Sensible Test Ordering Practice in an Emergency Department

Transcription

1 Sensible Test Ordering Practice in an Emergency Department Gerard Boran, FRCPath FRCPI Clinical Director of Diagnostics, Tallaght Hospital, Dublin Clinical Lead, HSE/RCPI National Clinical Programme in Pathology Peter Gaffney, MSc FAMLS Chief Medical Scientist, Tallaght Hospital, Dublin Sarah Condell, PhD Nursing & Midwifery Research & Development Lead, HSE

2 Background ED Physicians suspected high levels of pathology test overordering Do-everything profiles in use, unrelated to clinical presentation Inefficient Process Too many keystrokes to order core bloods Delays in getting specimens to the lab via the pneumatic chute system Unnecessary tests still had to be reviewed by ED physicians Against a background of a new build and other ongoing initiatives Held a meeting Decided to use the tools of Quality improvement to Implement Sensible Test Ordering Practice

3 The Tools of Quality Improvement! "# ## $ %& ## #' # &# #! (! )) ( * +' ( &) )# # + # +,! %## # " -#. ( / + +! ( +#+ ##! #+ # ( ( # + #! #( " # #(! 0 1 # " # # # $ # #! ( ## + +# # # # #' + # 2&),

4 10 Principles of Demand Management 0 $, # # (+(+ ## * ) (5 67) &( &#+ + : (( (# ; 0,(# 7 < ( 8 = Make structural changes in your process > Don t ignore the cost management of blood products Measure thyself (repeat often)

5 10 Principles of Demand Management 0 $, # # (+(+ ## * ) (5 67) &( &#+ + : (( (# ; 0,(# 7 < ( 8 = Make structural changes in your process > Don t ignore the cost management of blood products Measure thyself (repeat often)

6 Types of Demand Management Interventions (Astion 2006) Weaker Interventions Guidelines Lectures and Educational events Computerised Reminders regarding utilisation Intermediate Stronger Strongest Interventions Utilisation Report Cards Changes to the request form Changes to the Computerised Provider (Order) Entry System Utilisation Report Cards with Peer or Leadership Review Requirement for Higher Level Authorisation/ Traffic Light System (e.g. by pathologist, consultant) Utilisation Report Card with Peer/Leadership Review and Financial Penalties for abuse or Incentives to encourage good behaviour Outright Banning

7 The S.T.O.P. and Think! Project at Tallaght Hospital s Emergency Department: How quality improvement tools can be used to support Sensible Test Ordering Practice The STOP and Think technique for ED was developed in Australia Sensible Test Ordering Practice uses a Traffic Light Chart to recommend GREEN or AMBER tests appropriate for the clinical presentation It makes one Think about ordering a RED test but you can still order it after discussion It is NOT about stopping or hindering people from ordering tests!

8 RCPA STOP and Think Chart (Adapted for Tallaght Hospital ED)

9 AIM To reduce selected pathology tests by 50% in Tallaght Hospital s Emergency Department by the end of April 20 We focused on common clinical chemistry and haematology tests including coagulation screens, blood glucose, and c-reactive protein SMART Aim Statement Checklist Specific Measurable Our aim is precise, concise, with single focus and it means the same thing to all We have a measure Actionable Realistic Deliberate actions are required to achieve the aim The aim is worthwhile Timely There is a target date, the time is ripe with a sense of urgency, and staff can be assigned with no competing initiatives

10 METHODS We used the S.T.O.P. and Think! technique published in 2013 by the RCPA A working group that included all stakeholders was established After identifying a SMART aim, we Constructed a Driver Diagram Performed Stakeholder Analysis Made a Process Map Documented an Observational Visit ( Arthurs Day ) Plan-Do-Study-Act (PDSA) Cycles were implemented for 5 interventions Baseline data on tests ordered were collected and analysed Measurement commenced in January 20 and consisted of an annotated run chart with results provided weekly to the ED staff We also conducted: A Staff Satisfaction Survey An Analysis of Cost Savings A Patient Experience Time analysis, looking for any changes in Length of Stay To win hearts and minds: We helped with other Sub-Projects ( Side-Shows ) to improve process efficiency

