Electrolyte orders in the neuroscience intensive care unit: worth the value or waste?

Revisiting the Environmental Impact of Inappropriate Clinical Laboratory Testing: A Comprehensive Overview of Sustainability, Economic, and Quality of Care Outcomes

BACKGROUND

The use of laboratory resources has seen a substantial increase in recent years, driven by automation and emerging technologies. However, inappropriate use of laboratory testing, encompassing both overuse and underuse, poses significant challenges.

CONTENT

This review explores the complex interplay between patient safety, economic, and environmental factors-known as the "triple bottom line" or "3Ps" for people, profit, and planet-associated with inappropriate use of laboratory resources. The first part of the review outlines the impact of inappropriate laboratory testing on patient safety and economic outcomes. Then the review examines the available literature on the environmental impact of laboratory activities. Several practical solutions for mitigating the environmental impact of laboratories are discussed. Finally, this review emphasizes how decreasing unnecessary laboratory testing results in cost savings and environmental benefits, as evidenced by interventional studies, without compromising patient safety.

SUMMARY

The implementation of sustainable practices in laboratories can create a virtuous circle in which reduced testing enhances cost-efficiency, reduces the environmental footprint, and ensures patient safety, thereby benefiting the 3Ps. This review highlights the critical need for appropriate laboratory resource utilization in achieving sustainability in healthcare.

Routine Versus On-Demand Blood Sampling in Critically Ill Patients: A Systematic Review

OBJECTIVES

We aimed to provide an overview of the current evidence on routine versus on-demand blood sampling in critical care. We assessed the reported proportion of patients exposed to daily routine blood sampling, the tests performed, characteristics associated with more frequent blood sampling, and the reported benefits and harms of routine blood sampling compared with on-demand sampling.

DATA SOURCES

We systematically searched the Cochrane Library, the Excerpta Medica Database, and the Medical Literature Analysis and Retrieval System Online for studies assessing routine versus on-demand blood testing in critically ill patients from inception to September 2022.

STUDY SELECTION

Abstracts and full texts were assessed independently and in duplicate by two reviewers.

STUDY EXTRACTION

Data were extracted independently and in duplicate by two reviewers using predefined extraction forms.

DATA SYNTHESIS

Of 12,212 records screened, 298 full-text articles were assessed for eligibility. We included 70 studies; 50 nonrandomized interventional studies and 20 observational studies. Exposure to routine blood testing was 52-100% (very low certainty of evidence). Blood testing seemed to occur more frequently in medical intensive care settings with a median of 18 blood tests per patient day (interquartile range, 10-33) (very low certainty of evidence). Mixed biochemistry seemed to be the most frequently performed blood tests across all settings (five tests per patient day; interquartile range, 2-10) (very low certainty of evidence). Reductions in routine blood testing seemed to be associated with reduced transfusion rates and costs without apparent adverse patient outcomes (low certainty of evidence).

CONCLUSIONS

In this systematic review, routine blood testing in critically ill patients was common and varied considerably. A reduction in routine blood testing appeared to be associated with reduced transfusion rates and costs without adverse effects, but the evidence was very uncertain.

Electrolyte Analysis and Replacement: Challenging a Paradigm in Surgical Patients

Postoperative patients are susceptible to alterations in electrolyte homeostasis. Although electrolytes are replaced in critically ill patients, stable asymptomatic non-intensive care unit (ICU) patients often receive treatment of abnormal electrolytes. We hypothesize there is no proven benefit in asymptomatic patients. In 2016, using the electronic medical records and pharmacy database at a university academic medical center, we conducted a retrospective cost analysis of the frequency and cost of electrolyte analysis (basic metabolic panel [BMP], ionized calcium [Ca], magnesium [Mg], and phosphorus [P]) and replacement (potassium chloride [KCl], Mg, oral/iv Ca, oral/iv P) in perioperative patients. Patients without an oral diet order, with creatinine more than 1.4, age less than 16 years, admitted to the ICU, or with length of stay of more than 1 week were excluded. Nursing costs were calculated as a fraction of hourly wages per laboratory order or electrolyte replacement. One hundred thirteen patients met our criteria over 11 months. Mean length of stay was 4 days; mean age was 54 years; and creatinine was 0.67 ± 0.3. Electrolyte analysis laboratory orders (n = 1,045) totaled $6,978, and BMP was most frequently ordered accounting for 36% of laboratory costs. In total, 683 doses of electrolytes cost the pharmacy $1,780. Magnesium was most frequently replaced, followed by KCl, P, and Ca. Nursing cost associated with electrolyte analysis/replacement was $7,782. There is little evidence to support electrolyte analysis and replacement in stable asymptomatic noncritically ill patients, but their prevalence and cost ($146/case) in this study were substantial. Basic metabolic panels, pharmacy charges for potassium, and nursing staff costs accounted for the most significant portion of the total cost. Considering these data, further research should determine whether these practices are warranted.

