Pending lab test results at the time of discharge: a 3-year - - PowerPoint PPT Presentation

Nasir Wabea , Ling Lia, Gorkem Sezgina, Maria Dahma, Elia Vecelliob, Robert Lindemanb, Johanna Westbrooka and Andrew Georgioua

Pending lab test results at the time of discharge:

a 3-year retrospective comparison of paper versus electronic test ordering in three ED

aCentre for Health Systems and Safety Research, AIHI, Macquarie University, Sydney, Australia; bNSW Health Pathology, Prince of Wales Hospital, Sydney, Australia

Delivering safe and effective test result communication, management and follow-up

Establishment of effective test result management systems in hospitals

• Identifying the existing modes of communication, responsibility

and accountability

• Qualitative interviews, ethnographic observations

Harnessing health information technologies (IT)

• The effect of health IT on test result management
• Controlled pre- and post- studies utilising data analytics to

measure the impact on test requesting, follow-up and patient

• utcome.

Enhancing the contribution of consumers

• What do consumers want? What is needed to establish

patient-centred health care?

• Qualitative studies to explore patient and consumer views.

Introduction

Introduction

• Lab testing is one of the key drivers in the

clinical decision making.

• In ED, lab tests are commonly ordered

to establish a working diagnosis. In US, lab test are ordered for 42% of ED visits (CDC 2015). In one Australian hospital, 56.4% of all ED visits were ordered lab tests (Vecellio 2014).

Introduction…

• Ideally, a test result should be available as early as possible and prior

to patient discharge.

• However, evidence from systematic reviews has suggested that that

1.0%-75% of test results are pending at discharge (Callen 2011).

Introduction…

• What are the consequences of pending test results?
• Pending test results can have major health consequences (Dalal 2014, Callen

2011).

Less likely to be followed-up and therefore may lead to:

• Missed or delayed diagnosis,
• Increased hospital revisits and
• Adverse drug reactions

Introduction…

Introduction…

http://simsrad.net.ocs.mq.edu.au/login?url=https://search.proquest.com/docview/2039368518?accountid=12219

Introduction…

• So what is the role of EMR?
• Allow clinicians to order tests and receive results electronically.
• Provides a platform to streamline laboratory workflow.

Introduction…

• Paper-based systems:
• Can be more time-consuming to process within

the laboratory and therefore may delay test result availability.

• To date, studies assessing the relationship between

test order types (paper-based or electronic) and the rate of pending test results at patient discharge are lacking.

Aim of the study

• To determine the rate of pending test results at time of discharge from

ED, and compare the rate for paper-based and electronic orders.

• We hypothesised that tests ordered electronically would be less likely

to be pending at discharge compared to those ordered using paper- based system.

Methods

Methods

• Setting:
• 3 hospital EDs in NSW, Australia: one large metropolitan hospital with
• ver 500 beds [Hospital A] and two smaller regional hospitals [Hospital B

and C].

• Population:
• All patients attending the study EDs between Jan 2014 and Dec 2016.
• Only patients who were treated in ED and eventually discharged from ED

were included.

Methods…

• Dataset:
• Linked LIS and ED data
• Chemistry and haematology tests were

selected.

• POCT and add-ons were excluded.

EDDC LIS

 An add-on is an additional test that is carried out on a specimen that has already been delivered to the lab.  The process of add-on testing does not follow the same process as a new test

• rder.

Methods…

• Statistical Analysis:
• Descriptive statistics were reported as appropriate.
• Pearson’s Chi-squared test was used to compare the rates of

pending tests for paper-based and electronic orders.

• As a subgroup analysis, the top five most frequently ordered tests

were selected.

Results

Results

• A total of 71,466 ED visits fulfilled the inclusion criteria:

55.9% were female the median age was 49 years. Most visits occurred at Hospital A (38.7%) while presentations to Hospitals B and C were roughly the same (30.5% each).

Paper-based 2.8% (n=10,007) Total tests n=357,476 Total ED visits n=71,466 EMR 97.2% (n=347,469)

Results…

• The rate of paper-based test orders were:

roughly the same for chemistry (2.8%) and haematology (2.9%). slightly varied by study hospital.

Rate of pending results

• Electronic (6.6%) versus paper (9.7%): Diff=3.1% (P<0.001).

Test order type Test Count Pending Test Result Test Count % (95% CI) Paper 10,007 966 9.7 (9.1-10.2) Electronic 347,469 22,928 6.6 (6.5-6.7) Table 1. Rate of pending test results at ED discharge.

Rate of pending results by study EDs

The difference was significant for all hospitals

Figure 1: Rate of pending test results at ED discharge by study ED, 2014-2016. *P<0.001

0 . 0 2 . 5 5 . 0 7 . 5 1 0 . 0 1 2 . 5 1 5 . 0 P a p e r E M R H o s p i t a l A * P e n d i n g t e s u l t ( % ) * * H o s p i t a l B P a p e r E M R H o s p i t a l C P a p e r E M R D i f f = 3 . 0 % D i f f = 3 . 4 % D i f f = 2 . 7 %

Rate of pending test results over time

• Diff. was consistently significant.
• Did not change considerably over

time for paper orders

• for electronic orders the rate

dropped from 8.0% in 2014 to 5.4% in 2016.