11 Driver Diagram

12 Stakeholder Map Stakeholder Initial support Level of influence Key concern ED Consultant High High Wanting quick change to speedier process. Non-follow up of inappropriate tests. Steps to getting buy in Examine PTS issues ED NCHD High High Making right choice easy IT changes Examine PTS issues ED CNMs Medium Medium IT system perceived as very slow ED S/Ns High Medium IT system perceived as very slow Phoning lab for out-of-hours tests. IT changes Demo that bell sets off bleep Laboratory High High Any gains would be short-lived Ensure changes processes are embedded in the system and not reliant on individuals IT services High Medium Not all suggestions of change could be incorporated into IT system Needed time for work to be negotiated

13 Arthurs Day - Stills Arthur bleeds Harry, the patient Arthur sends Harry s blood specimens to the Lab via the ED pneumatic chute system Lab staff receive Harry s blood specimens Arthur gets interrupted checking the results

14 Process Map and Visual

15 PDSA Cycles Concept Cycle # Description of PDSA Cycle Responsible Demand Management Demand management Demand management 1 (induction) ED Consultant gives introductory induction talk and an on coagulation screen ordering to new doctors 2 (reinforcement) ED consultant gives scheduled teaching lecture to ED doctors ED consultant With team backup ED consultant + team 3 (visual aid) Provide visual aid (Chart) IT + team Improve TAT 4a (engagement) Additional canisters circulated Team (side-show) 4b Priority on PTS given to ED Team 4c New labelled canisters for ED Team Demand management 5 (ICT Change) Major change in Ordering Panels IT + team

16 Coag Numbers by week March Week 2 March Week 4 April Week 2 April Week 4 May Week 2 May Week 4 June Week 1 June Week 3 July Week 1 July Week 3 July Week 5 Aug Week 2 Aug Week 4 Sep Week 2 Briefing for new Medical staff at induction on misuse of Coag screens RESULTS Target 20 Median 2013 Median Education meeting reminder New OCS profiles initiated TAT Sub-project results New NCHD staff Jan Week 2 Jan Week 4 Feb Week 2 Feb Week 4

17 Coag Numbers by week March Week 2 March Week 4 April Week 2 April Week 4 May Week 2 May Week 4 June Week 1 June Week 3 July Week 1 July Week 3 July Week 5 Aug Week 2 Aug Week 4 Sep Week 2 Briefing for new Medical staff at induction on misuse of Coag screens RESULTS Target 20 Median 2013 Median Education meeting reminder New OCS profiles initiated New NCHD staff Jan Week 2 Jan Week 4 Feb Week 2 Feb Week 4

18 Coag Numbers by week Target 20 Median 2013 Median New OCS profiles initiated March Week 2 March Week 4 April Week 2 April Week 4 May Week 2 May Week 4 June Week 1 June Week 3 July Week 1 July Week 3 July Week 5 Aug Week 2 Aug Week 4 Sep Week 2 Briefing for new Medical staff at induction on misuse of Coag screens RESULTS Education meeting reminder TAT Visual Sub-project aid; and TAT results Subproject New NCHD staff results Jan Week 2 Jan Week 4 Feb Week 2 Feb Week 4

19 Coag Numbers by week Target 20 Median 2013 Median March Week 2 March Week 4 April Week 2 April Week 4 May Week 2 May Week 4 June Week 1 June Week 3 July Week 1 July Week 3 July Week 5 Aug Week 2 Aug Week 4 Sep Week 2 Briefing for new Medical staff at induction on misuse of Coag screens RESULTS Education meeting reminder New OCS profiles initiated TAT Visual Sub-project aid; and TAT results Subproject results Jan Week 2 Jan Week 4 Feb Week 2 Feb Week 4

20 Coag Numbers by week March Week 2 March Week 4 April Week 2 April Week 4 May Week 2 May Week 4 June Week 1 June Week 3 July Week 1 July Week 3 July Week 5 Aug Week 2 Aug Week 4 Sep Week 2 Briefing for new Medical staff at induction on misuse of Coag screens RESULTS Target 20 Median 2013 Median Education meeting reminder New OCS profiles initiated Visual aid; and TAT Subproject results New NCHD staff Jan Week 2 Jan Week 4 Feb Week 2 Feb Week 4

