Does admission order form design really matter? A reduction in urea blood test ordering

Abstract

Introduction: Laboratory blood testing is one of the most high-volume medical procedures and continues to increase steadily with instances of inappropriate testing resulting in significant financial implications. Studies have suggested that the design of a standard hospital admission order form and laboratory request forms influence physician test ordering behaviour, reducing inappropriate ordering and promoting resource stewardship.

Aim/method: To redesign the standard medicine admission order form-laboratory request section to reduce inappropriate blood urea nitrogen (BUN) testing.

Results: A redesign of the standard admission order form used by general internal medicine physicians and residents in two large teaching hospitals in one health zone in Alberta, Canada led to a significant step reduction in the ordering of the BUN test on hospital admission.

Conclusions: Redesigning the standard medicine admission order form-laboratory request section can have a beneficial effect on the reduction in BUN ordering altering physician ordering patterns and behaviour.

Keywords: continuous quality improvement; cost–benefit analysis; efficiency; organisational; quality improvement.

Figure 1

Medicine admission order form-laboratory section. The original admission order form-laboratory section compared to the redesigned admission order form laboratory section. The redesigned form, blood urea nitrogen/urea test is removed, frequency options included and a free text section maintaining physician ability to order any laboratory test required.

Figure 2

Interrupted time series (ITS) graphs for hospital A and B and comparison graph. Hospital A and B ITS graphs illustrate the average total blood urea nitrogen (BUN) monthly order volume preorder and postorder form redesign implementation. For hospital A the total average order volume declined from 1221 to 448 BUN tests and for hospital B the total average order volume declined from 1660 to 736 BUN tests. The comparison graph illustrates similar downward trends for both hospitals during this time frame and that when hospital A implemented the form design the intervention effect was also noted at hospital B where the original form design was still in use. Allocation concealment was not possible as residents and attending physicians rotate between hospital A and B.