A successful experiment to reduce unnecessary laboratory use in a community hospital.

A series of interventions at a 228-bed general hospital provided physicians with feedback at regular intervals concerning the amount of laboratory services employed in treating their patients. Case-mix-adjusted estimates of laboratory tests allowed each physician to compare use of laboratory tests with that of peers in the same department at the same hospital. Physicians with "excess" practice patterns ordered hundreds more laboratory tests than average each year. A multifaceted educational program included the following: 1) meetings were held concerning costs and unnecessary laboratory tests; 2) physicians were given descriptions of their practice patterns relative to their peers as part of both large and small departmental discussions; 3) the feedback was repeated a year later; 4) a consensus conference established guidelines for test ordering; and 5) a sample of patient records was examined for appropriateness of laboratory test ordering. A total of 37% of a sample of tests ordered during the baseline period by physicians with "excess" practice patterns was classified as inappropriate. The intervention resulted in a reduction of 1.8 tests per patient (P = 0.0005). Eight of the nine tests individually showed reductions in use. Charge data from the target hospital showed a statistically significant reduction in laboratory charges per patient in the quarter following program initiation (P = 0.02) and no evidence for change in a group of five comparison hospitals. There was no evidence for reductions in the ordering of essential tests. These results demonstrate a cost-effective approach to reducing unnecessary costs that can be implemented in hospitals with integrated data systems.

Computer-assisted concurrent antibiotic review in a community hospital.

A computer-assisted program that monitors the appropriateness of antibiotic prescribing by matching microbiology reports and patient drug profiles is described. An antibiotic review committee in conjunction with the quality assurance department developed the computer-assisted antibiotic review program. An antibiotic order sheet was incorporated into the physicians' order form. Automatic stop dates were assigned according to the reason the antibiotic was ordered, e.g., surgical prophylaxis or documented infection. Numerous reports are generated from the data gathered from the physicians' order form. A drug/microbiology report is used to match patients' antibiotic drug profiles with their microbiology culture and sensitivity results. This report identifies all patients who have been receiving antibiotics for 72 hours or longer with sensitivities on file and mismatched sensitivity results. All mismatches that are considered important are investigated. Any actions taken are reported to the antibiotic review committee for peer review. The computer-assisted program has helped this hospital screen large populations of inpatients receiving antibiotics. The concurrent review of the drug/microbiology report has made it possible to detect within 24 hours, patients who are receiving antibiotics inappropriately. A computer can be used to perform daily concurrent antibiotic use review as a by-product of order entry by both the pharmacy and laboratory.

Bugs, drugs, and computers.

The paper describes the development, implementation, and review of a daily reporting system using data from two modules of a hospital information system: drug sensitivity reports from Microbiology, and patient drug profiles from Pharmacy. The system reviews each patient receiving antibiotics and compares that information with the patient's microbiology findings, looking for and flagging "no cultures," "negative cultures," and "mismatches," i.e., the patient is receiving an antibiotic to which the organism is resistant. Reports are produced daily and reviewed by the hospital's Infection Control nurse, who, in turn, notifies the attending physician when appropriate.

Self-limited babesiosis in a splenectomized child.

This report describes a self-limited babesia infection in a splenectomized child with hereditary spherocytosis. This is the first report of infectious babesiosis in a child and the second case of babesiosis reported on Cape Cod. The infection manifested itself 6 weeks after a 4-hour exposure to Nantucket. Hemolysis lasted only 4 days and resolved without specific treatment. Parasitemia was documented after resolution of symptoms.