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Bell KJL, Stancliffe R. Less is more for greener intensive care. Intensive Care Med 2024; 50:746-748. [PMID: 38587554 DOI: 10.1007/s00134-024-07378-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/20/2023] [Accepted: 02/27/2024] [Indexed: 04/09/2024]
Affiliation(s)
- Katy J L Bell
- Sydney School of Public Health, The University of Sydney, Sydney, NSW, 2006, Australia.
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2
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Devis L, Catry E, Honore PM, Mansour A, Lippi G, Mullier F, Closset M. Interventions to improve appropriateness of laboratory testing in the intensive care unit: a narrative review. Ann Intensive Care 2024; 14:9. [PMID: 38224401 PMCID: PMC10789714 DOI: 10.1186/s13613-024-01244-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/11/2023] [Accepted: 01/03/2024] [Indexed: 01/16/2024] Open
Abstract
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.
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Affiliation(s)
- Luigi Devis
- Department of Laboratory Medicine, Biochemistry, CHU UCL Namur, Université catholique de Louvain, Yvoir, Belgium
| | - Emilie Catry
- Department of Laboratory Medicine, Biochemistry, CHU UCL Namur, Université catholique de Louvain, Yvoir, Belgium
- Institute for Experimental and Clinical Research (IREC), Pôle Mont Godinne (MONT), UCLouvain, Yvoir, Belgium
| | - Patrick M Honore
- Department of Intensive Care, CHU UCL Namur, Université catholique de Louvain, Yvoir, Belgium
| | - Alexandre Mansour
- Department of Anesthesia and Critical Care, Pontchaillou University Hospital of Rennes, Rennes, France
- IRSET-INSERM-1085, Univ Rennes, Rennes, France
| | - Giuseppe Lippi
- Section of Clinical Biochemistry and School of Medicine, University Hospital of Verona, Verona, Italy
| | - François Mullier
- Department of Laboratory Medicine, Hematology, CHU UCL Namur, Université catholique de Louvain, Yvoir, Belgium
- Namur Thrombosis and Hemostasis Center (NTHC), Namur Research Institute for Life Sciences (NARILIS), Namur, Belgium
- Institute for Experimental and Clinical Research (IREC), Pôle Mont Godinne (MONT), UCLouvain, Yvoir, Belgium
| | - Mélanie Closset
- Department of Laboratory Medicine, Biochemistry, CHU UCL Namur, Université catholique de Louvain, Yvoir, Belgium.
- Institute for Experimental and Clinical Research (IREC), Pôle Mont Godinne (MONT), UCLouvain, Yvoir, Belgium.
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3
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Hjortsø CJS, Møller MH, Perner A, Brøchner AC. Routine Versus On-Demand Blood Sampling in Critically Ill Patients: A Systematic Review. Crit Care Med 2023; 51:717-730. [PMID: 36951465 DOI: 10.1097/ccm.0000000000005852] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/24/2023]
Abstract
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.
