sensible test ordering practice in an emergency department · demand management in laboratory...

Sensible Test Ordering Practice

in an Emergency Department

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

Coag Numbers by week

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2014 2013 Target 2014 Median 2013 Median

Appropriate requesting of Coag tests restated at education meeting for ED staff

New OCS profiles initiated

Briefing for new Medical staff at induction on misuse of Coag screens

TAT Sub-project results New NCHD staff

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

August 15, 2014

Sensible Test Ordering Practice in an Emergency Department

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Declaration We declare that this work has been completed in compliance with the RCPI Quality Improvement Project Guidelines and is our own work Signed:

1. 2.

3. Date of submission: 15th August 2014


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Consent for dissemination We consent to the dissemination of our project abstract. We understand that neither the institution or the project authors’ names or affiliations will be made available without prior contact from RCPI.

1. 2.

3. Date: 15th August 2014


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Table of Contents Declaration................................................................................................................. ii Consent for dissemination ......................................................................................... iii Table of Contents...................................................................................................... iv List of Tables..............................................................................................................v List of Photographs ....................................................................................................v List of Common Abbreviations....................................................................................v List of Figures............................................................................................................vi Abstract..................................................................................................................... 1

Aim........................................................................................................................ 1 Methods ................................................................................................................ 1 Results .................................................................................................................. 2 Conclusion ............................................................................................................ 2

Introduction ............................................................................................................... 3

Tools from the science of Quality Improvement ..................................................... 3 Demand Management in Laboratory Medicine ...................................................... 4 Sensible Test Ordering Practice ............................................................................ 6 Evidence for effectiveness of demand management interventions in pathology..... 8 The QI project site ............................................................................................... 11 Justification for this project .................................................................................. 12

Aim statement ......................................................................................................... 13 Drivers for Improvement.......................................................................................... 15 Measures for Quality Improvement.......................................................................... 16

Analysis of baseline data..................................................................................... 17 Other data measurement tools used during the project ....................................... 18 Arthur’s Day ........................................................................................................ 19

Project Implementation, Results and Discussion ..................................................... 21

Financial Modelling of Savings ............................................................................ 29 Patient Experience Time: Length of Stay in ED ................................................... 30

Conclusions............................................................................................................. 31 Future Recommendations ....................................................................................... 33

Spreading the improvements nationally ............................................................... 34 References.............................................................................................................. 35 Appendix A: Surveys ............................................................................................... 37 Appendix B: Team Membership and Acknowledgements........................................ 39


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List of Tables Table 1. Concepts, Methods and Tools for Quality Improvement (©RCPI 2012) ....... 4 Table 2. Lewandrowski’s 10 tools for demand management in laboratory medicine.. 5 Table 3. Ranking of interventions from weak to strong (adapted from Astion 2006)... 5 Table 4. RCPA/ACEM Guideline for Pathology Testing in Emergency Departments . 7 Table 5. Studies estimating or analysing cost savings of test ordering interventions 10 Table 6. SMART Aim Statement Checklist .............................................................. 13 Table 7. Stakeholder Analysis ................................................................................. 16 Table 8. Plan for PDSA Cycles................................................................................ 18 Table 9. Estimates of cost savings from reduced pathology tests............................ 29

List of Photographs Photo 1. Test Screen of the KEY Order Communications system used to request pathology tests. ....................................................................................................... 11 Photo 2. Arthur bleeds Harry, the patient................................................................. 19 Photo 3. Arthur sends Harry’s blood specimens to the Lab via the ED pneumatic chute system........................................................................................................... 19 Photo 4. Lab staff receive Harry’s blood specimens ................................................ 19 Photo 5. Arthur gets interrupted checking the results .............................................. 19 Photo 6. ED team demonstrating IT system at a meeting. ....................................... 21

List of Common Abbreviations CPOE Computerised Provider/Physician Order Entry System CRP C-reactive protein CTPA Computed Tomography Pulmonary Angiogram ED Emergency Department KEY The CPOE/OCS in use at Tallaght Hospital LIS Laboratory Information System MAU Medical Admissions Unit OCS Order Communication System (same as CPOE) PDSA Plan-Do-Study-Act Cycle


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List of Figures Figure 1. Relationships between improved pathology test ordering and satisfaction.10 Figure 2. Driver Diagram ......................................................................................... 14 Figure 3. Percentage of blood tests ordered per 8 hour shift ................................... 17 Figure 4. Flow Diagram ........................................................................................... 20 Figure 5. Hand-drawn visual from observation exercise - Arthurs Day..................... 20 Figure 6. Cycle 1 - Induction.................................................................................... 22 Figure 7. Cycle 2 - Reinforcement ........................................................................... 22 Figure 8. Guidance development incorporating Tallaght ED Top 20 presentations.. 23 Figure 9. Run chart on sample time to laboratory using PTS/chute system ............. 24 Figure 10. Cycle 4 - Maintaining Engagement. ........................................................ 25 Figure 11. Cycle 4 - Maintaining Engagement (survey). .......................................... 26 Figure 12. Effect of PTS/chute system changes. ..................................................... 26 Figure 13. Redesigned Profiles ............................................................................... 27 Figure 14. Cycle 5 - IT Profile redesign ................................................................... 27 Figure 15. Annotated run chart summarising all PDSA Cycles ................................ 28 Figure 16. Blood test orders post-profile change ..................................................... 28 Figure 17. Point of care testing of blood glucose in ED ........................................... 29 Figure 18. Patient experience time. ......................................................................... 30 Figure 19. Pareto Chart showing that the ICT change was the critical factor ........... 31 Figure 20. Ogrine and Shojania's conceptual map of PDSA. ................................... 33


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Abstract

Inappropriate use of diagnostic laboratory services, particularly over-ordering, can

result in diagnostic error, poor patient outcomes and experience, as well as

increased costs and waste of hospital resources.

Aim Our aim was to encourage Sensible Test Ordering Practice to reduce the requesting

of selected pathology tests by 50% in the Emergency Department of a large Irish

teaching hospital by the end of April 2014. We focused on a range of clinical

chemistry and haematology tests including coagulation screens, blood glucose, and

c-reactive protein.

Methods We used the “S.T.O.P. and think!” technique successfully developed in 2004 in

Sydney, Australia, and published in 2013 as the influential Guideline for Pathology

Testing in the Emergency Department by the Royal College of Pathologists of

Australasia and the Australasian College for Emergency Medicine.

