Right test, right time, right patient

Interventions to improve appropriateness of laboratory testing in the intensive care unit: a narrative review

Healthcare expenses are increasing, as is the utilization of laboratory resources. Despite this, between 20% and 40% of requested tests are deemed inappropriate. Improper use of laboratory resources leads to unwanted consequences such as hospital-acquired anemia, infections, increased costs, staff workload and patient stress and discomfort. The most unfavorable consequences result from unnecessary follow-up tests and treatments (overuse) and missed or delayed diagnoses (underuse). In this context, several interventions have been carried out to improve the appropriateness of laboratory testing. To date, there have been few published assessments of interventions specific to the intensive care unit. We reviewed the literature for interventions implemented in the ICU to improve the appropriateness of laboratory testing. We searched literature from 2008 to 2023 in PubMed, Embase, Scopus, and Google Scholar databases between April and June 2023. Five intervention categories were identified: education and guidance (E&G), audit and feedback, gatekeeping, computerized physician order entry (including reshaping of ordering panels), and multifaceted interventions (MFI). We included a sixth category exploring the potential role of artificial intelligence and machine learning (AI/ML)-based assisting tools in such interventions. E&G-based interventions and MFI are the most frequently used approaches. MFI is the most effective type of intervention, and shows the strongest persistence of effect over time. AI/ML-based tools may offer valuable assistance to the improvement of appropriate laboratory testing in the near future. Patient safety outcomes are not impaired by interventions to reduce inappropriate testing. The literature focuses mainly on reducing overuse of laboratory tests, with only one intervention mentioning underuse. We highlight an overall poor quality of methodological design and reporting and argue for standardization of intervention methods. Collaboration between clinicians and laboratory staff is key to improve appropriate laboratory utilization. This article offers practical guidance for optimizing the effectiveness of an intervention protocol designed to limit inappropriate use of laboratory resources.

A descriptive study of routine laboratory testing in intensive care unit in nearly 140,000 patient stays

To describe the relationship between the use of laboratory tests and changes in laboratory parameters in ICU patients is necessary to help optimize routine laboratory testing. A retrospective, descriptive study was conducted on the large eICU-Collaborative Research Database. The relationship between the use of routine laboratory tests (chemistry and blood counts) and changes in ten common laboratory parameters was studied. Factors associated with laboratory tests were identified in a multivariate regression analysis using generalized estimating equation Poisson models. The study included 138,734 patient stays, with an ICU mortality of 8.97%. For all parameters, the proportion of patients with at least one test decreased from day 0 to day 1 and then gradually increased until the end of the ICU stay. Paradoxically, the results of almost all tests moved toward normal values, and the daily variation in the results of almost all tests decreased over time. The presence of an arterial catheter or teaching hospitals were independently associated with an increase in the number of laboratory tests performed. The paradox of routine laboratory testing should be further explored by assessing the factors that drive the decision to perform routine laboratory testing in ICU and the impact of such testing on patient.

Clinical Application of Genome and Exome Sequencing as a Diagnostic Tool for Pediatric Patients: a Scoping Review of the Literature

PURPOSE

Availability of clinical genomic sequencing (CGS) has generated questions about the value of genome and exome sequencing as a diagnostic tool. Analysis of reported CGS application can inform uptake and direct further research. This scoping literature review aims to synthesize evidence on the clinical and economic impact of CGS.

METHODS

PubMed, Embase, and Cochrane were searched for peer-reviewed articles published between 2009 and 2017 on diagnostic CGS for infant and pediatric patients. Articles were classified according to sample size and whether economic evaluation was a primary research objective. Data on patient characteristics, clinical setting, and outcomes were extracted and narratively synthesized.

RESULTS

Of 171 included articles, 131 were case reports, 40 were aggregate analyses, and 4 had a primary economic evaluation aim. Diagnostic yield was the only consistently reported outcome. Median diagnostic yield in aggregate analyses was 33.2% but varied by broad clinical categories and test type.

CONCLUSION

Reported CGS use has rapidly increased and spans diverse clinical settings and patient phenotypes. Economic evaluations support the cost-saving potential of diagnostic CGS. Multidisciplinary implementation research, including more robust outcome measurement and economic evaluation, is needed to demonstrate clinical utility and cost-effectiveness of CGS.

Reduction of Laboratory Utilization in the Intensive Care Unit

Objective:

In our academic intensive care unit (ICU), there is excess ordering of routine laboratory tests. This is partially due to a lack of transparency of laboratory-processing costs and to the admission order plans that favor daily laboratory test orders. We hypothesized that a program that involves physician and staff education and alters the current ICU order sets will lead to a sustained decrease in routine laboratory test ordering.

Design:

Prospective cohort study.

Setting:

Academic closed medical ICU (MICU).

Patients:

All patients admitted to the MICU.

Methods:

We consistently educated residents, faculty, and staff about laboratory test costs. We removed the daily laboratory test option from the admission order sets and asked residents to order needed laboratory test results every day. We only allowed the G3+I-STAT (arterial blood gas only) cartridges in the MICU in hopes of decreasing duplicative laboratory test results. We added laboratory review to the daily rounding checklist.

Measurement and Main Results:

Total number of laboratory tests per patient-day decreased from 39.43 to an average of 26.74 ( P <.001) over a 9-month period. The number of iSTAT laboratory tests per patient-day decreased from 7.37 to an average of 1.16 ( P < .001) over the same time period. The number of iSTAT/central laboratory processing duplicative laboratory tests per patient-day decreased from 0.17 to an average of 0.01 ( P < .001). The percentage of patients who have daily laboratory test orders decreased from 100% to an average of 11.94% ( P <. 001). US$123 436 in direct savings and US$258 035 dollars in indirect savings could be achieved with these trends. Intensive care unit morbidity and mortality were not impacted.

Conclusion:

A simple technique of resident, nursing, and ancillary staff education, combined with alterations in order sets using electronic medical records, can lead to a sustained reduction in laboratory test utilization over time and to significant cost savings without affecting patient safety.