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Affiliation(s)
- Carl J S Hjortsø
- Department of Intensive Care, Copenhagen University Hospital - Rigshospitalet, Copenhagen, Denmark
| | - Morten H Møller
- Department of Intensive Care, Copenhagen University Hospital - Rigshospitalet, Copenhagen, Denmark
| | - Anders Perner
- Department of Intensive Care, Copenhagen University Hospital - Rigshospitalet, Copenhagen, Denmark
| | - Anne C Brøchner
- Department of Intensive Care, University Hospital of Southern Denmark, Kolding, Denmark
- Department of Regional Health Research, University of Southern Denmark, Odense, Denmark
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4
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Keogh S, Dhanani J, Levido A, Gracie C, Ilushin V, Palmer J, Doubrovsky A, Parker SL, Pintara A, Huygens F, Coyer F. Evaluation of a closed loop-blood sampling system in intensive care: A pilot randomised controlled trial. The ENCLOSE trial. Intensive Crit Care Nurs 2023; 75:103364. [PMID: 36528456 DOI: 10.1016/j.iccn.2022.103364] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/14/2022] [Revised: 11/14/2022] [Accepted: 12/01/2022] [Indexed: 12/23/2022]
Abstract
OBJECTIVE To test the feasibility of conducting a randomised controlled trial to evaluate the impact of a closed-loop blood sampling system and blood conservation bundle. METHODS Single site, parallel group, pilot randomised control trial comparing open system sampling to closed system sampling and conservation bundle aligned with national guidelines. Randomisation sequence was generated by an independent statistician and allocation concealment maintained via sealed opaque envelopes. The study setting was the general intensive care unit of a major metropolitan public hospital in Queensland, Australia. Participants were ≥ 18 years who had an arterial catheter inserted in intensive care. Main outcome measures included trial feasibility, blood sample loss, haematocrit (HCT) change, and packed red blood cell transfusion use. RESULTS Eighty patients were randomised (n = 39 open group, n = 41 closed group). Characteristics in each group were equal at baseline with overall median age 60 years (IQR 48.6-70.4), 58 % male, and median APACHE II score 16 (IQR 11-22). The proportion of patients eligible was 29 % and missed eligible was 65 %. Otherwise, feasibility criteria were met with proportion of eligible patients agreeing to enrolment 99 %, 100 % of patients receiving allocated treatment; only 1 % of data missing. Analysis demonstrated a significant reduction in mean daily blood sample losses (open 32.7 (SD 1.58) mL vs closed 15.5 (SD 5.79) mL, t = -8.454, df = 78, p < 0.001). CONCLUSIONS A large, multi-site trial is feasible with enhanced eligibility criteria, increased recruitment support. The intervention reduced daily blood sample volumes and transfusion use. Further trials are required to provide both effectiveness and implementation outcomes.
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Affiliation(s)
- Samantha Keogh
- School of Nursing and Centre for Healthcare Transformation, Queensland University of Technology, Brisbane, Australia; Centre for Nursing and Midwifery Research and Intensive Care Services, Royal Brisbane and Women's Hospital, Brisbane, Australia; Alliance for Vascular Access Teaching and Research (AVATAR), School of Nursing and Midwifery, Griffith University, Brisbane, Australia.
| | - Jayesh Dhanani
- Centre for Nursing and Midwifery Research and Intensive Care Services, Royal Brisbane and Women's Hospital, Brisbane, Australia; UQ Centre for Clinical Research, Faculty of Medicine, University of Queensland, Brisbane, Australia
| | - Annabel Levido
- School of Nursing and Centre for Healthcare Transformation, Queensland University of Technology, Brisbane, Australia; Centre for Nursing and Midwifery Research and Intensive Care Services, Royal Brisbane and Women's Hospital, Brisbane, Australia
| | - Chris Gracie
- Centre for Nursing and Midwifery Research and Intensive Care Services, Royal Brisbane and Women's Hospital, Brisbane, Australia
| | - Vladislav Ilushin
- Centre for Nursing and Midwifery Research and Intensive Care Services, Royal Brisbane and Women's Hospital, Brisbane, Australia
| | - Jennifer Palmer
- Centre for Nursing and Midwifery Research and Intensive Care Services, Royal Brisbane and Women's Hospital, Brisbane, Australia
| | - Anna Doubrovsky
- School of Nursing and Centre for Healthcare Transformation, Queensland University of Technology, Brisbane, Australia
| | - Suzanne L Parker
- UQ Centre for Clinical Research, Faculty of Medicine, University of Queensland, Brisbane, Australia
| | - Alexander Pintara
- Centre for Immunology and Infection Control, Queensland University of Technology, Brisbane, Australia
| | - Flavia Huygens