Baseline data on tests ordered were collected and analysed. A working group that

included all stakeholders was established. Measurement commenced in January

2014 and consisted of an annotated run chart with results provided weekly to the

Emergency Department staff. Other measures included process mapping and

observation, a staff satisfaction survey, an analysis of cost savings achieved, and an

assessment for any changes in patient length of stay as a result of the interventions.


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Plan-Do-Study-Act cycles were conducted around five interventions; (1) education at

induction, (2) scheduled teaching sessions, (3) development of a visual aid for

guidance in test ordering, (4) improved test turnaround time, and finally (5) redesign

of the pathology test ordering panels on the electronic ordering system which turned

out to be the critical intervention.

Results Our aim was achieved after 4 months and 5 cycles, with a 50% reduction in

coagulation screens, 98% reduction in blood glucose tests, and significant reductions

in several other pathology tests. Savings due to the total reduction in pathology

testing were estimated at �94,500 per annum. We also confirmed that patient length

of stay was not adversely affected by the reduction in pathology testing.

Conclusion This project demonstrated that 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.


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Introduction

Appropriate use and management of demand for scarce and costly healthcare

resources is a growing problem of international importance, not least for diagnostic

laboratory medicine services which have seen annualised workload increases of 10%

over the past decade. In Ireland, laboratory diagnostics account for up to 9% of

typical hospital budgets (HSE). Over-utilisation and unnecessary investigation is an

unintended but wasteful and risky consequence stemming from increases in

healthcare information technology and automation, major advances in medical

practice and patient turnover, as well as clinician and client/patient expectations.

This project applies the tools of quality improvement to enhance the practice of

demand management in laboratory medicine, specifically to support better test

ordering practice and to thoughtfully address over-utilization of laboratory medicine

services in an Emergency Department setting. We will also tell the story of “Arthur’s

Day” in the Emergency Department to illustrate the tools in action.

Tools from the science of Quality Improvement Throughout this project we applied tools, methods, and concepts from the science of

quality improvement which were taught on the Diploma course, are summarised in

Table 1 below and are described fully in Langley et al (2009), Provost et al (2011),

and Pfeffer et al (2000).


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Table 1. Concepts, Methods and Tools for Quality Improvement (©RCPI 2012)

Demand Management in Laboratory Medicine Techniques for demand (utilisation) management in laboratory medicine have been

refined into a scientific approach and have been recently reviewed by Huck and

Lewandrowski (USA, 2014) who described 10 commonly used tools (see Table 2),

and Smellie (UK, 2013).

The Four Quadrants of Profound Knowledge SMART Aim Checklist Driver Diagram Run Charts PDSA Cycle Defining Variation The difference between natural and artificial variation Defining Flow Process Mapping Demand versus Capacity Scheduling Care Defining Patient Safety Techniques to foster a culture of safety Care of the Caregiver Characteristics of high reliability organisations The importance of risk management Finding the balance between clinicians and management Leveraging hierarchies to better patient care Understanding just culture The role of leadership in changing culture Strategies for bringing about cultural change Techniques to build trust within a culture that does not appear trustworthy How to adopt to change for success Recognising the need for change Getting buy in for quality improvement Sending clear messages about QI How to spread [change; improvements] by mobilising frontline staff Defining healthcare value How to increase healthcare value How to reduce waste in healthcare


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Table 2. Lewandrowski’s 10 tools for demand management in laboratory medicine

The usual approach is to design “interventions” which, according to Astion’s concept

(2006) may be weak or strong. Examples of common interventions including

educational efforts, guidelines and prompts, modifications to request forms and

Computerised Physician Order Entry Systems (CPOE), and authorisation/traffic light

systems can be found in Table 3.

Table 3. Ranking of interventions from weak to strong (adapted from Astion 2006)

A recent review of decision-support modifications to CPOE/order entry systems

found that beneficial patient outcomes vary and may be absent depending on the

change implemented (Georgiu, Australia, 2006). Minimum re-testing intervals are

now well documented (Lang, 2013) though can be complicated to implement, and

1. Develop a multidisciplinary team for Utilisation Management 2. Develop and implement institutional protocols including reflex testing algorithms for lab use. 3. Provide reliable and readily available test information to clinicians and nurses 4. Get to know your Computerised Provider Order Entry (CPOE) system 5. Review your referrals to Reference Labs, and the budget. 6. Provide interpretive support to avoid unnecessary workups. 7. Use order entry or the LIS to prevent or trap unnecessary repeat orders (minimum re-testing intervals) 8. Make structural changes in your process. 9. Don’t ignore the cost management of blood products. 10. Measure thyself (repeat often).

Weaker Interventions

Intermediate

Stronger

Strongest

Interventions Guidelines Lectures and Educational events Computerised Reminders regarding utilisation

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


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clinical guidelines and protocols are under development in many countries, including

the Irish National Clinical Programme in Pathology.

Sensible Test Ordering Practice

Authorisation systems have proved popular tools for implementing strong

interventions to manage demand and promote appropriate use in many healthcare

domains including pathology testing in Emergency Departments. Also sometimes

known as “traffic light systems” they commonly use a 3-tiered system to identify

common open access tests as for example “Green” which may be ordered by junior

staff grades, with more complex or expensive tests in “Amber” or “Red” tiers requiring

escalation to increasingly senior staff grades (e.g., registrar or consultant) before the

test can be ordered. Mc Carthy et al implemented such a system at the Prince of

Wales Hospital Emergency Department in Sydney supported by the Australian

Governments Quality in Pathology Program (Mc Carthy et al 2009, Tan et al 2004,

Stuart et al 2002), and aptly nicknamed it the “S.T.O.P. and think!” project after its

aim to encourage junior doctors to think more about “Sensible Test Ordering

Practice”. Notably, this traffic-light authorisation system led to a decrease in many

pathology tests including a 50% decrease in coagulation screen ordering when

implemented because the frontline ED doctors had to decide whether their patients

really needed a coagulation screen and discuss with their seniors before ordering the

test. Total pathology costs fell by AUS $49,000 per month. Their pivotal work

contributed to the influential Australasian Guideline (Table 4) jointly published by the

Royal College of Pathologists of Australasia and the Australasian College for

Emergency Medicine (RCPA/ACEM 2013).


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Table 4. RCPA/ACEM Guideline for Pathology Testing in Emergency Departments


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Evidence for effectiveness of demand management interventions in pathology Epner et al (2013) noted that inappropriate test ordering can result in false positive

findings resulting in diagnostic error and leading to a cascade of further unnecessary

investigations with additional inconvenience and anxiety for the patients concerned.

