Delivering safe and effective test-result communication, management and follow-up: a mixed-methods study protocol

Critical values notification: A nationwide survey of practices among clinical laboratories across Nigeria

Background

Critical value notification (CVN) entails notifying doctors or other laboratory users of aberrant laboratory results that threaten the patient's life and of any values for which reporting delays could negatively impact the patient's health. Critical value notification practices in clinical laboratories in Nigeria and sub-Saharan Africa are largely unknown.

Objective

We conducted a nationwide survey to obtain baseline information on CVN practice by Nigeria's laboratories.

Methods

This cross-sectional study was conducted among purposively selected secondary- and tertiary-tier, public and private clinical laboratories across northern and southern Nigeria between October 2015 and December 2015. Consenting senior laboratory staff completed and returned a structured questionnaire, that gathered data on respondents' demographics, designations, and institutional characteristics and practices regarding CVN.

Results

One hundred and thirty-four laboratories responded to the questionnaires. Only 69 (51.5 %) laboratories practised CVN; only 23 (33.3%) had existing written policies guiding the practice. Most (43; 62.3%) laboratories use similar critical values (CVs) for adult and paediatric populations. Most laboratories (27; 39.1%) obtained their CVs by combining published literature and local opinions from stakeholders. Physical dispatch (42; 60.9%) followed by telephone calls (38; 55.1%) were the most common means of notification. Private laboratories, compared with public hospital laboratories, were likelier to have separate paediatric CV lists (p = 0.019) and practise telephone notifications (p < 0.001).

Conclusion

Critical value notification practices vary and are often suboptimal in many clinical laboratories in Nigeria, which is exacerbated by the absence of guiding policies and national recommendations for post-analytical procedures.

What this study adds

This study provides baseline information on CVN practice by Nigeria's laboratories. The study explores the causes of practice variations that can serve as a foundation for enhancing critical reporting and post-analytical services, particularly in clinical laboratories in sub-Saharan Africa.

Critical Test Result Recall Supporting System (CTR RSS) Improves Follow-Up among Patients in the Community

Follow-up care of patients in the community is an important topic for improving patient outcomes, especially when medical personnel receives a notification of the critical test result (CTR) when the CTR becomes available after patients have been out of hospital; how to recall the patient back to the hospital and follow-up treatment is essential for preventing the healthcare risk of neglecting or delayed intervention with respect to the patient’s CTR. We are concerned that the follow-up of CTR and timely recall of our patients in the community improves and facilitates patient safety. We built the CTR Recall Supporting System (RSS) to follow up and recall our patients in the community. Measures were introduced to evaluate the effectiveness of CTR RSS; the rate of return of patients within 7 days increased from 58.5% to 88.8%, an increase of 30.3%, the patients in the community’s return follow-up interval days decreased from 10.9 days to 6.2 days, reduced by 4.7 days (p < 0.001), and the mortality rate of the patients in the community within 48 h decreased from 8.0% to 1.9%, a decrease of 6.1%, p < 0.001. The implementation of the CTR RSS significantly increases the discharged patient in he community’s CTR return follow-up within 7 days rate, decreases CTR return follow-up interval days, and reduces the CTR mortality rate within 48 h. This effectively improves the effects of CTR on return follow-up visits and provides a prototype system for hospitals that intend to improve this issue.

How is test-related information communicated in Australian Emergency Departments? - ED clinicians' and patients' perspectives

OBJECTIVES

To investigate the communication processes involving test-related information in Australian Emergency Departments (EDs); specifically what and how ED clinicians communicate test-related information to patients, what patients know and understand about the provided information, and how patients view the potential to access their test-results electronically.

METHODS

We conducted face-to-face semi-structured interviews with clinicians (n = 26) and patients (n = 32) across three Australian EDs. Interviews were transcribed and analysed iteratively, following principles of qualitative content analysis and grounded theory.

RESULTS

Depending on various contextual (e.g. time pressures) and patient factors (e.g. perceived health literacy), ED clinicians provided, and patients recalled receiving, test-related information along a continuum, ranging from "no or limited" information to "specific" information. Many patients were confused about how to access their test-results. Patients welcomed the potential for future electronic access to results but viewed their individual health and/or computer literacy skills and knowledge as potential barriers.

