The COVID-19 pandemic overshadows every conversation at my hospital and laboratory so much that I can’t push any stewardship projects forward. People say they are overwhelmed by the pandemic even though not all my colleagues have work dominated by COVID-19. My own motivation to focus on stewardship—still a high priority for my institution—is waning. Please help me.

Worldwide calamities like the COVID-19 pandemic produce widespread anxiety and mental fatigue. Anxious and mentally fatigued healthcare workers have difficulty prioritizing and performing creative work and work requiring sustained concentration (1). They also tend to experience the phenomenon of “load shedding,” which is a migration from higher priority, harder work to lower priority, easier work (see box).

Confession of a PLUGS member

Examples of simple, less important work include:

  • Reading about COVID-19.
  • Visually inspecting the lab with an emphasis on casual banter, finding snacks, and signing greeting cards.
  • Logging in to the health system’s benefits portal to determine one’s retirement date.
  • Cleaning and organizing one’s desk.

I recommend that anyone having trouble completing stewardship work should try performing this work sequestered from distractions and earlier in a shift when their energy is higher and distractions are lower. Consider one or more short-term interventions to reduce mental fatigue including taking stimulants like coffee, avoiding heavy meals, and turning off mobile devices, email, and other distractions.

When trying to improve the stewardship productivity of co-workers, choose fewer projects and develop more frequent, smaller milestones. Do not expect big gains. When gains occur, affirm the people who made them happen (2). In addition, consider scheduling stewardship-related meetings so work occurs during the meeting rather than expecting all work to be completed between meetings. 

As an example, consider a common stewardship project to reduce duplicate testing arising from the intensive care unit (3). A foundation of this project involves selecting specific tests and defining duplicates. This usually necessitates producing a table with a list of analytes. For each analyte, the table lists a time interval between tests, which defines the likelihood that the test is a duplicate. 

To start, schedule a project meeting with domain experts who have decision-making authority. Next, strongly resist the temptation to ask the experts via email to complete an exhaustive survey or fill in a huge table of tests and time intervals. If overcome by this temptation, lie down and let it pass. Then, compose an email with one short, easy question on what constitutes a duplicate for one common test. This question could be: “Do you agree that a basic metabolic panel is not needed more than once per 24 hours in most intensive care unit patients?” Even a load-shedder is likely to respond. The best emails are just one sentence, or can be asked in the subject header. For those individuals who do not reply, wait for the in-person meeting, present the consensus of the other experts, and ask if they agree. Thank everyone and repeat the process a few times until a small table of duplicates has been defined. The first part of the project, though smaller than hoped and taking longer than expected, has been achieved. 

The remainder of such a project would involve executing the table in the test ordering system of the electronic medical record (EMR). This usually causes the EMR to give a hard or soft stop when a duplicate test is ordered. Before the pandemic, that part of the project might have felt like crossing a river. During the pandemic, it probably will feel more like swimming across an ocean. Nevertheless, even an IT project will succumb by patiently breaking the work down into the smallest achievable units and affirming the team at each minor milestone. 

In the classic 1991 comedy “What About Bob?” the fictional psychiatrist, Dr. Leo Marvin, played by Richard Dreyfus, gives the same advice described above to Bob, his hapless and maddening patient played by Bill Murray. Dr. Marvin’s therapeutic philosophy, known as “baby steps,” is encompassed in this advice.

Breaking Down Projects Into Baby Steps
As described in the table, the baby steps approach can keep lab stewardship programs moving slowly forward during the pandemic. After the pandemic, I hope we can all move from baby steps to gigantic leaps and bounds. 

That's one good cup of joe! I'm revitalized and ready to improve stewardship.

Michael Astion, MD, PhD, is clinical professor of laboratory medicine at the University of Washington department of laboratory medicine and medical director of the department of laboratories at Seattle Children’s Hospital.Email: michael.astion@seattlechildrens.org

References:

1.       Fatigue and error: An interview with Dr. Matthew B. Weinger. Clinical Laboratory News 2009;35(1):10-1.

2.       Astion M, Hernandez J. Should I stick with this turnaround—or quit? Clinical Laboratory News 2017;43(7):50-1. https://www.aacc.org/publications/cln/articles/2017/july/should-i-stick-with-this-turnaround-or-quit-cln-patient-safety-focus

3.       Procop GW, Yerian LM, Wyllie R, et al. Duplicate laboratory test reduction using a clinical decision support tool. Am J Clin Pathol 2014;141:718-23.