Opportunities Revealed for Antimicrobial Stewardship and Clinical Practice with Implementation of a Rapid Respiratory Multiplex Assay.

Few studies assess the utility of rapid multiplex molecular respiratory panels in adult patients. Previous multiplex PCR assays took hours to days from order time to result. We analyze the clinical impact of switching to a molecular assay with a 3-h test-turnaround-time (TAT). We performed a retrospective review of adult patients who presented to our emergency departments with respiratory symptoms and had a respiratory viral panel (xTAG RVP; RVP) or respiratory pathogen panel (ePlex RP; RPP) within 48 h of presentation. The average TATs for the RVP and RPP were 27.9 and 3.0 h, respectively (P < 0.0001). In RVP-positive and RPP-positive patients, 68.9 and 44.5% of those with normal chest imaging received antibiotics (P = 0.013), while 95.4 and 89.6% of those with abnormal imaging received antibiotics, respectively (P = 0.187). There was no difference in antibiotic duration in RVP-positive and RPP-positive patients with abnormal chest imaging (6.2 and 6.0 days, respectively; P = 0.923) and normal chest imaging (4.5 and 4.3 days, respectively; P = 0.922). Fewer patients were admitted in the RPP-positive compared to the RVP-positive group (76.9 and 88.6%, respectively; P = 0.013), while the proportion of admissions were similar among RPP-negative and RVP-negative patients (85.3 and 87.1%, P = 0.726). Switching to a multiplex respiratory panel with a clinically actionable TAT is associated with reduced hospital admissions and, in admitted adults without focal radiographic findings, reduced antibiotic initiation. Opportunities to further mitigate inappropriate antibiotic use may be realized by combining rapid multiplex PCR with provider education, clinical decision-care algorithms, and active antibiotic stewardship.

The feasibility and impact of midnight routine blood draws on laboratory orders and processing time.

OBJECTIVES: To evaluate the feasibility of midnight routine blood draws and assess their impact on test result availability and stat laboratory orders. METHODS: We changed the timing of routine blood draws from early morning to midnight on five inpatient wards during the period November 16 to 30, 2011. RESULTS: For the entire institution, of all orders placed each day, laboratory test orders placed from 4:00 to 8:00 am decreased from 55% to 39%, and those placed from 12:00 to 4:00 am increased from 12% to 30%. Stat orders per day decreased during the intervention period (301 ± 53 vs 344 ± 55, P = .04). Morning specimens were more likely to be available by 9:00am (78.1% vs 58.9%, P < .001), and their turnaround time improved by 25.8 minutes (158 vs 184 minutes, P < .001). Patient survey revealed potential preference for midnight blood draws. CONCLUSIONS: Midnight is a feasible alternative for the timing of routine blood draws. Redesigning inflow of laboratory orders improved efficiency of laboratory processing and reduced stat orders.

The assessment of stat laboratory test ordering practice and impact of targeted individual feedback in an urban teaching hospital.

BACKGROUND: Overuse of inpatient stat laboratory orders ("stat" is an abbreviation of the Latin word "statim," meaning immediately, without delay) is a major problem in the modern healthcare system. OBJECTIVE: To understand patterns of stat laboratory ordering practices at our institution and to assess the effectiveness of individual feedback in reducing these orders. INTERVENTION: Medicine and General Surgery residents were given a teaching session about appropriate stat ordering practice in January 2010. Individual feedback was given to providers who were the highest utilizers of stat laboratory orders by their direct supervisors from February through June of 2010. MEASUREMENTS: The proportion of stat orders out of total laboratory orders per provider was the main outcome measure. All inpatient laboratory orders from September 2009 to June 2010 were analyzed. RESULTS: The median proportion of stat orders out of total laboratory orders was 41.6% for nontrainee providers (N = 500), 38.7% for Medicine residents (N = 125), 80.2% for General Surgery residents (N = 32), and 24.2% for other trainee providers (N = 150). Among 27 providers who received feedback (7 nontrainees, 16 Medicine residents, and 4 General Surgery residents), the proportion of stat laboratory orders per provider decreased by 15.7% (95% confidence interval: 5.6%-25.9%, P = 0.004) after feedback, whereas the decrease among providers who were high utilizers but did not receive feedback (N = 39) was not significant (4.5%; 95% confidence interval: 2.1%-11.0%, P = 0.18). Monthly trends showed reduction in the proportion of stat orders among Medicine and General Surgery residents, but not among other trainee providers. CONCLUSIONS: The frequency of stat ordering was highly variable among providers. Individual feedback to the highest utilizers of stat orders was effective in decreasing these orders.

Quality and financial outcomes from gainsharing for inpatient admissions: a three-year experience.

BACKGROUND: Gainsharing is a way to provide incentives to physicians to decrease hospital costs without compromising quality. METHODS: A pay-for-performance program was instituted over a three-year period from July 2006 to June 2009. Baseline length of stay (LOS) and case costs were developed during the year prior to the inception of the program. Best practice norms (BPNs) were established at the top 25th percentile of physicians for each all patient refined (APR)-diagnosis related group (DRG). Hospital costs were analyzed in several areas, including operating room charge (OR), supplies and implants, nursing and per-diem room costs. Payments were based upon case level performance compared to BPN's and the physician's historic performance. Eligible cases included commercial insurance only for the first 2 years but Medicare cases were included after October 2008 resulting from a Centers for Medicare and Medicaid Services (CMS)-approved demonstration project. Payments to physicians required meeting quality thresholds, including chart completion, and compliance with core measures. RESULTS: A total of 184 (54%) physicians enrolled into the program. There was a $25.1 million reduction in hospital costs during the 3 years ($16 million from participating and $9.1 million from non-participating physicians, P < 0.01). Most cost reductions were attributed to reduced LOS and reductions in medical supply costs. Total physician payouts were over $2 million (average $1,866 per quarter). Delinquent medical records decreased from an average of 43% in the second quarter 2006 to 30% (P < 0.0001) in the second quarter 2009. Quality measures improved during the study period but not by a statistical significance. CONCLUSIONS: Gainsharing provided an incentive for physicians to reduce hospital costs while maintaining hospital quality.