CONCLUSIONS

EDs are highly dynamic environments where contextual forces impinge on the amount and quality of test-related information that clinicians communicate to ED patients.

PRACTICE IMPLICATIONS

Systemic and patient factors need to be addressed to optimise the provision of test-related information in ED settings, improve patient understanding and foster patient empowerment.

Can patients contribute to enhancing the safety and effectiveness of test-result follow-up? Qualitative outcomes from a health consumer workshop

Background

Missed test‐results and failure to follow‐up test‐results are major patient safety concerns. Strategies to improve test‐results management have predominantly focused on clinician‐based interventions, with patients principally involved in studies of test‐result communication preferences, the impact of patient portals or experiences with reporting processes in primary care.

Objective

To identify consumer perspectives and experiences of the challenges they have faced with test‐results management, through consumer participation in qualitative data analysis.

Design and participants

Volunteers (n = 10) were recruited to participate in a health consumer reference group workshop on test‐results management. Prior to the workshop, consumers selected topics for discussion using a preference poll. During the workshop, consumers participated in qualitative data analysis of de‐identified excerpts of previously collected interview data discussing hospital test‐results management. Researchers (n = 5) guided consumers through the analytical process and discussion of themes. Discussions were audio‐recorded and transcribed for qualitative analysis.

Results

Consumer‐selected topics for discussion were ‘Transitions of Care’ and ‘Access’. Consumer data analysis prompted broader discussion including lived experiences. Following the workshop, a second level of content analysis pinpointed issues with implications for patient safety highlighting that consumers were astutely aware of macrolevel ‘Systems Factors’ relating to ‘Emergency Departments’ and the health system, as well as microlevel ‘Patient Factors’ (eg patient preferences and circumstances) which impact a patient's understanding during the ‘Communication’ (clinician to patient/between clinicians) of test‐results ‘Information’ (or lack thereof).

Conclusions

Consumers identified the challenges patients experience with test‐results management, and our findings highlight areas for potential improvement in patient safety.

Patient or public contribution

Ten health consumer volunteers actively participated in the test‐results management data analysis workshop conducted in this study. Two health consumers also volunteered to read and comment on the draft manuscript.

Development of an Artificial Intelligence-Based Automated Recommendation System for Clinical Laboratory Tests: Retrospective Analysis of the National Health Insurance Database

BACKGROUND

Laboratory tests are considered an essential part of patient safety as patients' screening, diagnosis, and follow-up are solely based on laboratory tests. Diagnosis of patients could be wrong, missed, or delayed if laboratory tests are performed erroneously. However, recognizing the value of correct laboratory test ordering remains underestimated by policymakers and clinicians. Nowadays, artificial intelligence methods such as machine learning and deep learning (DL) have been extensively used as powerful tools for pattern recognition in large data sets. Therefore, developing an automated laboratory test recommendation tool using available data from electronic health records (EHRs) could support current clinical practice.

OBJECTIVE

The objective of this study was to develop an artificial intelligence-based automated model that can provide laboratory tests recommendation based on simple variables available in EHRs.

METHODS

A retrospective analysis of the National Health Insurance database between January 1, 2013, and December 31, 2013, was performed. We reviewed the record of all patients who visited the cardiology department at least once and were prescribed laboratory tests. The data set was split into training and testing sets (80:20) to develop the DL model. In the internal validation, 25% of data were randomly selected from the training set to evaluate the performance of this model.

RESULTS

We used the area under the receiver operating characteristic curve, precision, recall, and hamming loss as comparative measures. A total of 129,938 prescriptions were used in our model. The DL-based automated recommendation system for laboratory tests achieved a significantly higher area under the receiver operating characteristic curve (AUROCmacro and AUROCmicro of 0.76 and 0.87, respectively). Using a low cutoff, the model identified appropriate laboratory tests with 99% sensitivity.

CONCLUSIONS

The developed artificial intelligence model based on DL exhibited good discriminative capability for predicting laboratory tests using routinely collected EHR data. Utilization of DL approaches can facilitate optimal laboratory test selection for patients, which may in turn improve patient safety. However, future study is recommended to assess the cost-effectiveness for implementing this model in real-world clinical settings.