Figure 2: Rate of pending test results by order types over time, 2014-2016. *P<0.001.

0 . 0 2 . 5 5 . 0 7 . 5 1 0 . 0 1 2 . 5 1 5 . 0

P a p e r E M R 2 0 1 4 * P e n d i n g t e s u l t ( % ) * * P a p e r E M R 2 0 1 5 P a p e r E M R 2 0 1 6

D i f f = 2 . 0 % D i f f = 3 . 2 % D i f f = 3 . 7 %

Rate of pending test results for top five tests

• Auto. Diff, EUC, LFT,

CaMgPO4 and CRP= represented 70% of the total tests.

• 4 of 5 tests had lower rates of

pending test results.

Figure 3: Rate of pending results type of tests, 2014-2016. *P<0.001.

0 . 0 2 . 5 5 . 0 7 . 5 1 0 . 0 1 2 . 5 1 5 . 0 1 7 . 5 2 0 . 0 2 2 . 5

P a p e r E M R

A u t o . D i f f . * P e n d i n g t e s u l t ( % ) * *

P a p e r E M R

E U C

P a p e r E M R

L F T

P a p e r E M R

C a M g P 0 4 *

P a p e r E M R

C R P

D i f f = 4 . 0 %

D i f f = 3 . 1 % D i f f = 1 . 8 % D i f f = 2 . 2 % D i f f = 0 . 4 %

Discussion and conclusion

Key findings

24

• The major finding is that the rate of pending results was significantly lower for electronic orders than for

paper orders.

• This could be due to improved timeliness of laboratory workflow when the electronic system is used:

 Shorter data entry time:

• Georgiou et al. (2013) found that the median data entry time was 3 minutes shorter for electronic orders

than paper order.  Shorter overall TAT.

• In study by Thompson et al. (2004) the overall TAT decreased from a median of 148 to 74 minutes

following the implementation of EMR.

Key implications

25

• Pending tests are a risk factor for the failure to follow-up test results

which can be a major source of harm for patients (Callen 2011). Lower rates of pending test results with electronic ordering could lead to a reduction in potentially harmful outcomes that may arise from abnormal laboratory results arriving after patient discharge.

Limitations of the study

26

• Information on the nature of the results (e.g. abnormal result returned post discharge)

were not included.  We did not assess whether the results of the pending tests were potentially actionable.

• Paper ordering has remained consistent at around 2-3% over the course of this study.

 Further research into this area should explore why paper systems continue to be used.

Conclusion

27

• Our findings highlighted an important benefit of ordering tests via the

electronic system which can potentially improve patient safety.

• Future research is needed to explore how pending test results are

managed, including how abnormal test results arriving after discharge from ED are communicated to clinicians and patients.

References

28

1.

• Forsman. Why Is the Laboratory an Afterthought for Managed Care Organizations?, Clin Chem 42 (1996), 813-816.

2. Walz et al. Pending Laboratory Tests and the Hospital Discharge Summary in Patients Discharged to Sub-Acute Care, J Gen Intern Med 26 (2011), 393-398. 3. Callen et al. The Safety Implications of Missed Test Results for Hospitalised Patients: A Systematic Review, BMJ Qual Saf 20, (2011), 194-199. 4.

• Jha. World Alliance for Patient Safety-Summary of the Evidence on Patient Safety: Implications for Research, World Health Organization, Spain, 2008.

5. Roy et al. Patient Safety Concerns Arising from Test Results That Return after Hospital Discharge, Ann Intern Med 143 (19 2005), 121-128. 6. Xu et al. Implementation of E-Health Record Systems in Australia, The International Technology Management Review 3, (2013), 92-104. 7. Baron et al. Computerized Provider Order Entry in the Clinical Laboratory, J Pathol Inform 2 (2011), 35. 8. Dahm et al. Delivering Safe and Effective Test-Result Communication, Management and Follow-Up: A Mixed-Methods Study Protocol, BMJ Open 8, (2018), e020235. 9. Li, et al. The Effect of Laboratory Testing on Emergency Department Length of Stay: A Multihospital Longitudinal Study Applying a Cross-Classified Random-Effect Modeling Approach, Acad Emerg Med 22, (2015), 38-46. 10. Vecellio et al. Examination of Variation in Hospital Pathology Investigations by Diagnosis-Related Groups and Associations with Outcomes and Costs, Report to Commonwealth of Australia, Department of Health, Quality Use of Pathology Committee, Australian Institute of Health Innovation, Macquarie University, 2015. 11. Georgiou et al. When Requests Become Orders--a Formative Investigation into the Impact of a Computerized Physician Order Entry System on a Pathology Laboratory Service, Int J Med Inform 76, (2007), 583-591. 12. Georgiou et al. Monitoring the Impact of the Electronic Medical Record on the Quality of Laboratory Test Ordering Practices, Stud Health Technol Inform 188 (2013), 33-38. 13. Thompson et al. Computerized Physician Order Entry of Diagnostic Tests in an Intensive Care Unit Is Associated with Improved Timeliness of Service, Crit Care Med 32 (2004), 1306-1309. 14. Westbrook et al. Computerised Pathology Test Order Entry Reduces Laboratory Turnaround Times and Influences Tests Ordered by Hospital Clinicians: A Controlled before and after Study, J Clin Pathol 59 (2006) 533-536.

Thank You!

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