The sustainable impact of an educational approach to improve the appropriateness of laboratory test orders in the ICU

INTRODUCTION

Few studies described strategies to improve the use of diagnostic tests in intensive care units (ICU). No study assessed whether their impact was sustained or not. In this study, we assessed whether a multi-faceted intervention for more appropriate use of laboratory testing can decrease the number of tests, is sustainable, is not associated with additional morbidity and represents a potential cost saving.

MATERIAL AND METHODS

An open-label prospective cohort study in two separated units of the same medical intensive care unit (ICU) including respectively 3315 and 2392 consecutive patients. After the observation period (2010), a reduction in ICU A of unnecessary diagnostics tests as part of a program including senior supervisory of juniors' orders, encouragements for orders containment at each everyday round discussions (period 2; 2011). Period 3 (2012) consisted in the prolongation of the protocol as a routine care without supervision; Period 4 (2013) was a new period of observation without intervention. No modification was implemented in ICU B in periods 2-4.

RESULTS

After the intervention, a decrease in the overall number of tests per ICU-patient-days (37.3±5.5 (baseline) to 15.2±3.2 (- 59%); p<0.0001) was observed. The total cost of the tests decreased from 239±41 to 104±28 euros per ICU-patient days; p<0.0001. The effect on laboratory test orders was sustainable in period 3 (-49%) and 4 (-30%). No significant secondary effect of the intervention was observed in period 2. In ICU B, there was no significant change in the overall laboratory test orders in between the periods.

CONCLUSIONS

Laboratory test containment is effective, likely safe and sustainable provided that an educational program is repeatedly promoted, that it makes sense for the whole team, that senior and junior physicians are both committed in the program, and that encouragements for laboratory orders containment at each everyday round discussions.

Impact of the acute care nurse practitioner in reducing the number of unwarranted daily laboratory tests in the intensive care unit

BACKGROUND

Frequent laboratory testing may be necessary at times for critically ill patients. However, the practice of indiscriminate laboratory test ordering is common.

PURPOSE

The purpose of this quality improvement project was to assess the effectiveness of the acute care nurse practitioner (ACNP) in reducing the number of unwarranted laboratory tests ordered for ICU patients. To determine whether the presence of an ACNP would make a difference, an ACNP was present on daily ICU multidisciplinary rounds to facilitate the discussion of the laboratory testing needs for each patient for the following 24-hour period.

CONCLUSIONS

Eighty-one patients were enrolled in the project, 41 in the comparison and 40 in the intervention group. No significant differences were noted between the two groups. The project demonstrated that although there was an increase in tests ordered for the intervention group, the increase was brought about by an increase in specific individual tests rather than an increase in panels of laboratory tests. A reduction in patient cost was observed for the number of tests ordered. No increase in adverse events was noted.

IMPLICATIONS FOR PRACTICE

Acute care nurse practitioner presence on multidisciplinary rounds may be an effective method to change the practice toward the ordering of tests based on clinical indication.

Reducing Unnecessary Postoperative Complete Blood Count Testing in the Pediatric Intensive Care Unit

CONTEXT

Complete blood count (CBC) testing commonly occurs to determine the need for blood transfusions after surgical procedures. Many clinicians believe postoperative CBCs are "routine."

OBJECTIVE

To decrease unnecessary routine CBC testing in a low-risk cohort of postoperative patients in the pediatric intensive care unit (PICU) at The Children's Hospital of Philadelphia by 50% in 6 months.

DESIGN

Quality-improvement study. Data from our institution regarding frequency of ordering laboratory studies and transfusion requirements were collected for prior quality-improvement work demonstrating the safety and feasibility of avoiding routine postoperative CBCs in this cohort. Baseline survey data were gathered from key stakeholders on attitudes about and utilization of routine postoperative laboratory testing. Patient and clinician data were shared with all PICU clinicians. Simple Plan-Do-Study-Act cycles involving education, audit, and feedback were put into place.

MAIN OUTCOME MEASURES

Percentage of postoperative patients receiving CBCs within 48 hours of PICU admission. Balancing measures were hemoglobin level below 8 g/dL in patients for whom CBCs were sent and blood transfusions up to 7 days postoperatively for any patients in this cohort.

RESULTS

Sustained decreases below our 50% goal were seen after our interventions. There were no hemoglobin results below 8 g/dL or surgery-related blood transfusions in this cohort within 7 days of surgery. Estimated hospital charges related to routine postoperative CBCs decreased by 87% during 6 postintervention months.

CONCLUSION

A simple approach to a systemic problem in the PICU of unnecessary laboratory testing is feasible and effective. By using local historical data, we were able to identify a cohort of patients for whom routine postoperative CBC testing is unnecessary.