Variation in electronic test results management and its implications for patient safety: A multisite investigation

Objective

The management and follow-up of diagnostic test results is a major patient safety concern. The aim of this qualitative study was to explore how clinicians manage test results on an everyday basis (work-as-done) in a health information technology–enabled emergency department setting. The objectives were to identify (1) variations in work-as-done in test results management and (2) the strategies clinicians use to ensure optimal management of diagnostic test results.

Materials and Methods

Qualitative interviews (n = 26) and field observations were conducted across 3 Australian emergency departments. Interview data coded for results management (ie, tracking, acknowledgment, and follow-up), and artifacts, were reviewed to identify variations in descriptions of work-as-done. Thematic analysis was performed to identify common themes.

Results

Despite using the same test result management application, there were variations in how the system was used. We identified 5 themes relating to electronic test results management: (1) tracking test results, (2) use and understanding of system functionality, (3) visibility of result actions and acknowledgment, (4) results inbox use, and (5) challenges associated with the absence of an inbox for results notifications for advanced practice nurses.

Discussion

Our findings highlight that variations in work-as-done can function to overcome perceived impediments to managing test results in a HIT-enabled environment and thus identify potential risks in the process. By illuminating work-as-done, we identified strategies clinicians use to enhance test result management including paper-based manual processes, cognitive reminders, and adaptive use of electronic medical record functionality.

Conclusions

Test results tracking and follow-up is a priority area in need of health information technology development and training to improve team-based collaboration/communication of results follow-up and diagnostic safety.

Evaluation of a health system-wide pharmacist-driven emergency department laboratory follow-up and antimicrobial management program

BACKGROUND

Emergency Department (ED) follow-up programs ensure that cultures, laboratory studies, and empiric antimicrobials are appropriately managed post-discharge. We sought to provide a comprehensive assessment of a pharmacist-driven laboratory follow-up process in a large, integrated health system.

METHODS

A retrospective, observational review of 13 EDs was conducted. Patients were included if they had a laboratory study sent from the ED between December 1, 2017 and May 31, 2018 that did not result while the patient was in the ED. Microbiology results analyzed were urine, wound, respiratory, stool, throat, bacterial vaginosis, vaginal candidiasis, and sexually transmitted infections (STI). Examples of laboratory results assessed were metabolic panels and drug levels. The primary objective was to quantify the number of interventions made by pharmacists.

RESULTS

During a 6-month period, pharmacists reviewed 9107 microbiology results and 6211 laboratory results. The majority of results were urine cultures (3998, 50.6%) followed by STI results (1198, 15.2%). Of 7663 encounters, 39.8% required interventions and/or follow-up with a total of 3049 interventions made and 3333 patients educated. The most common interventions were initiation of therapy (1629, 53.4%), change in medication (505, 16.6%), and follow-up with a clinician (322, 10.6%). Pharmacists reviewed microbiology results and completed interventions in a median of 25.3 h from the time the result was received in the electronic health record.

CONCLUSION

Almost 40% of ED encounters required an intervention after discharge. A pharmacist led laboratory follow-up program is an important adjunct to facilitating stewardship and culture management in the ED.

Interaction and innovation: practical strategies for inclusive consumer-driven research in health services

INTRODUCTION

Despite advances in the co-creation of clinical research involving consumers in the last few decades, consumer engagement in health services research generally remains inconsistent and is too often treated as a perfunctory exercise.

OBJECTIVE

Drawing on a health services study on diagnostic test result management, communication and follow-up, we: (1) outline practical strategies used to enhance the contribution of health consumer representatives across all stages of health services research, including active involvement in prioritising objectives for data analysis and participating in data analysis and the dissemination of findings; and (2) describe the impact of continued engagement of consumers on the programme of research, the interpretation of findings and their translational potential.

KEY INNOVATIONS

Key enabling innovations for engagement included: (1) planned opportunities for long-term consumer involvement across all stages of the research process from conception to dissemination; (2) enhanced consumer engagement capacity; (3) purposeful recruitment of appropriately trained consumers; (4) provision of support structures for active consumer involvement in research design, analysis and write-up; and (5) financial support for consumer involvement.

