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Eberlein TR, Knudsen J, Lylloff L, Markussen MS, Nielsen P, Mose FH. Reversing a trend towards overtesting in a department of internal medicine in Denmark. BMJ Open Qual 2023; 12:e001934. [PMID: 38123472 DOI: 10.1136/bmjoq-2022-001934] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/19/2022] [Accepted: 08/29/2023] [Indexed: 12/23/2023] Open
Affiliation(s)
| | - Judith Knudsen
- Department of Medicine, Gødstrup Hospital, Herning, Denmark
| | - Louise Lylloff
- Department of Clinical Biochemistry, Gødstrup Hospital, Herning, Denmark
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Halm MA. On Low-Value Nursing Care: Part 1, Why De-implementation Matters for Quality Care. Am J Crit Care 2022; 31:338-342. [PMID: 35773189 DOI: 10.4037/ajcc2022857] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/30/2023]
Affiliation(s)
- Margo A Halm
- Margo A. Halm is associate chief nurse executive, nursing research and evidence-based practice, VA Portland HealthCare System, Portland, Oregon
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Rethinking Blood Testing in Pediatric Cancer Patients: A Quality Improvement Approach. Pediatr Qual Saf 2022; 7:e552. [PMID: 35720866 PMCID: PMC9197359 DOI: 10.1097/pq9.0000000000000552] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/05/2021] [Accepted: 02/09/2022] [Indexed: 12/04/2022] Open
Abstract
Introduction: The overuse of blood tests burdens the healthcare system and can detrimentally impact patient care. Risks of frequent blood sampling include infection and clinician-induced anemia, which can negatively impact patients and their families. Pediatric cancer patients are particularly vulnerable as they are immunocompromised with a small blood volume. Four blood tests had become a daily practice. Therefore, we aimed to reduce the number of blood tests taken per bed day within the inpatient pediatric cancer unit by 15% within 8 months. Methods: This quality improvement project combined several strategies to reduce test frequency and empower clinicians on the rationale for blood test ordering. Recommendations were developed collaboratively presented in a summary table. Targeted behavior-change methodology built engagement and momentum for the change. All clinicians were challenged to STOP and THINK about why a test is necessary for each patient. The primary outcome measure was the frequency of the tests taken per bed day. Frequency was compared between pre- and postimplementation plus follow-up periods across 2019–2021. Results: 26,941 blood tests were captured in 1,558 admissions. The intervention led to an overall blood test reduction of 37% over 8 months. Liver Function Tests were the standout, with a 52% decrease in test frequency. Conclusions: A strategy incorporating education and culture change, combined with clear guidance on testing frequency, significantly reduced the ordering frequency of blood tests without increased patient harm.
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Rietbergen T, Spoon D, Brunsveld-Reinders AH, Schoones JW, Huis A, Heinen M, Persoon A, van Dijk M, Vermeulen H, Ista E, van Bodegom-Vos L. Effects of de-implementation strategies aimed at reducing low-value nursing procedures: a systematic review and meta-analysis. Implement Sci 2020; 15:38. [PMID: 32450898 PMCID: PMC7249362 DOI: 10.1186/s13012-020-00995-z] [Citation(s) in RCA: 17] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/17/2020] [Accepted: 04/29/2020] [Indexed: 11/11/2022] Open
Abstract
Background In the last decade, there is an increasing focus on detecting and compiling lists of low-value nursing procedures. However, less is known about effective de-implementation strategies for these procedures. Therefore, the aim of this systematic review was to summarize the evidence of effective strategies to de-implement low-value nursing procedures. Methods PubMed, Embase, Emcare, CINAHL, PsycINFO, Cochrane Central Register of Controlled Trials, Web of Science, and Google Scholar were searched till January 2020. Additionally, reference lists and citations of the included studies were searched. Studies were included that described de-implementation of low-value nursing procedures, i.e., procedures, test, or drug orders by nurses or nurse practitioners. PRISMA guideline was followed, and the ‘Cochrane Effective Practice and Organisation of Care’ (EPOC) taxonomy was used to categorize de-implementation strategies. A meta-analysis was performed for the volume of low-value nursing procedures in controlled studies, and Mantel–Haenszel risk ratios (95% CI) were calculated using a random effects model. Results Twenty-seven studies were included in this review. Studies used a (cluster) randomized design (n = 10), controlled before-after design (n = 5), and an uncontrolled before-after design (n = 12). Low-value nursing procedures performed by nurses and/or nurse specialists that were found in this study were restraint use (n = 20), inappropriate antibiotic prescribing (n = 3), indwelling or unnecessary urinary catheters use (n = 2), ordering unnecessary liver function tests (n = 1), and unnecessary antipsychotic prescribing (n = 1). Fourteen studies showed a significant reduction in low-value nursing procedures. Thirteen of these 14 studies included an educational component within their de-implementation strategy. Twelve controlled studies were included in the meta-analysis. Subgroup analyses for study design showed no statistically significant subgroup effect for the volume of low-value nursing procedures (p = 0.20). Conclusions The majority of the studies with a positive significant effect used a de-implementation strategy with an educational component. Unfortunately, no conclusions can be drawn about which strategy is most effective for reducing low-value nursing care due to a high level of heterogeneity and a lack of studies. We recommend that future studies better report the effects of de-implementation strategies and perform a process evaluation to determine to which extent the strategy has been used. Trial registration The review is registered in Prospero (CRD42018105100).