As in primary care, ED patients may have expectations (van Bokhoven et al, 2006)

that blood tests are performed as part of the healthcare visit. ED patient outcomes

from inappropriate test ordering are rarely reported in the literature and whilst

investigating this was not the aim of this project, concerns for patient safety and care

remains an important driver of this project (see driver diagram).

Most literature on inappropriate pathology testing concentrates on reducing the

increasing burden of over-requesting and associated costs. So, for example, Vegting

et al (2012) within a department of internal medicine used consultant commitment,

the unbundling of test profiles, increased awareness of national protocols,

information on test costs and six weekly feedback to effect change in laboratory

ordering patterns without impacting patient mortality or readmission rate but with

statistically significant cost reduction. Likewise, Calderon-Margalit et al (2005)

undertook a hospital wide initiative that included the development of a policy

restricting emergency blood test ordering and the frequency of repeat test orders,

including educational roll out and feedback on its impact. This reduced laboratory test

orders by 19% in the following 12 months.

Some studies have focused specifically on certain clinical settings within hospitals.

For example, Chu et al (2013) studied restricted intern and resident blood test

ordering in an adult tertiary-referral ED. On the basis of altering the blood test form

so as to reflect permissible test ordering (although any test could be ordered once

consultation with a registrar or consultant occurred), the mean number of tests


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ordered per 100 patients presenting fell significantly by 19%. Likewise, Hutton et al

(2009) in their university hospital ED and MAU setting used consultant only

requesting or agreed disease related protocols and produced an 85% reduction in

the number of c-reactive protein (CRP) requests and no evidence of subsequent

request shifting to ward areas. Similarly, Santos et al (2012) focused on ED ordering

of CRP in a medium-sized teaching hospital and showed that educational discussion

and departmental feedback with residents and medical students produced a 48%

reduction in adjusted annual CRP ordering rate. Additionally, Hughes et al (2009)

used the intervention of targeted education for ‘front door staff’ in a small district

hospital on the guidelines for coagulation screening to reduce test ordering in acute

medical admissions by 26% and without reducing the rate of appropriate screening.

These studies from the international literature suggest that blood test ordering is

amenable to interventions aimed at safely reducing blood test ordering and thus

eliminating waste.

All of the studies differ in size, methods, units of analysis, selected blood tests,

currencies, measurement timeframes and occurred over 8 years, rendering them

incomparable. However, almost all made either an estimate or analysis of cost

savings (see Table 5). Mostly, this was done using basic units of analysis, such as kit

costs. However, there can be other cost and value savings in reducing the number

of blood tests ordered. Fundamental change can improve several measures

concurrently (Langley et al, 2009) so improving laboratory efficiency through demand

management can potentially increase TAT and give faster, and possibly, safer

decisions for patient care, thereby improving the patient experience. It can also

reduce medical and laboratory staff workload. Figure 1 illustrates possible inter-

relationships.


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Table 5. Studies estimating or analysing cost savings of test ordering interventions

Figure 1. Relationships between improved pathology test ordering and satisfaction.

Author

Year

Country

Cost saving

Calderon-Margalit et al

2005

Israel

$247,000 p.a.

Hutton et al 2009 UK £10,000 p.a. Hughes et al 2009 UK £21,000 p.a. Vegting et al 2012 Netherlands �350,000 p.a. Chu et al 2013 Australia AUS$ 2633 /100 attendances


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The QI project site Tallaght Hospital is a 625-bedded facility in the South-West of Dublin, serving the

population of 6 Dublin suburbs, West Wicklow and parts of County Kildare. The

Emergency Department is the country’s largest, with over 77,000 patient attendances

per annum and approximately 50,000 patients had blood samples taken in 2013.

From a total staff of 50, 30 staff including doctors and some nurses had pathology

ordering rights.

Photo 1 shows a testscreen of the KEY Order Communications System (OCS) used

for requesting pathology investigations in the ED. It was state-of-the art when first

installed in 1998 but by December 2013 was on the “sunset” list of hospital

equipment needing replacement. An in-house team of systems analysts had

meticulously maintained the system, including re-programming of the inpatient

pathology ordering panels as required. However these had not been reviewed

substantively for over 5 years. The hospital also benefits from a networked

pneumatic tube system for transport of pathology specimens to the laboratory.

Details of each patient episode were recorded using the SYMPHONY database

management system in the ED, which was also due for an upgrade in the timeframe

of the project.

Photo 1. Test Screen of the KEY Order Communications system used to request pathology tests.


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Justification for this project The need for this project originated with an ED consultant (encouraged by the CEO)

who approached the Clinical Director of Diagnostics with the proposal to form a

group to improve pathology test ordering from ED. The same ED consultant had also

been familiar with the “STOP and think!” work of Mc Carthy et al in Australia during

his training there some years earlier. The justification for the project was two-fold.

First, we wanted to improve patient-centred care (including patient experience and

outcomes) as there was a high index of suspicion that over-ordering of pathology

tests was occurring, and secondly, cost-effectiveness would improve as a result. The

latter aim was particularly important as the ED was about to undergo a costly and

major expansion project itself.

Although this project is about Sensible Test Ordering Practice in the Emergency

Department, it is worth noting at the outset that the doctors and nurses who work in

our high-pressure ED are without doubt among the most dedicated and “sensible”

people we have ever met. Notwithstanding this, advances in ICT, laboratory

automation, imaging, and medical practice in general (“technology push”) have

conspired to make test ordering easier and more rapid, driving increases in workload

despite our best efforts. While we think about what is best for the patient, the tests

are already done. This project is more about making sense of the technology than

sensible doctors and nurses.


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Aim statement The aim of our project was to reduce by 50%, the requesting of the selected

pathology tests in the ED of Tallaght Hospital, by the end of April 2014. This aim

followed the SMART acronym of Specific, Measureable, Actionable, Realistic, and

Timely (see Table 6). Whilst the Diploma team considered this a ‘stretch’ goal in

terms of the level of reduction within the given timeframe, the decision was still made

to adopt it.

Table 6. SMART Aim Statement Checklist

We initially selected coagulation screens and CRP tests for special focus, where

ordering averaged 1200 and 1500 tests per month respectively. However, we

monitored the effect of each intervention (PDSA cycle) on all tests requested

particularly as we were planning a major revision of the electronic test ordering

panels.