IMPACT/CONCLUSION

Enhancing consumer contribution and establishing inclusive research design requires a negotiated, interactive, meaningful and transparent process. As a collaborative approach, consumer-driven research involvement offers opportunities for new, often unexpected or unexplored perspectives to feature across the whole research process. In a move away from tokenistic consumer involvement, consumers and researchers who participated in this novel and immersive research project identified inclusive research as a powerful tool to enhance health services research and its translation into effective policy.

A comparative study of the utilisation of an electronic test-result management system in emergency and intensive care settings

The purpose of this qualitative study was to identify differences in the utilisation of an electronic medical record test-result management system between two acute care departments. Field observations (130 min) and semi-structured interviews (n = 24) were conducted in the Intensive Care Unit and Emergency Department of an Australian hospital. Work processes identified from audio transcripts were modelled using business process modelling. Comparison of the Emergency Department and Intensive Care Unit identified the following: (1) test ordering variations according to clinical roles, (2) differences in the use of electronic medical record functionality according to specific demands of the clinical environment and (3) the non-linear components of the test-result management process. Variations were identified in the number of process decisions, external collaborations and temporal process workflows. Modelling the business processes, collaboration and communication needs of individual clinical environments can aid in enhancing the quality and appositeness of health information technology interventions and thus contribute to improving patient safety. Future health information technology interventions/evaluations aimed at improving the safety of test-result management processes need to address both the nuances of the clinical environment and accommodate the individual work practices of clinicians within that environment.

GOFlow: Smartwatch app to deliver laboratory results in emergency departments - A feasibility study

PURPOSE

Information Technology (IT) plays a critical role in supporting emergency physicians' (EPs) routines. Pagers, personal computers, and smartphones offer fast access to patient data, such as laboratory results. However, due to the inherent features of specimen processing and laboratory instruments, the turnaround time from test ordering to availability of results can be long. Lack of follow-up of abnormal results can lead to missed information that could impact patient care and safety. Despite the increasing use of ubiquitous technologies, a third of physicians remains devoid of reliable methods for ensuring that results have been received. In this feasibility study, we report the potential of using a smartwatch to deliver laboratory results to EPs at the point-of-care and to support efficiency in emergency care. Unlike mobile devices that are increasingly used by EPs, smartwatches are always accessible, even during hands-on procedures.

METHOD

Two EPs and four experts in human-computer interaction designed the smartwatch application following the Design Science Research Methodology (DSRM). The application was then evaluated in a pediatric emergency department through semi-simulated scenarios by eleven EPs. The primary outcome was to measure both the app perceived usability and satisfaction scores by the aim of the System Usability Scale (SUS), and the perceived usefulness and intention of its use by the aim of the Unified Theory of Acceptance and Use of Technology (UTAUT) scale. Secondary outcomes were to assess the application's efficiency by measuring the delay between the reception of the notification and 1) the access to its details and 2) the visit to the patient. Finally, open questions about the positive and negative aspects of the prototype as well as potential improvements were asked and evaluated qualitatively.

RESULTS

The prototype obtained a score of 81.4 out of 100 (good) on the SUS and a score of 5.96 out of 7 on the UTAUT scale. EPs using the smartwatch visited patients within 30 seconds receiving the laboratory results.

CONCLUSIONS

This study demonstrates the capacity of smartwatches to speed up the point-of-care delivery of laboratory results in the ED.

Timing of respiratory virus molecular testing in emergency departments and its association with patient care outcomes: a retrospective observational study across six Australian hospitals

OBJECTIVE

A rapid molecular diagnostic test (RMDT) offers a fast and accurate detection of respiratory viruses, but its impact on the timeliness of care in the emergency department (ED) may depend on the timing of the test. The aim of the study was to determine if the timing of respiratory virus testing using a RMDT in the ED had an association with patient care outcomes.

DESIGN

Retrospective observational study.

SETTING

Linked ED and laboratory data from six EDs in New South Wales, Australia.

