Right test, right time, right patient: Lab Stewardship Team focuses on appropriate medical testing, improving patient safety

Mar 19, 2018, 19:16 PM by KirstiAnn Clifford
The Lab Stewardship Team
Thousands. That’s how many different laboratory tests physicians may choose from when diagnosing, screening or monitoring a patient. It’s a vast menu—including common tests that measure glucose levels or specialty tests that screen for Zika virus.

Lab tests play a crucial role in patient care, as they influence up to 70 percent of medical decision making. However, growing evidence shows that just because a test is available, doesn’t mean it’s a good idea to have it done.

“About 30 percent of inpatient lab tests are unnecessary or wasteful,” said Dr. Todd Masel, assistant professor of neurology and director of UTMB’s Laboratory Stewardship Program. “In fact, they can even harm the patient. For example, studies have shown that excessive blood lab draws can cause hospital-acquired anemia—which could have serious consequences, especially for patients with cardiorespiratory diseases.”

Charged with improving patient safety, Masel and members of the interdisciplinary Lab Stewardship Team are now looking at ways to ensure the appropriate selection of tests at the right time for each patient. It’s one of five focus areas that builds upon the Best Care initiative to help UTMB become a high-value practicing organization.

“The truth is, it’s become so easy to order a lab test—just a click of a mouse— that often it takes less time to do that than it does to spend the time thinking about whether it really needs to be ordered,” said Masel. “We need to put more of a focus on teaching the importance of being judicious and only ordering tests out of necessity rather than habit.”

For example, when a patient is first admitted to the hospital, it may be necessary to order a daily complete blood count (CBC) test every eight hours, but when the patient’s condition starts to improve, it may only be needed every 24 hours. However, Masel sees many cases where these tests continue to be ordered every eight hours, although test results don’t change—often because the test is set to be ordered automatically.

“We will be looking into redesigning the electronic system used for ordering tests so that it creates ‘hard stops’ or makes it not quite as easy to order repeat labs,” he said. “Not only will these efforts lead to improved patient outcomes and satisfaction, they will also help control health care costs.”

Dr. Matthew Mrazek, assistant professor of general and internal medicine added, “Inappropriate utilization of laboratory resources is a multi-faceted problem with major financial and patient care implications. Our stewardship team is targeting the use of low-value studies, over-utilization of common ‘daily’ labs, as well as inappropriate use of less commonly ordered high-cost studies. The delivery of high-value care and teaching these principles to the next generation of physicians are top priorities at UTMB.”

In addition to clinicians, laboratory scientists have a seat at the stewardship table to help determine what labs are ordered most often and the appropriateness of both common and expensive orders.

“UTMB is one of the few hospitals that is taking the lab perspective into account in addition to the clinical perspective, which is really beneficial,” said Dr. Mayukh Sarkar, a laboratory scientist and member of the Lab Stewardship Team. “While many people know clinical lab scientists sit in a lab performing tests and interpreting results, they don’t know we can offer 24/7 expertise about what tests may be needed—or not needed.”

As lab testing options continue to grow and become more complex, Sarkar says interprofessional collaboration is more important than ever. He points to UTMB’s Diagnostic Management Teams as an example of effectively bringing pathologists and lab scientists to the bedside, helping physicians order the correct tests for their patients, and then using the results to select a treatment plan.

Recent research done by Sarkar and the Coagulation DMT showed significant room for improvement when it comes to test selection. The study evaluated 200 cases of patients being evaluated for bleeding or blood clotting issues from throughout UTMB’s Health System—and found test selection errors in 77 percent of the cases.

“Part of the problem was our ordering system had multiple names for the same test or the test was labeled in a confusing way,” said Sarkar. “We’ve been working to address that issue, and I have started reaching out to ordering residents or physicians to offer myself as a resource. I’m already seeing fewer and fewer errors as a result—and many physicians feel comfortable calling me up to discuss specific patient cases.”

Masel agrees that it will take a combination of approaches including educational campaigns, decision support tools, order requisition redesign, provider feedback—and most importantly, a team approach—to be more responsible stewards of lab testing. In the coming months, he hopes to see a movement across the institution, with all members of the health care team “choosing wisely”—not out of habit, but out of necessity. 

For more information about UTMB’s efforts to become a high-value practicing organization, visit intranet.utmb.edu/best-care.