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Affiliation(s)
- Tessa Rietbergen
- Department of Biomedical Data Sciences, Section Medical Decision Making, Leiden University Medical Center, Leiden, The Netherlands
| | - Denise Spoon
- Department of Internal Medicine, Nursing Science, Erasmus MC University Medical Center, Rotterdam, The Netherlands
| | | | - Jan W Schoones
- Leiden University Medical Center, Walaeus Library, Leiden, The Netherlands
| | - Anita Huis
- Department of Primary and Community Care, Radboud Institute for Health Sciences, Scientific Institute for Quality of Healthcare, Radboud University Medical Center, Nijmegen, The Netherlands
| | - Maud Heinen
- Department of Primary and Community Care, Radboud Institute for Health Sciences, Scientific Institute for Quality of Healthcare, Radboud University Medical Center, Nijmegen, The Netherlands
| | - Anke Persoon
- Department of Primary and Community Care, Radboud Institute for Health Sciences, Scientific Institute for Quality of Healthcare, Radboud University Medical Center, Nijmegen, The Netherlands
| | - Monique van Dijk
- Department of Internal Medicine, Nursing Science, Erasmus MC University Medical Center, Rotterdam, The Netherlands
| | - Hester Vermeulen
- Department of Primary and Community Care, Radboud Institute for Health Sciences, Scientific Institute for Quality of Healthcare, Radboud University Medical Center, Nijmegen, The Netherlands.,Faculty of Health and Social Studies, HAN University of Applied Sciences, Nijmegen, The Netherlands
| | - Erwin Ista
- Department of Internal Medicine, Nursing Science, Erasmus MC University Medical Center, Rotterdam, The Netherlands
| | - Leti van Bodegom-Vos
- Department of Biomedical Data Sciences, Section Medical Decision Making, Leiden University Medical Center, Leiden, The Netherlands.
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Regan W, Hothi D, Jones K. Sustainable approach to reducing unnecessary combined biochemistry tests on a paediatric cardiology ward. BMJ Open Qual 2018; 7:e000372. [PMID: 30397659 PMCID: PMC6203018 DOI: 10.1136/bmjoq-2018-000372] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/05/2018] [Accepted: 07/13/2018] [Indexed: 11/25/2022] Open
Abstract
We describe a quality improvement project (QIP) designed to reduce unnecessary biochemistry samples requested on a paediatric cardiology ward in Great Ormond Street Hospital. Prior to the intervention biochemistry tests were requested on a daily basis by nursing and junior doctor staff at an annual cost of around £27 000 for the ward. The lead author observed that for the majority the true indication for these biochemistry tests was for the purpose of monitoring renal function and plasma electrolytes. However, during a diagnostic analysis trying to understand the behaviours around ordering tests it appeared that a broader profile and more expensive combined test set was being requested that included unnecessary liver and bone profile analyses. A driver diagram identified three areas to target in order to rationalise blood test requests: (1) a critical understanding of the purpose of the test by those requesting the tests; (2) effective communication between professionals; and (3) improved utilisation of the computer system. An education-based QIP was initiated with the aim of reducing requests of these costly, unnecessary combined biochemical tests by half, by supporting and encouraging staff to switch to a simpler renal function assay. The project was designed to be engaging and fun and invited clinical teams to consider the cost of wasted resources in terms of the financial implications for the hospital, and in terms of the wider environmental impact of wasted resources illustrated in terms of estimated carbon dioxide use. This perhaps unusual approach of encouraging an awareness of both financial and environmental cost led to a sustained reduction in the ordering of expensive combined biochemical tests, saving an estimated £11 338 (or 13.5%) on biochemistry tests and around 17.8 tonnes of carbon dioxide across a 32-month follow-up period.
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Affiliation(s)
- William Regan
- Paediatric Cardiology Department, Great Ormond Street Hospital, London, UK
| | - Daljit Hothi
- Paediatric Cardiology Department, Great Ormond Street Hospital, London, UK
| | - Kevin Jones
- Quality Improvement Team, Great Ormond Street Hospital, London, UK
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