- Centre for Immunology and Infection Control, Queensland University of Technology, Brisbane, Australia
| | - Fiona Coyer
- School of Nursing and Centre for Healthcare Transformation, Queensland University of Technology, Brisbane, Australia; Centre for Nursing and Midwifery Research and Intensive Care Services, Royal Brisbane and Women's Hospital, Brisbane, Australia
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Rachakonda KS, Bhonagiri S, Maley MW, Descallar J, Lombardo L. Rational Clinical Pathology Assessment in Intensive Care Unit (RCPA-ICU): Follow-up study. Anaesth Intensive Care 2023; 51:149-151. [PMID: 36524289 DOI: 10.1177/0310057x221106488] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/23/2022]
Affiliation(s)
- Kanaka S Rachakonda
- Intensive Care Unit, Liverpool Hospital, South Western Sydney Local Health District, Liverpool, New South Wales (NSW), Australia.,Faculty of Medicine, Southwest Sydney Clinical School, University of New South Wales, Liverpool, NSW, Australia.,Faculty of medicine, Macquarie Clinical School (MQ health), Macquarie University, Macquarie Park, NSW, Australia
| | - Satyadeepak Bhonagiri
- Intensive Care Unit, Liverpool Hospital, South Western Sydney Local Health District, Liverpool, New South Wales (NSW), Australia.,Faculty of Medicine, Southwest Sydney Clinical School, University of New South Wales, Liverpool, NSW, Australia.,Faculty of medicine, Macquarie Clinical School (MQ health), Macquarie University, Macquarie Park, NSW, Australia.,Intensive Care Unit, Campbelltown Hospital, South Western Sydney Local Health District, Campbelltown, NSW, Australia.,School of Medicine, Western Sydney University, Campbelltown, NSW, Australia
| | - Michael W Maley
- South Western Sydney Local Health District, Liverpool, NSW, Australia.,Department of Microbiology and Infectious Diseases, NSW Health Pathology, Liverpool, NSW, Australia
| | - Joseph Descallar
- Faculty of Medicine, Southwest Sydney Clinical School, University of New South Wales, Liverpool, NSW, Australia.,Ingham Institute for Applied Medical Research, Liverpool, NSW, Australia
| | - Lien Lombardo
- South Western Sydney Local Health District, Liverpool, NSW, Australia.,Ingham Institute for Applied Medical Research, Liverpool, NSW, Australia.,Nepean Blue Mountains Local Health District, Penrith, NSW, Australia
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6
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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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7
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Hardy NL, Jacobs J, Mullins K, Christenson R, Cox T, Murphy C, Koka R. Pathology Trainees Gain Clinical Pathology Experience as Lab Consultants Through Auditing Myeloid Mutation Panel Send-Out Tests. Arch Pathol Lab Med 2022; 146:1286-1290. [PMID: 35089993 DOI: 10.5858/arpa.2021-0334-ep] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 09/16/2021] [Indexed: 11/06/2022]
Abstract
CONTEXT.— Inappropriate laboratory testing and the threat it poses to patient care and rising health care costs has become an important focus in the medical literature. Pathology residents, as physicians with an intimate knowledge of laboratory testing, may be uniquely equipped with the tools to intervene in situations of inappropriate testing and also benefit from lab use experience as part of their clinical pathology training. OBJECTIVE.— To employ a resident-driven initiative aimed at incorporating pathology residents as consultants for appropriate ordering of high-volume, send-out myeloid mutation panel testing. DESIGN.— During a 6-month study period, all myeloid mutation panel send-out tests were screened by senior pathology residents on their clinical chemistry rotation prior to approval at an academic medical center. A retrospective review of myeloid mutation panels from the prior 6 months was conducted with the same criteria to determine effectiveness of the intervention. RESULTS.— Of the 234 tests ordered during the study period, screening resulted in cancellation of 17% (n = 39), with proportional cost savings. The number of inappropriate orders successfully cancelled was significant compared with the preintervention period (control, 0%; intervention, 76.5%; P < .001, Fisher exact test). There was no significant difference in the proportion of inappropriate tests before and after intervention. CONCLUSIONS.— Although test ordering patterns did not substantially change during the intervention period, pathology residents effectively reduced inappropriate myeloid mutation panel testing through prospective send-out auditing, leading to significant cost savings. Moreover, assessment of test use and appropriateness provided critical clinical pathology training within the areas of hematology, molecular genetics, and laboratory management.