Specific

Our aim is precise, concise, with single focus and it means the same thing to all

Measurable We have a readily understandable measure of our aim. The measure is directly and quantitatively related to aim achievement, can be proceduralised, and various sampling intervals may be used.

Actionable Deliberate actions are required to make an improvement towards and achieve the aim, with team members capable and willing to make these actions

Realistic The aim is worthwhile, has leadership support with a good prospect of success, is within our control and influence with both time and resources available and is not limited by regulatory, legal, or ethical constraints.

Timely There is a target date, the time is ripe with a sense of urgency, and staff can be assigned with no competing initiatives


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As the project progressed a number of secondary objectives were identified (“side-

shows” or “sub-projects”) to encourage continued staff engagement and clinical buy-

in (i.e. winning their hearts and minds). One was to address a shared concern to

improve turnaround time (TAT) by reducing the percentage of samples taking more

than 20 minutes from OCS to the arrival at the laboratory. Another sub-project aimed

to reduce the movement of laboratory staff to collect samples from the chute system.

Figure 2. Driver Diagram


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Drivers for Improvement

The need for change and justification for this project was firstly, improving patient

centred care, and secondly, reducing waste by examining and improving the systems

involved. Of course, the ED clinicians had many concerns and suggestions for

improvement for us apart from the perceived indiscriminate ordering of tests and

demand management problem which was our primary concern. For example, the

turnaround time (TAT) was felt to be unacceptable and needed improvement. Also,

technical limitations and bugs in the out-dated electronic system for test ordering (e.g.

non-specificity of both the ordering clinician and allocated consultant for reporting

purposes) were causing frustration. These concerns correspond to the first three of

Singh et al’s (2009) taxonomy of diagnostic error dimensions, namely provider-

patient encounter, performance and interpretation of diagnostic tests, and follow-up

and tracking.

Given the timeframe for this project, the Diploma team decided to maintain focus on

the first concern – that of demand management of blood test orders from the ED.

Demand management centres on appropriate test ordering (Fryer and Smellie, 2013)

or as Smellie (2012; p323) states “the right test in the right patient at the right time”.

The team recognised that “big improvements can often be realised by making small

changes directed at the right places in the system” (Langley et al, 2009. p 114). The

team constructed a Driver Diagram (Figure 2) as a means of describing its theory for

improvement (Langley et al, 2009). Together with the driver diagram, the model for

improvement guided the project. The question of what we were trying to accomplish

was set in our aim statement, so the next question was how will we know if a change

was an improvement?


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Measures for Quality Improvement ‘The work before the work’: this is how Batalden (2014; p 7) describes the essential

prerequisites in preparing for a quality improvement change. In our project, there

were several steps involved including a series of small ‘start-up’ huddle meetings

over a two month timeframe (Nov-Dec 2013). Here, an important element was

listening to all the issues that were being raised by ED staff in relation to pathology

blood test ordering. Overwhelmingly, there was a sense of frustration with processes

and a degree of demoralisation from the waste they contained, both in relation to use

of professional’s time and the cost of the service. From this exercise, key time-points

were identified; stakeholders were assessed for their level of influence and reaction

to change (Table 7); project aims were clarified and feasibility and achievability of

requisite tasks was assessed.

Table 7. Stakeholder Analysis

Stakeholder

Initial

support

Level of

influence

Key concern

Steps to getting buy in

ED Consultant High High Wanting quick change to speedier process.

Non-follow up of inappropriate tests.

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


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Analysis of baseline data During start-up initial data from November 2013 was examined to set the baseline

and identify potential actions. For example, an analysis of the time of ordering blood

tests was undertaken to consider if variability between staff shifts was an issue. The

following chart (Figure 3) indicates that this would not be a fruitful issue to pursue

within the project.

Relative % ED Requests Across shifts

0.0%

5.0%

10.0%

15.0%

20.0%

25.0%

RPCRP

Gluc LPAMY

TropTox

2 BP CK MgBNP

TFT FeUrat

e

Test

% T

ests

00:00 to 08:00 08:00 to 17:00 17:00 to 00:00

Figure 3. Percentage of blood tests ordered per 8 hour shift Another measure that could have had potential use was a Box Plot by grade of

doctor or nurse ordering the tests. However, this data was not available from the

Symphony system. These start-up meetings and an initial walk-through of the test

ordering process allowed a PDSA cycle plan (Table 8) to be drawn up.


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Table 8. Plan for PDSA Cycles

Other data measurement tools used during the project The run chart of coagulation screen orders was commenced in January 2014. The

figures were collated weekly and consisted of total coagulation screen test orders

and as a percentage of haematology requests. The weekly updated chart was

circulated to all ED staff via the ED team. The charts were annotated and the runs

examined to interpret the data for shifts or trends. A retrospective Pareto chart was

developed to show the action with largest impact.

The project was further informed by a flow diagram from a detailed process mapping,

conducted by the Hospital’s Quality Manager with input provided by both a doctor

and nurse (Figure 4). An observation session (see “Arthur’s Day”) of ‘following the

patient” was carried out by the Diploma team. Staff satisfaction was measured by 2

short surveys (< 10 items) using the Survey Monkey system (Appendix A). We also

evaluated with the assistance of Tallaght Hospitals’ Business Intelligence Unit for any

Concept

Cycle #

Description of PDSA Cycle

Responsible

Demand Management

1 (induction)

ED Consultant gives introductory induction talk and an email on coagulation screen ordering to new doctors

ED consultant With team backup

Demand management

2 (reinforcement)

ED consultant gives scheduled teaching lecture to ED doctors

ED consultant + team

Demand management

3 (visual aid)

Provide visual aid (Chart) IT + team

Improve TAT 4a Additional canisters circulated Team (side-show) 4b Priority on PTS given to ED Team 4c New labelled canisters for ED Team Demand management

5 Major change in Ordering Panels IT + team


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changes in the Patient Length of Stay (LOS) as a patient outcomes marker. Changes

in pathology costs were also estimated, using three different financial models.

Arthur’s Day

On Monday 31st March 2014, the Diploma team went to the ED for an observational

visit to see test ordering in practice (see Photos 2-5). Our host that day was Dr.

Arthur and one of his patients who agreed to our intrusion who we will call “Harry” to

protect his anonymity. Proceedings were minuted and recorded on video as well as

in a hand-drawn visual (see Figure 5). Harry was about 70, had come in to ED in the

ambulance that morning clearly short of breath and had been on warfarin. No way

was it the first time for Harry to be phlebotomised so Arthur prepared the bottles and

got on with it. The samples were placed in the chute (PTS) after innumerable clicks

on the computer to order the tests. Harry then went for a Chest XRay and we went to

the lab to follow the coagulation screen, blood count, CRP, and chemistry tests.

