Reducing Electrolyte Test Overuse Using Quality Imporvement Methods

Introduction: Overuse of laboratory testing is a significant source of low-value care. Frequently ordered laboratory tests, such as electrolyte panels, are a prime target for value improvement efforts. The aim of our... [ view full abstract ]

Introduction: Overuse of laboratory testing is a significant source of low-value care. Frequently ordered laboratory tests, such as electrolyte panels, are a prime target for value improvement efforts. The aim of our improvement work was to utilize quality improvement methods to reduce electrolyte testing within a hospital medicine service by >25% within 6 months.

Methods: We worked with 6 resident teams on the hospital medicine service at 2 locations of a >700 bed children’s hospital system.  We assembled a multi-disciplinary team to create a process map, assess key drivers and design Plan-Do-Study-Act (PDSA) cycles.  Electronic medical record (EMR) data for all electrolyte test results and patient census data were used to determine baseline testing rates.  Rates over time were displayed on a run chart, and established rules for recognizing special cause variation were employed.  Interventions included education to providers via lectures and meetings, shared lab plans via standardized note templates and formalized rounding lab-plan “read-back”, and creation of workstation lab cost tools. 

Results: Substantial variation in weekly rates of electrolyte testing were observed before our interventions. With improvement interventions, we have observed a decrease from 2.2 electrolyte lab tests per 10 patient-days during the baseline period, to 1.4 electrolyte lab tests per 10 patient-days (Figure).  This represents a 36% reduction in overall electrolyte testing rate within one month of intervention initiation.   

Discussion: Our improvement intervention was associated with substantial, significant and rapid reductions in electrolyte testing.  Interventions focused on improved processes around team communication of lab plan and improving a providers’ ability to assess a test’s value.  Future efforts will target continued improvement through high-reliability interventions such as EMR orderset modification, provider-level ordering feedback, and standardization of best-practice around high-value electrolyte ordering in specific conditions. This approach may generalize to other instances of low-value lab testing