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Affiliation(s)
- Naomi L Hardy
- From the Department of Pathology (Hardy, Jacobs), University of Maryland Medical Center, Baltimore
| | - Jonathan Jacobs
- From the Department of Pathology (Hardy, Jacobs), University of Maryland Medical Center, Baltimore
| | - Kristin Mullins
- Pathology and Lab Chemistry (Mullins, Christenson), University of Maryland School of Medicine, Baltimore, Maryland
| | - Robert Christenson
- Pathology and Lab Chemistry (Mullins, Christenson), University of Maryland School of Medicine, Baltimore, Maryland
| | - Thoko Cox
- Laboratories of Pathology (Cox), University of Maryland Medical Center, Baltimore
| | - Colin Murphy
- Transfusion Medicine in Laboratories of Pathology (Murphy), University of Maryland School of Medicine, Baltimore, Maryland
| | - Rima Koka
- The Department of Pathology (Koka), University of Maryland School of Medicine, Baltimore, Maryland
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8
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McGain F, Corke M, Dade F, Hazard R, Grant D, French C. How often do routine ICU coagulation tests become abnormal? CRIT CARE RESUSC 2021; 23:423-426. [PMID: 38046688 PMCID: PMC10692608 DOI: 10.51893/2021.4.br2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Affiliation(s)
- Forbes McGain
- Western Health, Melbourne, VIC, Australia
- Department of Critical Care, University of Melbourne, Melbourne, VIC, Australia
| | | | | | | | | | - Craig French
- Western Health, Melbourne, VIC, Australia
- Department of Critical Care, University of Melbourne, Melbourne, VIC, Australia
- Department of Epidemiology and Preventive Medicine, Monash University, Melbourne, VIC, Australia
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9
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Hardy NL, Luethy PM. Evaluation of Inappropriate COVID-19 RT-PCR Test Utilization at an academic medical center. J Appl Lab Med 2021; 6:1484-1491. [PMID: 34191020 PMCID: PMC8344747 DOI: 10.1093/jalm/jfab081] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/11/2021] [Accepted: 06/22/2021] [Indexed: 11/30/2022]
Abstract
Background An evolving COVID-19 testing landscape and issues with test supply allocation, especially in the current pandemic, has made it challenging for ordering providers. We audited orders of the Xpert® Xpress SARS-CoV-2 RT-PCR platform—the fastest of several other testing modalities available—to illuminate these challenges utilizing a multidisciplinary laboratory professional team consisting of a pathology resident and microbiology lab director. Methods Retrospective review of the first five hundred Xpert® Xpress SARS-CoV-2 RT-PCR test orders from a 2-week period to determine test appropriateness based on the following indications: emergency surgery, emergent obstetric procedures, initial behavioral health admission, and later including discharge to skilled care facilities and pediatric admissions. Our hypothesis was that a significant proportion of orders for this testing platform were inappropriate. Results Upon review, a significant proportion of orders were incorrect, with 69.8% (n = 349, p < 0.0001) not meeting indications for rapid testing. Of all orders, 249 designated as emergency surgery were inappropriate, with 49.0% of those orders never proceeding with any surgical intervention; most of these were trauma related (64.6% were orders associated with a trauma unit). Conclusions Significant, pervasive inappropriate ordering practices were identified at this center. A laboratory professional team can be key to identifying problems in testing and play a significant role in combating inappropriate test utilization.
