Impact and ease of implementation are two general ways to categorize laboratory stewardship interventions (1). For example, sending an email about best practice guidelines is easy to do but most likely will have little impact on actual practice. Conversely, building rules in an electronic health record to alert when best practice guidelines are not being followed is more difficult to implement but has a higher impact on actual practice. A recent meta-analysis by Rubenstein and colleagues reviewed the effectiveness of various laboratory stewardship interventions, and found that those with the highest evidence ratings involved computerized-provider order entry (CPOE) systems and combined interventions (2). But, as discussed in a recent lighthearted editorial in Clinical Laboratory News, knowing what to do and actually doing it are different things that involve different skills (3). What follows is a practical story of both knowing and doing. While the story highlights a specific esoteric test, the approach this case describes would apply broadly to any stewardship challenge.
As part of our active laboratory stewardship program, we review at the time of order every miscellaneous test request. In addition, any time we receive more than five orders for a miscellaneous test we perform a more detailed evidence review to determine if the test should be defined in our laboratory information system. Through these processes, we observed a sudden increase in functional panels for C3 glomerulonephropathy (C3GN) and thrombotic microangiopathy (TMA). Nephrologists requested these panels be performed by a specific specialty laboratory. During this time, we had a rotating pathology fellow working with the lab stewardship team—and so began our journey to “knowing.” Our fellow reviewed the cases and literature in detail, and compiled the facts (Figure 1).
Most laboratory tests cross multiple disciplines, and it is important to engage the relevant stakeholders when exploring interventions to improve laboratory stewardship. In this case, the stakeholders included nephrologists who see the patients and order the tests, pathologists who have expertise about tests related to their cases, and lab send-outs staff who devote considerable resources to coordinating miscellaneous tests (using complex, manual processes to do so). Our pathology fellow’s investigation was instrumental to starting the discussion—everyone was able to get behind collaborating when it involved educating a trainee. Of course, collaboration alone doesn’t equate to success. It is a part of the “doing” process in laboratory stewardship and is a learned skill (Figure 2).
The ideal state for any laboratory stewardship intervention is complete consensus among the relevant stakeholders. If you are wondering about what this looks like, it’s something akin to, “This is a great idea and I have no other questions or concerns about your proposal.” In reality, achieving harmony takes planning, meetings (sometimes many, many meetings!), and persistence to reach such an ideal state. In this case, we identified a champion in nephrology who worked with us on designing alternatives that were clinically acceptable, and in getting feedback and necessary buy-in from his colleagues. While easy to summarize in one sentence, it took several iterations consisting of lab meetings with the champion, champion meetings with the nephrology division, and rinsing and repeating. Ultimately, we reached a consensus in 7 months. The champion went through the 18 tests offered in the panel and asked what decision would be based on the results. Through this exercise, we determined that only eight tests would result in a clinical action—the remaining tests were deemed still investigational. Yay, and we’re done! Well …not quite …
Using CPOE to Hard-wire the Solution
A simple assumption is that care team members know which test results will impact clinical management, so they should only order those tests—especially since most of those tests are defined as individual orderables in the electronic medical record. However, that assumption would not be effective. Providers working in CPOE systems are bombarded with extra clicks and steps for every task they must complete, and will naturally try to cut down on extra time when possible. It is definitely easier to order an unnecessarily large panel (one click) than to search and add eight individual tests (more than eight clicks).
In addition to these human-CPOE interface factors, our original individual orders were built to go to several different laboratories, making the collection, processing, and resulting of these tests unnecessarily complicated. When we reached this point in our process review, we decided to re-evaluate the reference laboratories, consolidate testing when possible, and submit a request to build a new order set with these tests and additional ordering instructions (e.g., “If C3 Nephritic Factor is negative, consider the following additional tests …”). These changes took an additional 3 months.
This story was a quintessential example of the knowing versus doing dichotomy. The knowing part was easy and comforting. Our fellow took just 2 months to dig in, learn about the testing, review our cases, and feel comfortable with our conclusion that there must be a better way to get the clinical answers for C3GN cases. But it was the doing part that—pardon the expression—really took some doing. The overall process required 10 months to collaborate, refine the proposal, get consensus, and work within our IT system to make a systems solution. Reflecting on this a full year later, we feel at peace with the process and will use this roadmap for future efforts in laboratory stewardship.
- Dickerson JA, Fletcher AH, Procop G, et al. Transforming laboratory utilization review into laboratory stewardship: Guidelines by the PLUGS National Committee for Laboratory Stewardship. J Appl Lab Med 2017;2:259-68.
- Rubinstein M, Hirsch R, Bandyopadhyay K, et al. Effectiveness of practices to support appropriate laboratory test utilization: A laboratory medicine best practices systematic review and meta-analysis. Am J Clin Pathol 2018;149:197-221.
- Astion M. Knowing versus doing in quality improvement. Clinical Laboratory News 2018;44(7):48-9.
Jane Dickerson, PhD, DABCC, is clinical associate professor at the University of Washington and co-director for clinical chemistry at Seattle Children’s Hospital in Seattle. +Email: email@example.com