Our New-Resident Trainee Educational Intervention Efforts Play a Significant Role in Reduction of Inappropriate Laboratory Add-on Testing Orders

Background: Since our hospital’s Meditech system lacks a sophisticated rules-based physician order entry system, we sought to improve add-on test (AOT) order accuracy through using resident training initiatives. An AOT is an order for a test to be performed on a specimen already collected for previous testing purposes. While AOT helps reduce new specimen collections on patients and can assist in the reduction of iatrogenic anemia or infection, several issues have challenged our laboratory in handling inappropriate AOT orders from our new resident physicians. The majority of our inappropriate AOT orders include: 1) a duplicate order for a test already performed, 2) the order is added on to a wrong specimen sample type and/or collection tube/container, 3) specimen instability issues for the add-on analyte requested, and 3) the remaining quantity of specimen is not enough for the new add-on order.

Methods: We performed two studies with each using AOT data extracted from our Meditech laboratory information system in a one-week period in November 2015 and August 2016. The 2015 study served as a baseline for the follow-up study conducted one month after an educational initiative for new medicine residents to improve the quality of AOT ordering at the beginning of the academic year in July 2016, including introducing our specimen collection “pocket” tube guide and specimen collection requirements. Also, an order-entry alert was added to the AOT order module when ordering a test listed on our “ inappropriate AOT” test list. We examined AOT patterns including ordering physicians, total number of AOTs, number and types of performed AOTs as well as the non-performed or rejected AOTs. Chi-square was used with significant criteria of p < 0.05.

Results: We observed significant decreases in the total numbers of ordered AOT (941 to 874, p=0.001) and the rejected AOT (161 to 116, p= 0.027). However, within the latter group, we did not observe a statistically significant reduction in the total number AOT rejections for duplicate orders (p= 0.443), wrong specimen collection tube/container (p=0.597), quantity not sufficient, and/or specimen stability AOT rejections (p = 0.999).Conclusion: It appears that our resident educational intervention could have played a significant but relatively minor role in the improvement of AOT issues in terms of 1) reducing the total number of AOT and 2) the number of problem AOT and 3) perhaps shifting add-on testing over to increased tests ordered on the original test request....yet another desirable educational outcome. We did not, however, observe a statistically significant reduction in the number AOT rejections for duplicate orders, wrong specimen collection tube/container, quantity not sufficient, and/or specimen stability AOT rejections. We, therefore, conclude that these latter issues cannot be effectively handled without the use of a sophisticated, rules-based expert physician order entry computer system that alerts the new resident physician interactively at the time of order when an AOT is not possible.