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Affiliation(s)
- Naomi L Hardy
- Department of Pathology, University of Maryland School of Medicine, Baltimore, Maryland, USA
| | - Paul M Luethy
- Department of Pathology, University of Maryland School of Medicine, Baltimore, Maryland, USA
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10
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Onuska K. Reducing Phlebotomy Tube Collection Types by Performing a Complete Review of All In-House Testing. J Appl Lab Med 2021; 6:808-811. [PMID: 33742205 DOI: 10.1093/jalm/jfaa164] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/25/2019] [Accepted: 06/01/2020] [Indexed: 11/12/2022]
Affiliation(s)
- Ken Onuska
- Department of Pathology and Laboratory Medicine, Halton Healthcare, Oakville, ON, Canada
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11
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Hooper KP, Anstey MH, Litton E. Safety and efficacy of routine diagnostic test reduction interventions in patients admitted to the intensive care unit: A systematic review and meta-analysis. Anaesth Intensive Care 2021; 49:23-34. [PMID: 33554634 DOI: 10.1177/0310057x20962113] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/29/2022]
Abstract
Reducing unnecessary routine diagnostic testing has been identified as a strategy to curb wasteful healthcare. However, the safety and efficacy of targeted diagnostic testing strategies are uncertain. The aim of this study was to systematically review interventions designed to reduce pathology and chest radiograph testing in patients admitted to the intensive care unit (ICU). A predetermined protocol and search strategy included OVID MEDLINE, OVID EMBASE and the Cochrane Central Register of Controlled Trials from inception until 20 November 2019. Eligible publications included interventional studies of patients admitted to an ICU. There were no language restrictions. The primary outcomes were in-hospital mortality and test reduction. Key secondary outcomes included ICU mortality, length of stay, costs and adverse events. This systematic review analysed 26 studies (with more than 44,00 patients) reporting an intervention to reduce one or more diagnostic tests. No studies were at low risk of bias. In-hospital mortality, reported in seven studies, was not significantly different in the post-implementation group (829 of 9815 patients, 8.4%) compared with the pre-intervention group (1007 of 9848 patients, 10.2%), (relative risk 0.89, 95% confidence intervals 0.79 to 1.01, P = 0.06, I2 39%). Of the 18 studies reporting a difference in testing rates, all reported a decrease associated with targeted testing (range 6%-72%), with 14 (82%) studies reporting >20% reduction in one or more tests. Studies of ICU targeted test interventions are generally of low quality. The majority report substantial decreases in testing without evidence of a significant difference in hospital mortality.
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Affiliation(s)
- Katherine P Hooper
- Intensive Care Unit, Fiona Stanley Hospital, Perth, Australia.,Intensive Care Unit, Royal Melbourne Hospital, Melbourne, Australia
| | - Matthew H Anstey
- Medical School, Faculty of Health and Medical Sciences, University of Western Australia, Perth, Australia.,Intensive Care Unit, St John of God Subiaco Hospital, Perth, Australia
| | - Edward Litton
- Intensive Care Unit, Fiona Stanley Hospital, Perth, Australia.,Medical School, Faculty of Health and Medical Sciences, University of Western Australia, Perth, Australia.,Intensive Care Unit, St John of God Subiaco Hospital, Perth, Australia
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12
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McNett M, O'Mathúna D, Tucker S, Roberts H, Mion LC, Balas MC. A Scoping Review of Implementation Science in Adult Critical Care Settings. Crit Care Explor 2020; 2:e0301. [PMID: 33354675 PMCID: PMC7746210 DOI: 10.1097/cce.0000000000000301] [Citation(s) in RCA: 20] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/12/2023] Open
Abstract
OBJECTIVES The purpose of this scoping review is to provide a synthesis of the available literature on implementation science in critical care settings. Specifically, we aimed to identify the evidence-based practices selected for implementation, the frequency and type of implementation strategies used to foster change, and the process and clinical outcomes associated with implementation. DATA SOURCES A librarian-assisted search was performed using three electronic databases. STUDY SELECTION Articles that reported outcomes aimed at disseminating, implementing, or sustaining an evidence-based intervention or practice, used established implementation strategies, and were conducted in a critical care unit were included. DATA EXTRACTION Two reviewers independently screened titles, abstracts, and full text of articles to determine eligibility. Data extraction was performed using customized fields established a priori within a systematic review software system. DATA SYNTHESIS Of 1,707 citations, 82 met eligibility criteria. Studies included prospective research investigations, quality improvement projects, and implementation science trials. The most common practices investigated were use of a ventilator-associated pneumonia bundle, nutritional support protocols, and the Awakening and Breathing Coordination, Delirium Monitoring/Management, and Early Exercise/Mobility bundle. A variety of implementation strategies were used to facilitate evidence adoption, most commonly educational meetings, auditing and feedback, developing tools, and use of local opinion leaders. The majority of studies (76/82, 93%) reported using more than one implementation strategy. Few studies specifically used implementation science designs and frameworks to systematically evaluate both implementation and clinical outcomes. CONCLUSIONS The field of critical care has experienced slow but steady gains in the number of investigations specifically guided by implementation science. However, given the exponential growth of evidence-based practices and guidelines in this same period, much work remains to critically evaluate the most effective mechanisms to integrate and sustain these practices across diverse critical care settings and teams.