21 Changes in Requesting Patterns 40% 20% 0% -20% Post Profile Changes CC Tests Requested from ED (May Week 1 to June Week 2) 0% 0% 16% Total CRP RP LP BP Trop Amy Gluc -9% -15% -19% -40% -60% -51% -80% POCT Glucose 20 POCT Glucose % % 50 New OCS profiles initiated 0 April Week 1 April Week 2 April Week 3 April Week 4 May Week 1 May Week 2 May Week 3 May Week 4

22 100% 90% 80% 70% 60% 50% 40% 30% 20% 10% 0% Winning Hearts and Minds % > 20 mins from OCS to Lab % > 20mins Monitoring Started Target Additional canisters > 20mins Median put into circulation Priority on PTS given to ED New canisters labelled for Adult ED PTS line 1 down twice this week to to to to to to to to to to to to to to to to to to to to to to to to 1506

23 The critical intervention Pareto Chart for the Impact of each Improvement Cycle Weekly Reduction in Coag Requests Cumulative Reduction ICT change (Cycle 5) Induction (Cycle 1) Engagement (Cycle 4) Inclusion (Cycle 3) Reinforcement (Cycle 2)

24 Staff Satisfaction Survey After the critical intervention, staff found ordering to be quicker (quick) 3 5 (slow) Pre IT change

25 Staff Satisfaction Survey After the critical intervention, staff found ordering to be quicker (quick) 3 5 (slow) Pre IT change Post IT change

26 Results patient experience time Median Time in ED (hrs) Average Time in ED (hrs) May Wk 2, 2013 (Pre) May Wk 2, 20 (Post) 0.00 May Wk 2, 2013 (Pre) May Wk 2, 20 (Post) Number of patients < 6 hrs in ED % of Patients < 6 hrs in ED 0 30% % % 80 15% May Wk 2, 2013 (Pre) May Wk 2, 20 (Post) 10% 5% 0% May Wk 2, 2013 (Pre) May Wk 2, 20 (Post)

27 Financial modelling of savings Model 1 Commercial charges (based on a published commercial tariff) Coag CRP RP LP BP Trop Amy Gluc Difference Number of weeks counted Annualised decrease/increase Coag CRP RP LP BP Trop Amy Gluc Profile cost (SJH price list) Savings 93,073 27,426 4,208 21,899 33,625-9,583, ,932 Total Savings 286,230.29

28 Financial modelling of savings Model 2 Marginal pricing (public hospital) Coag CRP RP LP BP Trop Amy Gluc Difference Number of weeks counted Annualised decrease/increase *Coag costs are greater than Clinical Chemistry test costs as they require a separate sample and additional hardware and staffing input Coag* CRP RP LP BP Trop Amy Gluc Profile cost Savings 82,123 6,329 1,913 13,936 18,341-4,472 7,325 33,644 Total Savings 159,138.57

29 Financial modelling of savings Model 3 Minimal Cost Pricing (Tallaght costs for reagents, staff, overheads) Coag CRP RP LP BP Trop Amy Gluc Difference Number of weeks counted Annualised decrease/increase *Coag costs are greater than Clinical Chemistry test costs as they require a separate sample and additional hardware and staffing input Coag* CRP RP LP BP Trop Amy Gluc Profile cost (Minimal Tallaght Costs) Savings 54,749 4,219 1,8 7,963 9,171-3,194 3,662 16,822 Total Savings 94,539.71

30 Conclusion: Spreading Improvement Successfully reducing unnecessary pathology testing in Emergency Departments is possible using the tools of quality improvement following identification and careful selection of the optimal intervention

31 6 #! +$ # C " 6 Team!?$ &#@!?+$ $ 5 A!?* A@*!?B$ $!?),)! A, #0 A) $ $ $! $ 63#($ 6 ((@) #, ( 5 # # $ " # C # ##(# &), * )! $ D@BD We also acknowledge and thank all the patients and staff in the ED and the Pathology Laboratory, particularly on the day of our observational visit (Arthur s Day)