Harry’s INR was in the region of 4 so the lab phoned it back to Arthur who was

interrupted a few times as he picked up the phone. As there was a risk of pulmonary

embolus, Harry proceeded to a CTPA and Arthur didn’t waste time doing a d-dimer

assay.

Photo 2. Arthur bleeds Harry, the patient

Photo 3. Arthur sends Harry’s blood specimens to the Lab via the ED pneumatic chute system

Photo 4. Lab staff receive Harry’s blood specimens

Photo 5. Arthur gets interrupted checking the results


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Figure 4. Flow Diagram

Figure 5. Hand-drawn visual from observation exercise - Arthurs Day


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Project Implementation, Results and Discussion

The working group was established with both core (ED consultant, Diploma

participants) and an invited membership including clinical staff representatives,

quality manager, the laboratory IT officer, technical services staff, and pharmacy (see

appendix B). Meetings were then held either weekly or fortnightly in the ED. The

invited membership attended if and when there were pertinent issues for discussion

so that all attendees contributed at the meetings. Meetings lasted between 25 to 40

minutes. The question for the working group was what changes could we make that

would result in an improvement? With this question and using the tools outlined in

our measures for quality improvement (above) we commenced our PDSA cycles.

Photo 6. ED team demonstrating IT system at a meeting.

The first PDSA cycle (Figure 6) focused on providing information (verbal and

introductory email) on appropriate blood test ordering of coagulation screens to

NCHDs at their induction. We predicted that this might be a key moment when they

would be receptive to this information and the data showed the predicted response.


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Coag Num bers by w eek

100

150

200

250

300

350

Jan W

eek 2

Jan W

eek 4

Feb W

eek 2

20142013Target

Figure 6. Cycle 1 - Induction

The second cycle (Figure 7) was whether the reduction in coagulation screen

requesting could be maintained by reiteration of the information using weekly

teaching sessions and feedback. Our data analysis for this cycle showed that whilst

reinforcement might maintain the reduction, the ‘Consultant as Champion’ might be a

required presence; such that when the individual concerned was on holidays,

coagulation screen requests rose.


100

150

200

250

300

350

Jan

Wee

k2

Jan

Wee

k3

Jan

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k4

Feb

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k1

Feb

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k2

Feb

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k3

Feb

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k4 M

arch

Wee

k 1

Mar

chW

eek

2M

arch

Wee

k 3


Figure 7. Cycle 2 - Reinforcement

Question: Will reinforcement of message at education meetings maintain reduction? Prediction: ‘Consultant as Champion’ presence required

Question: Can induction talk reduce coag screen requesting? Prediction: Yes by ~ 20%


23

The burden that reinforcement placed on key staff was recognised and so for our

next cycle of change we decided to develop a quick visual aid for appropriate blood

test ordering. Using the 2013 top 20 ED presentations to Tallaght, the Diploma team

in conjunction with the ED Specialist Registrar, SHO and nurse team members

adapted the RCPA/ACEM 2013 Guideline (Table 4) to correspond to Tallaght ED’s

top 20 presentations and associated tests (Figure 8)

Figure 8. Guidance development incorporating Tallaght ED Top 20 presentations This further highlighted what we knew already, that the ED profiles on the Key OCS

electronic ordering system were in need of urgent review. In addition, the process

mapping highlighted problematic and redundant steps within the IT ordering system.

A case was made to release an IT staff member to undertake the work though this

could not be scheduled for at least 8 weeks.

At this stage the project had been running for a number of weeks and the clinical staff

were reluctant to test the visual aid without concomitant changes in the IT system;

however the projected date for IT changes was a further 8 weeks away. While we

were waiting, we had time to focus on the “side-show” sub-projects to help maintain

clinical buy-in. Our fourth cycle of change was therefore directed to the TAT sub-


24

project to test if supporting other initiatives around blood test ordering would help

maintain clinical staff support for the project aim. In start-up meetings staff had

complaints about the pneumatic chute system (PTS) for transporting samples from

ED to the Laboratory (Photo 3): problems identified included insufficient canisters in

the system, canister hoarding by some departments, and variable time for sample

transport depending on pneumatic line usage. Small tests of change were conducted

within this cycle including commencing monitoring of canisters, the addition and

labelling of 24 extra canisters for ED, and priority for ED over other departments on

PTS (Figure 9).

% > 20 mins from OCS to Lab

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% > 20minsTarget> 20mins Median

Monitoring Started Additional canisters

put into circulation

New canisters labelled for Adult ED

Priority on PTS given to ED

PTS line 1 down twice this week

Figure 9. Run chart on sample time to laboratory using PTS/chute system

As it initially showed some promise (Figure 10), the decision was made to continue

this initiative alongside the original aim in an effort to maintain ‘hearts and minds’ of

the ED clinical staff.


25

C o a g N u m b e r s b y w e e k

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2014 2013 T arget

Figure 10. Cycle 4 - Maintaining Engagement.

Prior to the IT changes being implemented, we measured staff satisfaction using a

short survey (Appendix A). The Survey Monkey link was circulated by the clinical

members of the working group. Pre-intervention, eight nurses but no doctors

responded. The nurses were highly experienced with 6 having worked more than 5

years in Tallaght ED and 2 having worked between 2 and 5 years in the ED. Seven

reported high confidence levels in their knowledge on the types of patients requiring

coagulation screen tests. They reported the IT system as slow to use and there was

a mixed response on its ease of use (Figure 11). Whilst 5 reported the PTS/Chute

system changes as being for the better with 2 unsure and 1 reporting no change,

there was greater variation in their perceptions of the effect that this might have on

clinical decision making (Figure 12). Four used the open question at the end of the

survey to make further suggestions such as increasing the number of computer

points where sample labels could be printed.

Question: Will supporting other initiatives help maintain ED support? Prediction: Yes but perhaps not sustainable, yet critical to retain


26

Current IT system

0

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easy 1quick

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Figure 11. Cycle 4 - Maintaining Engagement (survey).

Effect of POD/chute system changes on timeliness of clinical decision

making

quicker

no change

unsure

Figure 12. Effect of PTS/chute system changes. Up to this point our run chart had shown that whilst there was an initial trend (5+

consecutive points) in reducing numbers of coagulation screen orders, this had not

been maintained with cycle 3 and 4 tests of change. Our fifth test PDSA cycle was

the IT system change of redesigned profiles (Figure 13) adapted from the

Australasian guideline.

