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Mindfulness-Based Laboratory Reduction: Reducing Utilization Through Trainee-Led Daily ‘Time Outs’

https://doi.org/10.1016/j.amjmed.2017.01.011Get rights and content

Abstract

Background

Overuse of laboratory investigations is widely prevalent in hospitalized patients, leads to discomfort, and increases direct and indirect costs.

Objective

We implemented a simple, inexpensive, mindfulness strategy on our inpatient medical clinical teaching unit to reduce unnecessary laboratory orders through education, a forcing function, and daily structured laboratory “time outs.”

Methods

On a 26-bed unit in an academic hospital center, the per-period laboratory costs per patient were compared pre- and postintervention using segmented regression analysis of an interrupted time series.

Results

The average cost per admitted patient decreased from $117 to $66, with an estimated savings of $50,657 over 985 admissions. After adjusting for fiscal period and the presence of our intervention, there was a significant reduction in the per-patient number of total tests, complete blood counts, and electrolyte panels performed (P <.001 for all level and time trend changes).

Conclusion

This trainee-designed and -led intervention, centered around structured, mindfulness-based laboratory test ordering, was successful at decreasing the overuse of common daily blood work in hospitalized patients.

Section snippets

Study Population

The intervention was conducted on our 26-bed medical clinical teaching unit at the Royal Victoria Hospital in Montreal, Quebec (517 total beds). This unit has an established culture of quality improvement, with twice-monthly dedicated academic rounds attended by the ward team.

Intervention and Implementation Data Sources

At baseline, doctors would write admission orders for daily blood tests, as was the prevailing culture. Orders were written on paper and transcribed into the computer by administrative personnel. The computer system did

Results

The total, per-period, and per-admission laboratory costs are shown in Table 1. Crudely, the average cost per admitted patient decreased from $117 to $66, with an estimated savings based on 985 admissions of $50,657. In the time series analysis, after adjusting for fiscal period and the presence of our intervention, there was a significant reduction in the overall number of per-patient tests, complete blood counts, and electrolyte panels (Figures 1 and 2; P <.001 for all level and time trend

Discussion

Providing tertiary care has become increasingly complex, and the pressure for residents to accomplish multiple competing tasks throughout the day has likely influenced routine ordering practices on the clinical teaching unit. The concept of mindfulness involves removing oneself from autopilot; the pairing of regular education sessions with periodically mandated reassessment of tests or medications is a type of “medical mindfulness,” which successfully cultivated attention directed at an area of

Conclusion

We reduced routine laboratory testing on our clinical teaching unit using daily structured laboratory “time outs.” Fewer blood draws translate to less patient discomfort and increased efficiency of phlebotomists, nurses, and physicians. Laboratory timeouts lend themselves well to a changing culture toward a more mindful medical practice, addressing many of the drivers of test overuse for hospitalized patients. This is the type of inexpensive focused intervention that is fundamental to moving

Acknowledgment

We are especially grateful to George Christodoulou for his help in designing the intervention. We would like to thank the McGill University Health Centre's Department of Quality, Patient Safety & Performance for providing the laboratory data. We also thank all faculty and residents who participated in the project, made it a success, and took it to other units.

References (11)

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Funding: This project was completed without any internal or external funding.

Conflict of Interest: The authors have no conflicts of interest to declare.

Authorship: All authors had full access to all the data in the study and take responsibility for the integrity of the data and the accuracy of the analysis.

Study concept and design: RRS, TCL; Acquisition of data: RRS, TCL, EGM; Analysis and interpretation of data: RRS, TCL, EGM; Drafting of the manuscript: TCL, EGM; Critical revision of the manuscript for important intellectual content: TCL, RRS, EGM; Statistical analysis: TCL, EGM; Study supervision: TCL, EGM.

1

For the purposes of authorship, EGM and RRS share credit as first named author.

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