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Affiliation(s)
- Molly McNett
- Helene Fuld Health Trust National Institute for Evidence-based Practice in Nursing and Healthcare, The Ohio State University, Columbus, OH
- College of Nursing, The Ohio State University, Columbus, OH
| | - Dónal O'Mathúna
- Helene Fuld Health Trust National Institute for Evidence-based Practice in Nursing and Healthcare, The Ohio State University, Columbus, OH
- College of Nursing, The Ohio State University, Columbus, OH
| | - Sharon Tucker
- Helene Fuld Health Trust National Institute for Evidence-based Practice in Nursing and Healthcare, The Ohio State University, Columbus, OH
- College of Nursing, The Ohio State University, Columbus, OH
| | - Haley Roberts
- Helene Fuld Health Trust National Institute for Evidence-based Practice in Nursing and Healthcare, The Ohio State University, Columbus, OH
| | - Lorraine C Mion
- College of Nursing, The Ohio State University, Columbus, OH
- Center for Healthy Aging, Self Management, and Complex Care, The Ohio State University, Columbus, OH
| | - Michele C Balas
- College of Nursing, The Ohio State University, Columbus, OH
- Center for Healthy Aging, Self Management, and Complex Care, The Ohio State University, Columbus, OH
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13
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Yu L, Li L, Bernstam E, Jiang X. A deep learning solution to recommend laboratory reduction strategies in ICU. Int J Med Inform 2020; 144:104282. [PMID: 33010730 PMCID: PMC10777357 DOI: 10.1016/j.ijmedinf.2020.104282] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/02/2020] [Revised: 09/16/2020] [Accepted: 09/20/2020] [Indexed: 11/20/2022]
Abstract
OBJECTIVE To build a machine-learning model that predicts laboratory test results and provides a promising lab test reduction strategy, using spatial-temporal correlations. MATERIALS AND METHODS We developed a global prediction model to treat laboratory testing as a series of decisions by considering contextual information over time and across modalities. We validated our method using a critical care database (MIMIC III), which includes 4,570,709 observations of 12 standard laboratory tests, among 38,773 critical care patients. Our deep-learning model made real-time laboratory reduction recommendations and predicted the properties of lab tests, including values, normal/abnormal (whether labs were within the normal range) and transition (normal to abnormal or abnormal to normal from the latest lab test). We reported area under the receiver operating characteristic curve (AUC) for predicting normal/abnormal, evaluated accuracy and absolute bias on prediction vs. observation against lab test reduction proportion. We compared our model against baseline models and analyzed the impact of variations on the recommended reduction strategy. RESULTS Our best model offered a 20.26 % reduction in the number of laboratory tests. By applying the recommended reduction policy on the hold-out dataset (7755 patients), our model predicted normality/abnormality of laboratory tests with a 98.27 % accuracy (AUC, 0.9885; sensitivity, 97.84 %; specificity, 98.80 %; PPV, 99.01 %; NPV, 97.39 %) on 20.26 % reduced lab tests, and recommended 98.10 % of transitions to be checked. Our model performed better than the greedy models, and the recommended reduction strategy was robust. DISCUSSION Strong spatial and temporal correlations between laboratory tests can be used to optimize policies for reducing laboratory tests throughout the hospital course. Our method allows for iterative predictions and provides a superior solution for the dynamic decision-making laboratory reduction problem. CONCLUSION This work demonstrates a machine-learning model that assists physicians in determining which laboratory tests may be omitted.
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Affiliation(s)
- Lishan Yu
- School of Biomedical Informatics, UTHealth, United States; Department of Mathematical Sciences, Tsinghua University, China
| | - Linda Li
- Department of Pediatric Surgery, McGovern Medical School, UTHealth, United States
| | - Elmer Bernstam
- School of Biomedical Informatics, UTHealth, United States; Division of General Internal Medicine, McGovern Medical School, UTHealth, United States
| | - Xiaoqian Jiang
- School of Biomedical Informatics, UTHealth, United States.