The team considered that this was the intervention that would make the right choice

easy and could have additional benefits by reducing the orders for other pathology

tests. Figure 14 shows achievement of target with the redesigned IT profiles within

two weeks of target date. Figure 15 shows an annotated run chart summarising all

PDSA cycles.


27

Figure 13. Redesigned Profiles Figure 14. Cycle 5 - IT Profile redesign

Question: Will new profiles reflect appropriate testing & reduce unnecessary testing? Prediction: Additional 25% drop in coag screen orders as minimum +


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28


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Appropriate requesting of Coag tests restated at education meeting for ED staff


Briefing for new Medical staff at induction on misuse of Coag screens

TAT Sub-project results New NCHD staff

Figure 15. Annotated run chart summarising all PDSA Cycles

In addition, and as predicted, the redesigned profiles showed a reduction in other test

ordering (Figure 16). Two elements were unexpected though. Firstly, the 98 %

reduction in laboratory glucose testing was startling. However, glucose testing in the

ED by point of care glucometry was maintained in the 4 weeks before and after the IT

change (Figure 17), also implying that the laboratory glucoses were superfluous.

Post Profile Changes CC Tests Requested from ED 2014 - 2013 (M ay Week 1 to June Week 2)

0%

-9%

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Total CRP RP LP BP Trop Amy Gluc

Figure 16. Blood test orders post-profile change


29

POCT Glucose 2014

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Figure 17. Point of care testing of blood glucose in ED

Secondly, the additional 16% increase in Troponins was unanticipated. The profiles

were then re-examined by the Diploma team and ED Specialist Registrar and a

decision made to remove Troponin from the Sepsis profile. This test of change

resulted in Troponin test orders at +9% after 6 weeks

Financial Modelling of Savings We used three laboratory test costing financial models (see Table 9) to estimate the

savings resulting from fewer pathology tests being ordered. Model 1 used a

commercial pathology test tariff to calculate a saving of �286,000 per annum saving.

Model 2 also used a commercial tariff but based on marginal pricing, and this gave

an estimate of �159,000 per annum. Model 3 used a minimal costing approach,

giving the lowest estimate of �94,500 per annum, which most closely reflects the

expected savings in a large publicly funded teaching hospital environment.

Table 9. Estimates of cost savings from reduced pathology tests

Model 1

Commercial charges (based on a published commercial tariff)

168221831-6393057199138321105475Annualised decrease/increase

1414141414141414Number of weeks counted

4529493-17282353610356814742013-2014 Difference

GlucAmyTropBPLPRPCRPCoag

�100,932�14,649-�9,583�33,625�21,899�4,208�27,426�93,073Savings

�6.00�8.00�15.00�11.00�11.00�11.00�13.00�17.00Profile cost (SJH price list)


�286,230.29

Total Savings

Model 2

Marginal pricing (public hospital)



4529493-17282353610356814742013-2014 Difference


�33,644�7,325-�4,472�18,341�13,936�1,913�6,329�82,123Savings

�2.00�4.00�7.00�6.00�7.00�5.00�3.00�15.00Profile cost

GlucAmyTropBPLPRPCRPCoag*

*Coag costs are greater than Clinical Chemistry test costs as they require a

separate sample and additional hardware and staffing input

�159,138.57

Total Savings

Model 3

Minimal Cost Pricing (Tallaght costs for reagents, staff, overheads)



4529493-17282353610356814742013-2014 Difference


�16,822�3,662-�3,194�9,171�7,963�1,148�4,219�54,749Savings

�1.00�2.00�5.00�3.00�4.00�3.00�2.00�10.00Profile cost (Minimal Tallaght Costs)

GlucAmyTropBPLPRPCRPCoag*

*Coag costs are greater than Clinical Chemistry test costs as they require a

separate sample and additional hardware and staffing input

�94,539.71

Total Savings


30

Patient Experience Time: Length of Stay in ED In order to evaluate whether the reduced pathology testing might adversely impact on

patient outcomes, we chose one particular metric and examined the patient

experience time (PET) assisted by the hospital’s Business Intelligence Unit who

routinely collect and analyse PET data. Figure 18 shows when selected weeks in

May 2013 and May 2014 were compared, the median Length of Stay (LOS) time in

ED (in hours) decreased, as did the average time spent in ED. The number and

percentage of patients spending less than 6 hours in ED also improved. The May

2014 data would have been after the critical intervention (the changes in the Ordering

Panels). Although the reasons for this improvement are clearly multi-factorial (due to

ongoing improvements in the ED unrelated to our project), it is reassuring to assume

that the reduced pathology testing may assist with a better and shorter PET as

hypothetically there would be fewer unnecessary pathology tests to follow-up.

Figure 18. Patient experience time.

Median Time in ED (hrs)

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31

Pareto Chart for the Impact of each Improvement Cycle

0

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ICT change (Cycle 5) Induction (Cycle 1) Engagement (Cycle 4) Inclusion (Cycle 3) Reinforcement (Cycle 2)

Weekly Reduction in Coag Requests

Cumulative Reduction

Figure 19. Pareto Chart showing that the ICT change was the critical factor

Conclusions

The STOP and think! Project at Tallaght Hospital’s ED confirms that demand

management of pathology test ordering in the ED is possible. We achieved our

SMART aim of reducing coagulation screens within a four month timeframe, and

achieved significant other reductions due to re-design of the ordering panels. The

slight delay while an IT staff member was released to undertake the necessary ICT

changes was worth waiting for. A retrospective Pareto Chart (Figure 19) showed that

the most successful PDSA cycle (the critical factor) in effecting a reduction in

coagulation screens was the ICT change, followed by the education at induction.

In addition, we reduced other inappropriate pathology test orders with estimated

savings of �94,500 per annum to the hospital. Whilst there has been some

improvement in TAT by July 2014, changes have yet to reach target or be sustained.


32

A number of lessons were learnt from the project. The inclusion of multidisciplinary

stakeholders in the working group meant that the approach to the project was one of

facilitation or collaboration rather than ownership by the Diploma team. This was

critical to successful ‘buy in’ by all required to make the necessary changes. As

frontline staff working with the processes of blood test ordering, it was essential to

listen to clinical working group members regarding project implementation and hear

their solutions to potential problems. It meant that they determined the timing of tests

of change and all communication was through their working group members. This

led to moments of frustration where meetings were cancelled due to clinical

precedence, delayed communication, or staff leave.