PARTICIPANTS

Adult patients presenting to EDs during the 2017 influenza season and tested for respiratory viruses using a RMDT. The timing of respiratory virus testing was defined as the time from a patient's ED arrival to time of sample receipt at the hospital laboratory.

OUTCOME MEASURES

ED length of stay (LOS), >4 hour ED LOS and having a pending RMDT result at ED disposition.

RESULTS

A total of 2168 patients were included. The median timing of respiratory virus testing was 224 min (IQR, 133-349). Every 30 min increase in the timing of respiratory virus testing was associated with a 24.0 min increase in the median ED LOS (95% CI, 21.8-26.1; p<0.001), a 51% increase in the likelihood of staying >4 hours in ED (OR, 1.51; 95% CI, 1.41 to 1.63; p<0.001) and a 4% increase in the likelihood of having a pending RMDT result at ED disposition (OR, 1.04; 95% CI, 1.02 to 1.05; p<0.001) after adjustment for confounders.

CONCLUSION

The timing of respiratory virus molecular testing in EDs was significantly associated with a range of outcome indicators. Results suggest the potential to maximise the benefits of RMDT by introducing an early diagnostic protocol such as triage-initiated testing.

The Relationship between Health Information Technology Laboratory Tracking Systems and Hospital Financial Performance and Quality

The objective of this study is to explore the relationship between hospitals Health Information Technology (HIT), and financial and quality performance. The study merged the 2017 Centers for Medicare & Medicaid Services (CMS) Healthcare Cost Report Information System, American Hospital Association Annual Survey, and two CMS Hospital Compare datasets. A total of 3002 hospitals were analyzed using multivariate analysis. We found that hospitals with laboratory tracking systems reported better financial performance on five financial performance measures. Policymakers should consider developing policies that facilitate exploration and adoption of various hospital HIT capabilities that measurably improves hospital quality of care.

Barriers and facilitators impacting reliability of the electronic health record-facilitated total testing process

OBJECTIVE

Despite ongoing efforts to improve reliability of the total testing process (TTP), breakdowns continue to occur resulting in diagnostic delays and suboptimal patient outcomes. We performed an exploratory study to identify factors that impact TTP reliability in electronic health record (EHR)-enabled care.

MATERIALS AND METHODS

We interviewed experts at three large EHR-enabled health care organizations and identified all TTP steps performed from clinician test ordering to result communication to patients. Findings from all sites were combined to develop a detailed process map of known TTP activities. We additionally asked experts about factors that positively or negatively impacted TTP reliability at each step. We describe the specific TTP steps identified and associated barriers and facilitators to TTP reliability.

RESULTS

We interviewed 39 experts involved in or overseeing the TTP. Most TTP activities identified were similar across sites, but we found significant differences with test order transmission to diagnostic services and relay of results back to clinicians and patients. Twenty-five unique barriers were identified related to technology and EHR usability issues, time and resource constraints, suboptimal clinic workflows, patient-related factors, information access limitations, and insufficient clinician training. Twenty-four unique facilitators were identified related to personnel training, workflow optimization and standardization, helpful EHR features, and improved electronic communication between clinics and diagnostic services.

DISCUSSION

Barriers related to EHR usability and with communication between clinicians and diagnostic services increase TTP vulnerability and should be targeted by future efforts to improve process reliability. Several facilitators identified in the study could inform future strategies and solutions to improve TTP reliability.

Patient groups, clinicians and healthcare professionals agree - all test results need to be seen, understood and followed up

Background Diagnostic testing provides integral information for the prevention, diagnosis, treatment and management of disease. Inadequate test result reporting and follow-up is a major risk to patient safety. Factors contributing to failure to follow-up test results include unclear delineation of responsibility about who is meant to act on a test result; poor coordination across different levels of care; and the absence of integrated health information systems for the efficient information communication. Methods A 2016 Australian Stakeholder Forum brought together over 30 representatives from 14 different consumer, clinical and management stakeholder organisations to discuss safe and effective test result communication, management and follow-up. Thematic analysis was conducted drawing on multimodal data collected in the form of observational fieldnotes and document artefacts produced by participants. Results The forum identified major challenges which pose immediate risks to patient safety. Participants recommended priorities for addressing issues relating to: (i) the governance of test result management processes; (ii) integration of health care processes through the utilisation of effective digital health solutions; and (iii) involving patients as key partners in the decision-making and care process. Conclusions Stakeholder groups diverged slightly in their priorities. Consumers highlighted the lack of patient involvement in the test result management process but were less concerned about standardisation of reports and critical result thresholds than pathologists. The forum foregrounded the need for a systems approach, capable of identifying and addressing interconnections and multiple factors that contribute to poor test result follow-up, with a strong emphasis on enhancing the contribution of patients.

