or CABG (76.7%, n=354,945) during admission compared to those with PCI and CABG (83.9%, n=296,584, p ≤ .001 and 76.7%, n=354,945, p≤001 respectively). Conclusions: Patients who were aged ≥80 years, Hispanic, or did not receive a PCI or CABG had lower referral rates. These results support a gap in referral for cardiac rehabilitation remains and there’s a need for quality improvement

A Retrospective Analysis of Surgeon Estimated Time and Actual Operative Time to Develop an Efficient Operating Room Scheduling System

Problem: Surgical departments account for sizable budgets in hospitals. To ensure efficiency, optimal processes need to be maintained. The current practice for posting a surgical case is using surgeon estimated times (SETs), which only includes the reporting points of component 2 (C2) incision to dressing. Objective: To analyze if there was a significant difference in minutes between actual operative times (AOT) and SET in patients undergoing outpatient general laparoscopic and inpatient orthopedic total joint surgery. Methods: The facility is a level one trauma teaching center, with 371 beds, and a yearly surgical volume of 17,000 cases. This retrospective study used random sampling to compare and analyze the difference between AOT and SET, as well as actual operating room time (AORT): component one (C1) - patient in OR to before incision and component 3 (C3) - after dressing to patient out of OR. With a statistical power level of 0.8%, an alpha of 0.05%, a sample size of 120 surgical patients from each category was included. Results: In hypotheses testing for outpatient general laparoscopic and inpatient orthopedic total joint patients, the results indicated that SET time (mean=105.8, + 31.6; mean=147, +36.4) in minutes was significantly greater than the AOT times (mean=75.5, + 30.6; p=0.001; mean=111.5, +23.4; p=0.0001) in minutes, respectively. Conclusions: The results uncovered a significant variance between AOT and SET suggested over booking; whereas in AORT and SET, results suggested under booking. An interdisciplinary team will be assembled to develop an efficient scheduling system