Targeted reduction in neurosurgical laboratory utilization: resident-led effort at a single academic institution

Object

Given economic limitations and burgeoning health care costs, there is a need to minimize unnecessary diagnostic laboratory tests.

Methods

The authors studied whether a financial incentive program for trainees could lead to fewer unnecessary laboratory tests in neurosurgical patients in a large, 600-bed academic hospital setting. The authors identified 5 laboratory tests that ranked in the top 13 of the most frequently ordered during the 2010–2011 fiscal year, yet were least likely to be abnormal or influence patient management.

Results

In a single year of study, there was a 47% reduction in testing of serum total calcium, ionized calcium, chloride, magnesium, and phosphorus. This reduction led to a savings of $1.7 million in billable charges to health care payers and $75,000 of direct costs to the medical center. In addition, there were no significant negative changes in the quality of care delivered, as recorded in a number of metrics, showing that this cost savings did not negatively impact patient care.

Conclusions

Engaging physician trainees in quality improvement can be successfully achieved by financial incentives. Through the resident-led quality improvement incentive program, neurosurgical trainees successfully reduced unnecessary laboratory tests, resulting in significant cost savings to both the medical center and the health care system. Similar programs that engage trainees could improve the value of care being provided at other academic medical centers.

Potassium sparing diuretics as adjunct to mannitol therapy in neurocritical care patients with cerebral edema: effects on potassium homeostasis and cardiac arrhythmias

BACKGROUND

Mannitol therapy to treat cerebral edema induces osmotic diuresis and electrolyte loss. In neurocritical care patients, potassium is the electrolyte that most often needs replacement. Objective of this study was to evaluate the effects of adding potassium sparing diuretic (canrenone) to mannitol therapy on potassium urinary excretion, potassium plasma levels, and incidence of new cardiac arrhythmias in patients receiving neurocritical care for cerebral edema.

METHODS

Fifty-six patients were prospectively assigned to mannitol or mannitol plus i.v. canrenone. Potassium urinary excretion, potassium plasma levels, urinary volume, and the incidence of new cardiac arrhythmias were recorded during the first 8 days of therapy.

RESULTS

In patients treated with mannitol the potassium urinary excretion was stable over the first 3 days and significantly increased, compared to baseline, on day 4th to 8th (baseline 20.3 ± 10.6 mEq/l/die, day 8th 24.6 ± 10.6 mEq/l/die, P < 0.05); while potassium plasma levels significantly decreased. In patients receiving mannitol plus canrenone potassium urinary excretion decreased from day 3rd to 8th (baseline 21.9 ± 11.6 mEq/l/die, day 8th 15.9 ± 10.9 mEq/l/die, P < 0.015) and potassium plasma levels increased but remained within normal values range. The incidence of new cardiac arrhythmias was higher in the mannitol group than the mannitol plus canrenone group (35.7 vs. 10.7%; P < 0.01). Urinary volumes, potassium balance, and sodium plasma concentration were similar in the 2 study groups.

CONCLUSION

In patients receiving neurocritical care for cerebral edema, the adjunct of a potassium sparing diuretic (canrenone) to mannitol therapy reduces potassium urinary loss, prevents hypokalemia, and reduces the incidence of new cardiac arrhythmias.

How to save costs by reducing unnecessary testing: lean thinking in clinical practice

BACKGROUND

The burden of health care expenditure on national budgets has increased dramatically over the past decade. A pilot study in our hospital demonstrated that many unnecessary diagnostic tests were performed routinely. The aim of this study was to reduce the costs of unnecessary diagnostic tests.

METHODS

All diagnostic costs between 2006 and 2008 of the internal medicine department of the VU University Centre were evaluated. A target was set to reduce diagnostic expenditure by 7.5% in 2009 compared to 2008. A few interventions were introduced including introducing posters and pocket cards detailing the costs of diagnostic tests, six weekly feedback on diagnostics costs, mentorship of junior doctors, unbundling panel tests and increasing protocol adherence. Main outcome measures were the reduction in the total diagnostic costs and the total number of laboratory tests performed in the internal medicine department in 2009.

RESULTS

In 2009, we achieved a 13% reduction in the total diagnostic costs compared to 2008. The department of internal medicine spent 2.80 million euro and 2.45 million euro on the diagnostic tests in 2008 and 2009 respectively and thereby saved 350.000 euro in 2009. The largest reduction was achieved by reducing the number of laboratory tests performed.

CONCLUSION

Introduction of a few simple measures to improve awareness among the physicians led to a significant reduction in the diagnostic costs in the department of internal medicine. Extending these measures to the entire hospital and even entire country will in our opinion lead to significant reduction in the health care costs.