The impact of rapid molecular diagnostic testing for respiratory viruses on outcomes for emergency department patients

OBJECTIVE

To determine whether rapid polymerase chain reaction (PCR) testing for influenza and respiratory syncytial viruses (RSV) in emergency departments (EDs) is associated with better patient and laboratory outcomes than standard multiplex PCR testing.

DESIGN, SETTING

A before-and-after study in four metropolitan EDs in New South Wales.

PARTICIPANTS

1491 consecutive patients tested by standard multiplex PCR during July-December 2016, and 2250 tested by rapid PCR during July-December 2017.

MAIN OUTCOME MEASURES

Hospital admissions; ED length of stay (LOS); test turnaround time; patient receiving test result before leaving the ED; ordering of other laboratory tests.

RESULTS

Compared with those tested by standard PCR, fewer patients tested by rapid PCR were admitted to hospital (73.3% v 77.7%; P < 0.001) and more received their test results before leaving the ED (67.4% v 1.3%; P < 0.001); the median test turnaround time was also shorter (2.4 h [IQR, 1.6-3.9 h] v 26.7 h [IQR, 21.2-37.8 h]). The proportion of patients admitted to hospital was also lower in the rapid PCR group for both children under 18 (50.6% v 66.6%; P < 0.001) and patients over 60 years of age (84.3% v 91.8%; P < 0.001). Significantly fewer blood culture, blood gas, sputum culture, and respiratory bacterial and viral serology tests were ordered for patients tested by rapid PCR. ED LOS was similar for the rapid (7.4 h; IQR, 5.0-12.9 h) and standard PCR groups (6.5 h; IQR, 4.2-11.9 h; P = 0.27).

CONCLUSION

Rapid PCR testing of ED patients for influenza virus and RSV was associated with better outcomes on a range of indicators, suggesting benefits for patients and the health care system. A formal cost-benefit analysis should be undertaken.

An evaluation of variation in pathology investigations and associated factors for adult patients presenting to emergency departments with chest pain: An observational study

OBJECTIVE

To determine variation in pathology test ordering practices and identify associated factors for adult patients presenting to emergency departments (ED) with chest pain and subsequently admitted with ischaemic heart disease.

METHODS

A retrospective study across six hospital EDs in New South Wales, Australia. A total of 6769 patient presentations between January 2014 and December 2017 met the inclusion criteria. Ordered pathology tests were grouped into three categories based on Australasian College for Emergency Medicine and the Royal College of Pathologists of Australasia recommendations: category I (no restriction in ordering), category II (can be ordered after consulting a supervisor) and category III (not for routine ordering in ED). The primary outcome was the proportion of category III test ordering across study EDs. Factors associated with category III test ordering were identified using a logistic regression.

RESULTS

A total of 34 936 pathology tests were ordered: 65.6% (n = 22 932) were category I/II tests and 34.4% (n = 12 004) were category III tests. Five tests (Calcium Magnesium Phosphate, Coagulation Studies, Lipase, C-reactive Protein and Blood Gas tests) accounted for 84.7% of all category III tests. The proportion of category III tests ordered varied by hospitals from 29.8% to 45.9%. The proportion of patients with at least one category III test was 76.3% (range across hospitals: 68.3%-95.6%). Increasing age, presentation to an ED at night, and those in an imminently life-threatening triage category were significantly associated with increased likelihood of category III test ordering. The proportion of category III tests decreased over time. EDs in medium and/or regional hospitals were more likely to order a category III test.

CONCLUSION

Pathology investigations for patients presenting with chest pain varied significantly across EDs suggesting opportunities to improve standardisation of test ordering practices.