EZ Medicine Quality Council - SCIC Newsletter

EZ MEDICINE QUALITY COUNCIL-SCIC EZMQC-Strategic Clinical Improvement Committee -Quarterly Newsletter

March 2019

2019 Project List: 1. Ensuring appropriate Oxygen Use-UAH GIM Units 2. Scale and Spread –Tackling Lab test ordering overuse (SCH, GNCH and Provincial) 3. Geriatrics-Ending PJ Paralysis 4. Dermatology- Development of a Vulvar care action plan 5. Supporting Patients with Sickle cell anemia in timely ED care 6. Pet Therapy– Determining Clinical Impact 2018 Project list carry over: RAH Antepartum Bed, Ensuring correct Liver biopsy ordering, and UAH ED GIM Patient Flow Initiatives Quality Improvement Education

Congratulations!

PGME Sessions:

Ensuring Adequate Nutritional Intake While Reducing Oral Nutritional Supplement Wastage project will be presented at the Nutrition Services Food Matters Conference in April 2019.

Royal Alexandra Hospital-Reducing Excessive Laboratory Ordering for Preeclampsia Bloodwork: Be Hip Gone with PIH will presented at the Choosing Wisely National conference

Wednesday, March 6 12:30 pm to 4:30 pm (RAH) Thursday, April 11 8:00am - 12:00pm (Lister Hall, Maple Leaf Room)

Wednesday, April 24 12:30 pm to 4:30 pm (UAH) Thursday, June 6 8:00 am to 12:00 pm (ECHA, room 1-430)

AHS Quality Summit and AHS & UA Collaborative

Email: Taniya Birbeck <tbirbeck@ualberta.ca>

Both events have been canceled due to Connect Care

Connect Care Ready 

Final standard operating procedure manual for referral entry completed

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Physician triage within E-Clinician underway-MaryAnn Dempsey developed a training handout and can come to your division to assist your group if needed. Please email MaryAnn.Dempsey@albertahealthservices.ca if you need assistance.

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The UAH/MAZ/KEC is slated to go live with Connect Care November 2, 2019

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The DoM CC-Physician group has formed with a representative from each division and stakeholders. We are currently recruiting physician super users. There will be one super user for 7-10 physicians. Please let you divisional representative know if you are interested

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A physician resource site has been developed by the CMIO to support physicians-http://qwci.qwogo.com/clint/hirex.asp?

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Featured Quality Improvement Projects Ensuring Appropriate Lab Test Ordering at Hospital Admission In the Edmonton Zone lab tests have increased by 1.5 million in the last 5 years (AHS, 2018) this growth is not sustainable. The EZMQC in 2017 started a series of QI projects to understand the behavioral factors that influence lab test ordering at patient hospital admission with an aim to reduce initial core lab tests ordered. The QI research question framing these initial projects are: what are the interdependent relationship of physician behavioral factors, the teaching hospital admission and clinical ward practices, and hospital policies that collectively promote lab test ordering overuse. This intersection of physician lab ordering behavior (test selection and test order frequency) along with hospital admission and ward practices are currently minimally understood in the published literature. The QI projects were located at the UAH GIM Units, UAH Nephrology Unit, MCH GIM Units and RAH Obstetric Units. Each project approached lab tests ordering upon admission and the resulting interventions provide insight to further identifying the key general actions required to support a sustained reduction in lab test ordering at hospital admission.

University of Alberta Hospital-GIM Units Project leads: Dr Narmin Kassam and Dr Inka Toman QI intervention initially involved one GIM ward– 5D2 with continual test of change cycles occurring over one year (Feb 2017-Feb 2018) and has spread to all 5 units. Interventions were: Physician team actively reviews lab order frequency consistently reviewing the unit Lab Kardex, auto-substitution label (daily to dailyx3) was used initially until ‘daily’ admission ordering decreased. Lastly, the medicine admission order form-lab section was updated by removing the urea test, de-bundled all lab tests, and frequency options of a one time order, drawn on the next lab draw were added along with the option of physician indicated frequency.

Key learning included: 1.Admission lab tests order frequency is not known to the physician team therefore they cannot make timely frequency adjustments post admission, 2. The order form supported lab test overuse at admission as lab tests were bundled together and no frequency options were provided therefore daily was written by most physicians, 3. The updated order form demonstrated lab tests ordered on admission can be safely ordered once followed by physician team assessment, and the urea test upon admission for the vast majority of GIM patient admissions was not needed, 4.Increasing physician and resident awareness of lab test ordering overuse at admission along with a deliberate conversation shift from the traditional clinical decision making-“can this test give me more information” to “will the result of this test change the management of my patient?” are critical to reducing lab test ordering at admission.