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14
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Ambasta A, Pancic S, Wong BM, Lee T, McCaughey D, Ma IWY. Expert Recommendations on Frequency of Utilization of Common Laboratory Tests in Medical Inpatients: a Canadian Consensus Study. J Gen Intern Med 2019; 34:2786-2795. [PMID: 31385217 PMCID: PMC6854150 DOI: 10.1007/s11606-019-05196-z] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/01/2019] [Accepted: 07/09/2019] [Indexed: 10/26/2022]
Abstract
BACKGROUND Repetitive inpatient laboratory testing in the face of clinical stability is a marker of low-value care. However, for commonly encountered clinical scenarios on medical units, there are no guidelines defining appropriate use criteria for laboratory tests. OBJECTIVE This study seeks to establish consensus-based recommendations for the utilization of common laboratory tests in medical inpatients. DESIGN This study uses a modified Delphi method. Participants completed two rounds of an online survey to determine appropriate testing frequencies for selected laboratory tests in commonly encountered clinical scenarios. Consensus was defined as agreement by at least 80% of participants. PARTICIPANTS Participants were 36 experts in internal medicine across Canada defined as internists in independent practice for ≥ 5 years with experience in medical education, quality improvement, or both. Experts represented 8 of the 10 Canadian provinces and 13 of 17 academic institutions. MAIN MEASURES Laboratory tests and clinical scenarios included were those that were considered common on medical units. The final survey contained a total of 45 clinical scenarios looking at the utilization of six laboratory tests (complete blood count, electrolytes, creatinine, urea, international normalized ratio, and partial thromboplastin time). The possible frequency choices were every 2-4 h, 6-8 h, twice a day, daily, every 2-3 days, weekly, or none unless there was specific diagnostic suspicion. These scenarios were reviewed by two internists with training in quality improvement and survey methods. KEY RESULTS Of the 45 initial clinical scenarios included, we reached consensus on 17 scenarios. We reached weak consensus on an additional 19 scenarios by combining two adjacent frequency categories. CONCLUSIONS A Canadian expert panel of internists has provided frequency recommendations on the utilization of six common laboratory tests in medical inpatients. These recommendations need validation in prospective studies to assess whether restrictive versus liberal laboratory test ordering impacts patient outcomes.
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Affiliation(s)
- Anshula Ambasta
- Cumming School of Medicine University of Calgary, Calgary, Alberta, Canada. .,Ward of the 21st century, University of Calgary, Calgary, Alberta, Canada.
| | - Stefana Pancic
- Cumming School of Medicine University of Calgary, Calgary, Alberta, Canada
| | - Brian M Wong
- Faculty of Medicine, University of Toronto, Toronto, Ontario, Canada.,Center for Quality Improvement and Patient Safety, Toronto, Ontario, Canada
| | - Todd Lee
- Faculty of Medicine, McGill University, Montreal, Quebec, Canada
| | - Deirdre McCaughey
- Cumming School of Medicine University of Calgary, Calgary, Alberta, Canada.,Department of Community Health Sciences, University of Calgary, Calgary, Alberta, Canada
| | - Irene W Y Ma
- Cumming School of Medicine University of Calgary, Calgary, Alberta, Canada.,Ward of the 21st century, University of Calgary, Calgary, Alberta, Canada
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Hjortsø CJS, Brøchner AC, Perner A, Møller MH. Routine vs on-demand blood sampling in critically ill patients-Protocol for a scoping review. Acta Anaesthesiol Scand 2019; 63:1109-1112. [PMID: 31206584 DOI: 10.1111/aas.13417] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/08/2019] [Accepted: 05/19/2019] [Indexed: 12/01/2022]
Abstract
BACKGROUND In intensive care units, blood sampling is done commonly as part of daily routine. It remains unknown whether this practice is associated with harms or benefits, as not all routine blood tests may be clinically indicated, and blood sampling done without specific indications may be problematic. Accordingly, we aim to assess the body of evidence regarding the usage of routine vs on-demand blood sampling in critically ill patients in a scoping review. METHODS We will conduct a scoping review in accordance with the Preferred Reporting Items for Systematic and Meta-Analysis (PRISMA) statement as well as the PRISMA Extension for Scoping Reviews (PRISMA-ScR). Using a PICO-based search strategy, we will systematically search the Cochrane Library, Embase and Medline for relevant studies regardless of design. Two authors will independently screen studies for inclusion and extract data. We will provide a descriptive analysis of the data and asses the quality of evidence in accordance with the Grading of Recommended Assessment, Development and Evaluation approach. DISCUSSION The outlined scoping review will provide an important overview on the current body of evidence regarding the use of daily routine vs on-demand blood sampling in critical care settings. The findings of this scoping review will guide further research.