Induction of NCHD’s was viewed by clinical working group members as an excellent

opportunity to implement change. This meant that PDSA cycles (1 and future cycle

6) were scheduled to coincide with induction hence altering our potential project

timelines. So ‘buy in’ involved a ‘trade off’ in terms of meeting project interests for

Diploma purposes; affirming Langley & Denis’ (2011:pi45) “different but equally

legitimate value sets”. As noted elsewhere, PDSA cycles are not as clear as they

look, or as easy to execute (Tomolo, 2009) or applied with rigour (Taylor et al, 2014).

Ogrine and Shojania (2014) show a more realistic concept that, at times, reflected

our experience (Figure 19) within a busy ED department.


33

Figure 20. Ogrine and Shojania's conceptual map of PDSA.

Future Recommendations The STOP and think project at Tallaght Hospital ED is ongoing with the intention of

maintaining optimal local sustainability. PDSA cycles are being developed for

appropriate testing and improving TAT. With regard to the former the next cycle is

another IT change - that of single log-on to the ED blood test profiles. This will be

tested with the new NCHDs in mid-July. In addition, the guidance document will be

utilised at their induction. Since this completes all possible IT system redesign, the

post-intervention survey will then be circulated. We believe that these are the final

actions required to embed our innovation into routine practice at Tallaght’s ED.

Ongoing weekly data collection will be required to confirm this before evolving into

regular audit.


34

With regard to further improving TAT, the Head of Technical Services has agreed to

take the lead on the PTS/chute system issues and a strategy for canister

replacement is to be developed. The observation session revealed how samples

delivered by chute have to be ‘walked’ between laboratories. A business case has

been accepted and funding acquired to build a single point of chute entry accessible

by both laboratories, so reducing time and potential ‘loss’ of samples.

Spreading the improvements nationally This project has potential for replication to other hospital EDs, either as direct

adoption or with some adaptation, depending on local context (Ibanez de Opacua,

2013). In our case, the critical change factor was a re-design of out-dated Ordering

Panels. Different interventions may work better in other EDs, as was the case in the

Prince of Wales Hospital ED in Sydney. As a minimum, we would suggest that all

EDs discuss their pathology test ordering patterns with their local pathologists with a

view to identifying areas for improvement and reduction in unnecessary testing. Too

often these discussions focus only on TAT which, like laboratory automation and IT,

may even be a driver for unnecessary testing.

Details of the project will be published in guidelines being produced by the National

Clinical Programme in Pathology, which will be disseminated nationally by the HSE

and RCPI. The ED Specialist Registrar will also be presenting the project on behalf of

the team at the annual Irish Association of Emergency Medicine scientific meeting in

Autumn 2014, as part of a series of anticipated presentations by the Diploma team. A

number of journal articles are also planned.


35

References

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Batalden P (2014) Making improvement interventions happen – the work before the work: four leaders speak. BMJ Qual Saf 24: 4-7.

Berwick D (2003). Disseminating Improvements in Health Care. JAMA, April 2003, Vol 289, No. 15.

Calderon-Margalit R, Mor-Yosef S, Mayer M, Adler B & Shapira SC (2005) An administrative intervention to improve the utilisation of laboratory tests within a university hospital. Int J for Qual in Health Care 17:3, 243-248.

Chu K, Wagholikar AS, Greenslade JH, O’Dwyer JA & Brown AF (2013) Sustained reductions in emergency department laboratory test orders: impact of a simple intervention. Postgrad Med J 89; 566-571.

van Bokhoven MA, Pleunis-van Empel MCH, Koch H, Grol R, Dinant G-J & van der Weijden T (2006) Why do patients want to have their blood tested? A qualitative study of patient expectations in general practice. BMC Family Practice 7:75 doi: 10.1186/1471-2296-7-75

Epner PL, Gans JE, & Graber ML (2013) When diagnostic testing leads to harm: a new outcomes-based approach for laboratory medicine. BMJ Quality & Safety 22: ii6-ii10.

Fryer A & Smellie WSA (2013) Managing demand for laboratory test: a laboratory toolkit. J Clin Pathol 66: 62-72.

Georgiou A, Williamson M, Westbrook JI, Ray S (2007). The impact of computerised physician order entry. International journal of medical informatics 76: 514-529 Huck A and Lewandrowski K (2014). Utilization management in the clinical laboratory: An introduction and overview of the literature. Clinica Chimica Acta 427:111-117 Hughes MA, Duckworth AD, Edmond I, Tan LL, Ripley DP, Tucker J and Leslie PJ (2009) Indiscriminate coagulation screening of acute medical admissions: national cost ramifications. Scot Med J 54:4, 32-35.

Hutton HD, Drummond HS & Fryer AA (2009) The rise and fall of C-reactive protein: managing demand within clinical biochemistry. Annals of Clinical Biochemistry 46: 155-158.

Ibanez de Opacua A (2013) Guide on Spread and Sustainability. Health Improvement Scotland. (weblink, last accessed 11 August 2014) Lang T (2013) National minimum re-testing interval project: a final report detailing consensus recommendations for minimum re-testing intervals for use in clinical biochemistry. Association for Clinical Biochemistry and Laboratory Medicine, UK.

Langley A & Denis JL (2011) Beyond evidence: the micropolitics of improvement. BMJ Quality & Safety 20 (Suppl 1): i43-i46.

Langley GJ, Moen RD, Nolan KM, Nolan TW, Norman CL, Provost LP (2009) The Improvement Guide. (2nd ed) Jossey-Bass, San Francisco.


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McCarthy S (2009). S.T.O.P. and think! Sensible test ordering practice at Prince of Wales Hospital Emergency Department. Australian Government Department of Health and Ageing, Quality Use of Pathology Program, Best Practice Pathology Requesting Workshop, Department of Health and Ageing, Canberra (workshop presentation)

Ogrinc G, and Shojania KG (2014) Building knowledge, asking questions. BMJ Quality and Safety 23:265-267

Provost L, Murray S (2011). The Health Care Data Guide. Learning from data for improvement. Jossey-Bass Wiley

Pfeffer J and Sutton R (2000). The Knowing-Doing Gap. How smart companies turn knowledge into action. Harvard Business School Press, Boston, Massachusetts Royal College of Pathologists of Australasia/Australasian College for Emergency Medicine. Guideline on Pathology Testing in the Emergency Department. ACEM Guideline Nr: G125. RCPA Document Nr 1/2013 (weblink, last accessed 12 August 2014)

Salinas M, Lopez-Garrigos M, Uris J (2013) Differences in laboratory requesting patterns in emergency department in Spain. Annals of Clinical Biochemistry 50(4), 353-359.