Royal Alexandra Hospital-Preeclampsia (PEC) Lab test Algorithm Project Leads: Dr Winnie Sia and Dr Xavier Emmanuelle Thompson Project started in Sept, 2017. The main intervention was the development of a new PEC panel of lab tests with the following tests removed: AST,

UREA, LYTES and DDIMER from an outdated PEC panel. Lab data analysis limitation is that all patients lab orders on these obstetrical units are captured. With preeclampsia patients representing~20% of patients on these wards. However lab volumes totals have still shown an sustained reduction. Baseline data showed 10,462 investigations were ordered ($69,350) (Jan-Apr, 2017). Postintervention data (Sept 2017- April 2018) revealed a 39% reduction in investigation cost ($6851/month), particularly those of low clinical utility including D-dimer (69%) and urea (71%). Weekly data show the post-intervention reduction in excessive laboratory investigations were sustained and stable. This simple and inexpensive intervention reduced overall laboratory test ordering for preeclampsia especially for tests of low clinical utility. This resulted in annualized savings of $89060 (39%). However, healthcare provider individual ordering practices remain a barrier to change and some providers are resistant.

University of Alberta Hospital-Nephrology Unit Project leads: Dr Narmin Kassam and Dr Priyanka Mysore Project started June 4, 2018. Focus was appropriate creatinine and urea ordering for nephrology patients at admission. Intervention includes development of an algorithm to assist ordering for both creatinine and urea, a formal lab frequency discussion added to the unit weekly team discussion and the team sheet (informs lab frequency) is reviewed by the medical team daily. Appropriate creatinine and urea testing has improved confirmed via weekly chart audit. However, lab order frequency is variable as this is highly dependent on physician ordering practice. PDSA Cycle 2 will start in May 2019 Key learning for both the UAH-Nephrology and RAH– PEC included: Same as the UAH GIM units with the addition of residents and attending physicians appreciated the use of algorithms based on clinical best practice to support lab test ordering at admission and the results suggest a sustained reduction and adherence to the developed algorithms for both of these QI projects.

Misericordia Community Hospital- GIM Units Project lead: Dr Mona Gill Project started August 2018. Focus was a reduction core lab tests for GIM units where the admission process does not utilize an admission order set but merely physician hand write the lab tests they wish to order. Interventions included a targeted education sessions, updated electronic lab Kardex to track tests and frequency for all staff on the unit to view, an auto-substitution sticker for

UAH interventions were structured physician and Staff education and removal of the urea test from the order set. Intervention dates-Feb 2017project and started, March 2017 education and test removed from the order set April 2018.

RAH intervention were order set (urea test removed) placed in ED sept 2018, no educational sessions and no unit staff awareness MIS intervention were non formal educational awareness for both physicians and unit staff held in May 2018 and auto- sub process for Urea started in Sept 2018 Limitations: Residents who were educated on the intervention move throughout these sites and each site has a different number of units and different unit specific processes Approximately, $200,000.00 cost reduction has been identified in the Edmonton zone since Feb 2017

Ensuring Appropriate Lab Test Ordering at Hospital Admission QI Projects Summary 

Residents are aware that some labs are ordered unnecessarily but may fear consequences, or are directed to order the lab tests, habitual ordering on admission of the core lab tests, were unaware of the costs, and the admission order form bundled tests and tick box eases ordering overuse.

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Nephrology patient (hemodialysis) and preeclampsia obstetric patient requires specific lab tests ordered along with specific frequency based on lab results; algorithms/panels for specific medical conditions support physician ordering practices and are easily adhered to and sustained. However; these panels need to be reviewed with clinical best practice and adjustments made over time.

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Admission Order sets with lab tests unbundled and order frequency clearly outlined-i.e. once, on next lab draw, and daily x3 prevent lab tests being ordered upon admission as indefinite (daily) for the patient’s entire length of stay.

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Ensuring all physicians and residents are aware of the lab order frequency upon admission is critical to supporting and sustaining lab test ordering overuse.

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Increasing physician and resident awareness of lab test ordering overuse at admission along with a deliberate conversation shift from the traditional clinical decision making-“can this test give me more information” to “will the result of this test change the management of my patient?” is critical to reducing lab test ordering at admission.

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Changing physician cultural ordering practice is difficult and if we rely only on educational interventions change and impact will be very slow with limited sustainability. Therefore a recommendation that all hospital admission lab test orders can be ordered once with frequency adjusted post the initial test result and that the lab test order process supports physician diagnostic reasoning that impacts the patient care plan.

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The removal and /or justification of the Urea lab test at hospital admission initial impact data suggests that this offers a safe cost effective impact to the lab test overuse problem within the Edmonton zone and the EZMQC recommends that further development a focused provincial intervention targeting the Urea test similar to what has been already achieved for vitamin D testing within Alberta would be beneficial.

2019 EZMQC-SCIC Meetings: Save the dates!

March 20, 2019-*Wednesday June 20, 2019 September 19, 2019 December 5, 2019

Contact Us Pamela Mathura-QI Consultant pam.mathura@ahs.ca Dr. Narmin Kassam-Associate Chair, Clinical Affairs nkassam@ualberta.ca Yvonne Suranyi-Executive Directive EZ Medicine yvonne.suranyi@ahs.ca

EZMQC-Strategic Clinical Improvement Committee Dedicated to QI Capacity, Capability and Collaboration Visit Us: https://www.ualberta.ca/department-of-medicine/ezmqc-scic