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Affiliation(s)
- Carl Johan S. Hjortsø
- Department of Intensive Care Copenhagen University Hospital – Rigshospitalet Copenhagen Denmark
| | - Anne C. Brøchner
- Department of Intensive Care University Hospital Kolding Denmark
- Department of Regional Health Research University of Southern Denmark Sønderborg Denmark
| | - Anders Perner
- Department of Intensive Care Copenhagen University Hospital – Rigshospitalet Copenhagen Denmark
- Centre for Research in Intensive Care (CRIC) Copenhagen Denmark
| | - Morten H. Møller
- Department of Intensive Care Copenhagen University Hospital – Rigshospitalet Copenhagen Denmark
- Centre for Research in Intensive Care (CRIC) Copenhagen Denmark
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16
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Clouzeau B, Caujolle M, San-Miguel A, Pillot J, Gazeau N, Tacaille C, Dousset V, Bazin F, Vargas F, Hilbert G, Molimard M, Gruson D, Boyer A. The sustainable impact of an educational approach to improve the appropriateness of laboratory test orders in the ICU. PLoS One 2019; 14:e0214802. [PMID: 31042718 PMCID: PMC6493704 DOI: 10.1371/journal.pone.0214802] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/14/2018] [Accepted: 03/20/2019] [Indexed: 12/02/2022] Open
Abstract
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.
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Affiliation(s)
- Benjamin Clouzeau
- Department of Intensive Care Medicine, Pellegrin Hospital, Bordeaux, France
| | - Marie Caujolle
- Department of Intensive Care Medicine, Pellegrin Hospital, Bordeaux, France
| | - Aurelie San-Miguel
- Department of Intensive Care Medicine, Pellegrin Hospital, Bordeaux, France
| | - Jerome Pillot
- Department of Intensive Care Medicine, Pellegrin Hospital, Bordeaux, France
| | - Nathalie Gazeau
- Economic and Financial Department, Pellegrin Hospital, Bordeaux, France
- Departments of Laboratories, Pellegrin Hospital, Bordeaux, France
| | | | - Vincent Dousset
- Department of Radiology, Pellegrin Hospital, Bordeaux, France
| | - Fabienne Bazin
- INSERM, U657 Pharmaco-Epidémiologie et Evaluation de l'Impact des Produits de Santé sur les Populations, France
| | - Frederic Vargas
- Department of Intensive Care Medicine, Pellegrin Hospital, Bordeaux, France
| | - Gilles Hilbert
- Department of Intensive Care Medicine, Pellegrin Hospital, Bordeaux, France
| | - Mathieu Molimard
- Departments of Laboratories, Pellegrin Hospital, Bordeaux, France
- INSERM, U657 Pharmaco-Epidémiologie et Evaluation de l'Impact des Produits de Santé sur les Populations, France
| | - Didier Gruson
- Department of Intensive Care Medicine, Pellegrin Hospital, Bordeaux, France
| | - Alexandre Boyer
- Department of Intensive Care Medicine, Pellegrin Hospital, Bordeaux, France
- INSERM, U657 Pharmaco-Epidémiologie et Evaluation de l'Impact des Produits de Santé sur les Populations, France
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Corke CF. Thinking beyond routine daily pathology testing in the intensive care unit. Anaesth Intensive Care 2018; 46:257. [PMID: 29716483 DOI: 10.1177/0310057x1804600302] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
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