Reducing Unnecessary Laboratory Utilization in the Medical ICU: A Fellow-Driven Quality Improvement Initiative

Abstract

Objectives: Overutilization of laboratory services is now recognized as harmful to patients and wasteful. In fact, the American Board of Internal Medicine's Choosing Wisely campaign recommends against ordering routine testing that does not answer a clinical question. Per peer benchmarking, our institution as a whole occupied an extreme outlier position at the 100th percentile for laboratory utilization. We sought to address this problem starting in our medical ICUs with a quality improvement project.

Design: Quality improvement project using the design, measure, analyze, improve, and control process. The primary endpoint was a sustained reduction in laboratory utilization. Counterbalance metrics were also followed, and these included mortality, renal replacement therapy initiation rates, stat laboratory orders, and central catheter-associated blood stream infections.

Setting: The medical ICU at the Ohio State University Medical Center.

Patients: All patients admitted to the medical ICU from March 2019 to March 2020.

Interventions: Root causes were identified and addressed with the implementation of a wide range of interventions involving a multidisciplinary team led by trainee physicians.

Measurements and main results: There was a sustained 20% reduction in the number of tests performed per patient day, with no change in the counterbalance metrics.

Conclusions: Trainees can affect positive change in the culture and processes at their institutions to safely reduce laboratory utilization.

Keywords: critical care; evidence-based medicine; healthcare costs; laboratories; patient safety; quality improvement.

Figure 1.

Timeline of roll-out of interventions. CRRT = continuous renal replacement therapy.

Figure 2.

XmR control chart showing laboratory utilization in the 24-bed medical ICU depicted as laboratories per patient day. Center line (teal), upper control limit (UCL), and lower control limit (LCL) (red dash), 1 sigma variation (orange dash), and 2 sigma variation (blue dash) are denoted. The benchmark utilization level is obtained by averaging data from March 5, 2017, until the beginning of the lead-in period on March 3, 2019. Note down shift in process center line due to special cause variation during the lead-in and implementation periods.

Figure 3.

Run charts of counterbalance metrics for the 24-bed medical ICU. Center line reflects average values. No significant sustained changes are noted. CLABSI = central catheter-associated bloodstream infection, RRT = renal replacement therapy.