Santos IS, Bensenor IM, Machado JBA, Fedeli LMG & Lotufo PA (2012) Intervention to reduce C-reactive protein determination requests for acute infections at an emergency department. Emerg Med J 29, 965-968. De Silva Debra (2014). Spreading Improvement Ideas. Evidence Scan No. 20. The Health Foundation.

Singh H, Weingart SN (2009) Diagnostic errors in ambulatory care: dimensions and prevention strategies. Adv Health Sci Educ Theory Pract 14(1): 57-61.

Smellie WSA (2012) Demand management and test request rationalisation. Annals of Clinical Biochemistry 49: 323-336.

Stuart PJ, Crooks S, and Porton M 2002. An interventional program for diagnostic testing in the emergency department. Med J Aust 177:131–4. Tan C, Bragg M, Mc Carthy SM (2004). “STOP and think!” changing medical culture is as easy as “red, orange, green”. Abstracts of the Australasian Scientific Conference of the ACEM . EMA 7(2), A1-A15, Australia.

Taylor MJ, McNicholas C, Nicolay C, Darzi A, Bell D, & Reed JE (2014) Systematic review of the application of the plan-do-study-act method to improve quality in healthcare. BMJ Quality & Safety 23: 290-298 Tomolo AM et al. (2009) A case study of translating ACGME practice-based learning and improvement requirements into reality: systems quality improvement projects as the key component to a comprehensive curriculum Postgrad Med J 85: 530-537.

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37

Appendix A: Surveys

Survey 1 – Pre-intervention As part of a quality improvement project, we are making some changes to blood test ordering from adult ED. We would like to know if this will improve staff satisfaction and so invite you to participate in this small voluntary, survey. The survey takes approximately 5 minutes to complete. All responses are anonymous and will be collated by the extern (Sarah) on the project team. A second short survey will be circulated once further changes occur. You are not obliged to complete either survey, but doing so will help us to demonstrate the worth of quality improvement and can help us to plan future actions. Gerard, Peter & Sarah 1. What is your current job?

Staff nurse Clinical Nurse Manager Intern Senior House Officer Reg/SpReg Consultant

2. How long have you worked in this ED?

< 6 months 6-12 months 1-2 years 2-5 years >5 years

3. How confident do you feel about your knowledge on the types of patient that require coagulation screens?

1 2 3 4 5 Not confident Very confident

4. How confident do you feel about your knowledge on the types of patient that require CRPs?


5. We will be undertaking some changes to the IT blood test ordering system. Please rate how do you find the current system?

1 2 3 4 5 Easy to use Difficult to use 1 2 3 4 5 Time consuming Quick

6. We have recently made some changes to the pod/chute system. How do you find these?

A change for the better No change A change for the worst Unsure

7. In your opinion, what effect has changes to the pod/chute system had on clinical decision making?

Enabled quicker decisions about patient treatment No change in decision timeframe about patient treatment Unsure

8. If you have any ideas about how we could improve blood test ordering from ED that could improve patient care please tell us


38

Survey 2 – Post-intervention As part of a quality improvement project, we made some changes to blood test ordering from adult ED. We would like to know if this will improve staff satisfaction and so invite you to participate in this small voluntary, survey. The survey takes approximately 5 minutes to complete. All responses are anonymous and will be collated by the extern (Sarah) on the project team. You are not obliged to complete the survey, but doing so will help us to demonstrate the worth of quality improvement. We’d also like to take this opportunity to thank you for all your support on this project. Gerard, Peter & Sarah 1. What is your current job?

Staff nurse Clinical Nurse Manager Intern Senior House Officer Reg/SpReg Consultant

2. How long have you worked in this ED?

< 6 months 6-12 months 1-2 years 2-5 years >5 years

3. How confident do you feel about your knowledge on the types of patient that require coagulation screens?


4. How confident do you feel about your knowledge on the types of patient that require CRPs?


5. We have made all possible changes to the IT blood test ordering system that we can. Please rate how do you find the system now?

1 2 3 4 5 Easy to use Difficult to use 1 2 3 4 5 Slow to use Quick to use

6. In your opinion, has the effect of the IT and POD system changes improved efficiency of blood test ordering? 1 Yes, the system is now very efficient 2 Yes, efficiency has improved but more can be done 3 There has been no change 4 No, the process has become more inefficient. 7. In your opinion, has the effect of the IT and POD system changes improved timeliness of clinical decision making? 1. No, there has been no change in the timeliness of clinical decision making 2. Yes, clinical decision making has become quicker with the system changes 3. I am unsure if the changes have had any effect on clinical decision making. 8. Did you complete survey 1? Yes No Thank you.


39

Appendix B: Team Membership and Acknowledgements

Word Count (excluding references, diagrams, cover pages and appendices): 5410

Team Membership showing multidisciplinary stakeholders Department

Team Member

(* denotes Diploma participant)

Role

Emergency Department Dr. Martin Rochford Lead ED Consultant for project Dr. SiobhanMcArdle ED SPR/lead NCHD for project Dr. Arthur Hennessy ED SPR Dr. Catriona Tiernan ED NCHD Marguarita O’Brien ED Nursing staff Laboratory Medicine Dr. Gerard Boran* Lead Consultant Pathologist for

project Clinical Director of Diagnostics

Peter Gaffney* Chief Medical Scientist – clinical chemistry

Dr Johnny McHugh Consultant haematologist Dymnpna Murphy Chief Medical Scientist -

haematology Nursing Executive (external)

Dr Sarah Condell* Representing nursing executive

ICT Department Brendan Carr Director of ICT Meliosa Moran IT systems analyst Tony Moulton Pathology IT officer Business Intelligence Unit

Deaglan MagFhloinn Business Intelligence Manager

Executive Management Team sponsors

Eilish Hardiman CEO (now former CEO); originator and sponsor for this project in 2012

David Slevin Director of Finance (now CEO) Process Improvement Office

Mary Hickey Process Improvement Manager

Pharmacy Niamh Kilcullen Pharmacist Technical services Gary Keane Technical services Seamus Foran Technical services 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)

sensible test ordering practice in an emergency department · demand management in laboratory...

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