Bedside Assessment of the Necessity of Daily Lab Testing for Patients Nearing Discharge

There were 1579 discharges in the preintervention period and 1308 discharges in the postintervention period. The average age of the patient population was similar in the baseline and postintervention groups (61.5 vs 59.3 years; P = 0.400), and there was no difference in the mean LOS before and after implementation (3.67 vs 3.68 days; P = 0.817).

Our structured, multifaceted approach effectively reduced daily lab testing in the 24 to 48 hours prior to discharge. Bedside IDR provided a unique opportunity to effectively communicate to the patient about necessary (or unnecessary) testing. Moreover, given the complexity of identifying clinical stability, our strategy focused on the onset of discharge planning, a more easily discernible and less obtrusive focal point to promote the discontinuation of lab testing.

Though the nature of bundled interventions can make it difficult to identify which intervention is most effective, we believe that all interventions were effective in different capacities during various phases in the intervention period. We believe that the decrease in lab testing in the 24 to 48 hours preceding discharge was primarily driven by the new rounding structure. This is evident in the significant decrease seen in the first few months of the intervention period. Six months into the intervention, we begin to see a decrease at 72 hours prior to discharge. Additionally, we see a decrease in the mean number of labs per patient day over the entire hospitalization period. We attribute these results to a gradual shift in the culture in our division as a direct consequence of educational sessions and individual feedback provided during this time.

To our knowledge, this is the first study to use anticipated discharge as a correlate for clinical stability and therefore as an opportunity to prompt discontinuation of laboratory testing. Other studies evaluated interventions targeting the EMR and the ease with which providers can order recurring labs. These include restricting recurring orders in the EMR,⁴ a robust education and awareness campaign targeting house staff,⁵ and other multifaceted approaches to decreasing lab utilization,⁶ all of which have shown promising results. While these approaches show varying degrees of success, ours is unique in its focus on the period prior to discharge. In addition, the intervention can be readily implemented in settings that utilize scripted IDR. It also brings high-value decision-making to the bedside by informing the patient that in the setting of presumed clinical stability, no additional tests are warranted.

Our study has several limitations. First, while interdisciplinary discharge rounds are widely implemented,^7,8 our rounds occur at the bedside and employ a script, potentially limiting generalizability. The structured prompting may be feasible during structured IDR in a standard conference room setting, though we did not assess this model. Second, bedside rounds only included patients who were able to participate. Rounding on patients unable to participate, such as patients with delirium with agitation, was done outside the patient room rather than at the bedside. A modified script was used in these instances (absent questions addressed to the patient), allowing for the prompt to be incorporated. These patients were included in the analysis. Lastly, as previously stated, we cannot clearly identify which intervention (the prompt, education, or feedback) most effectively led to a sustained decrease in lab ordering.

Our structured, multifaceted intervention reduced laboratory testing during the last 48 hours of admission. Hospitals that aim to decrease potentially unnecessary lab testing should consider implementing a bundle, including a prompt at a uniform and structured point during the hospitalization of patients who are expected to be discharged within 24 to 48 hours, clinician education, an audit, and feedback.