Do We Really Need Those Labs: A Student-Led Investigation of Cross- Disciplinary Attitudes on Daily Lab Ordering in Academic Inpatient Medicine

Background: Over-ordering of daily labs affects patient safety through hospital-acquired anemia, patient discomfort, frontline staff burden, and unnecessary downstream testing resulting in the delivery of low-value care. Routine ordering of unnecessary tests occurs for many reasons and can additionally increase cost of care. At our center, previous interventions have targeted lab ordering, but have struggled to remain sustainable. Our student-run project, as part of a high value care curriculum, set out to understand current state practice and local culture to inform future high-value care and quality improvement interventions to target over-ordering of daily labs. Methods: We employed mixed methods to assess lab ordering behaviors and attitudes at an urban quaternary academic medical center. Electronic medical record (EMR) data was gathered to assess the number of daily labs (BMP, CMP, and CBC) ordered on a general medicine unit from June–October 2020. We surveyed internal medicine (IM) attendings, residents, physician assistants (PA), nurse practitioners (NP), registered nurses (RN), and patient care associates (PCA) to understand cross-professional beliefs and attitudes about daily lab testing. Results:An average of 2.2 labs were collected per patient day. This was an increase from the 1.3 labs per patient day found in a similar patient population from March 2016 to August 2017 after the last daily lab reduction intervention. A widely distributed survey yielded 127 frontline staff responses: 29 (22.8%) attending physicians, 43 (33.9%) resident physicians and fellows, 12 (9.4%) PAs, 10 (7.9%) NPs, 14 (11.0%) RNs, and 19 (15%) PCAs. Of the 94 ordering providers (MD, DO, PA, NP), 73% thought they were unnecessary. No attending physicians designated daily lab testing as necessary, in contrast to 10% of NPs, 33% of PAs and 25% of residents. Only 29% of ordering providers agreed that daily testing improved patient care and safety; moreover, 89% believe it has potential harms. Of the residents, NP, and PAs, 68% cited worry over attending reaction and 97% cited training/habit as a reason for ordering unnecessary labs. Conclusions: Analysis of prior interventions on unnecessary lab testing has demonstrated a strong need for sustainable interventions to improve patient care and reduce costs. Our multidisciplinary survey highlights a major discrepancy between attendings and other ordering providers on the necessity of daily tests. These results reveal the potential impact of planned PDSA (plan-do-study-act) cycle interventions including planned educational sessions, the initiation of monthly audit and feedback email, and attending-led rounding discussions on necessary labs. Learning Objective #1: To describe the current state of daily labs ordered per patient in the context of prior interventions to reduce lab burden as a means to identify areas of improvement for future quality initiatives. Learning Objective #2: To assess interdisciplinary attitudes on daily laboratory testing to develop a sustainable quality improvement intervention.