Interventions to Improve Follow-Up of Laboratory Test Results Pending at Discharge: A Systematic Review
Failure to follow up test results pending at discharge (TPAD) from hospitals or emergency departments is a major patient safety concern. The purpose of this review is to systematically evaluate the effectiveness of interventions to improve follow-up of laboratory TPAD. We conducted literature searches in PubMed, CINAHL, Cochrane, and EMBASE using search terms for relevant health care settings, transition of patient care, laboratory tests, communication, and pending or missed tests. We solicited unpublished studies from the clinical laboratory community and excluded articles that did not address transitions between settings, did not include an intervention, or were not related to laboratory TPAD. We also excluded letters, editorials, commentaries, abstracts, case reports, and case series. Of the 9,592 abstracts retrieved, 8 met the inclusion criteria and reported the successful communication of TPAD. A team member abstracted predetermined data elements from each study, and a senior scientist reviewed the abstraction. Two experienced reviewers independently appraised the quality of each study using published LMBP™ A-6 scoring criteria. We assessed the body of evidence using the A-6 methodology, and the evidence suggested that electronic tools or one-on-one education increased documentation of pending tests in discharge summaries. We also found that automated notifications improved awareness of TPAD. The interventions were supported by suggestive evidence; this type of evidence is below the level of evidence required for LMBP™ recommendations. We encourage additional research into the impact of these interventions on key processes and health outcomes.
© 2018 Society of Hospital Medicine
None of the interventions completely resolved the problems of documentation, awareness, or follow-up of TPAD. New interventions should consider the barriers to coordination identified by Jones et al.27 and Callen et al.7 Both studies identified a lack of systems, policies, and practices to support communication across different settings, including lack of access or difficulty navigating electronic medical records at other institutions; unclear or varied accountability for follow-up care; and inconsistent receipt of discharge documents after initial follow-up visit. These systemic problems were exacerbated by a lack of personal relationships between the community physicians, hospital, and ED clinicians, and between acute care clinicians and patients. In EDs, high patient throughput and short length of stay were found to contribute to these barriers. Although laboratories have a responsibility, required by CLIA regulations, to ensure the accurate and complete transmission of test reports,28 none of the interventions appeared to include laboratorians as stakeholders during the design, implementation, or evaluation of the interventions. Incorporating laboratory personnel and processes into the design of follow-up solutions may increase their effectiveness.
Medical informatics tools have the potential to improve patient safety during care transitions. Unfortunately, the evidence regarding informatics interventions to improve follow-up of TPAD was limited by both the number and the quality of the published studies. In addition, better-designed studies in this area are needed. Studies of interventions to improve follow-up of TPAD need to include well-chosen comparator populations and single, well-defined interventions. Evaluation of the interventions would be strengthened if the studies measured both the targeted outcome of the intervention, such as physician awareness of TPAD, and its impact on patient outcomes. Evaluation of the generalizability of the interventions would be strengthened by multi-site studies and, where appropriate, application of the same intervention to multiple study populations. As failure to communicate or follow up on abnormal laboratory tests is a critical threat to patient safety, more research and interventions to address this problem are urgently needed.
Acknowledgments
The authors appreciate the thoughtful insights offered by the following expert panel members: Joanne Callen, PhD; Julie Gayken, MT; Eric Poon, MD; Meera Viswanathan, PhD; and David West, PhD. The authors thank Dr. Jennifer Taylor for her review of the draft manuscript.
Funding
This work was funded by contract number 200-2014-F-61251 from the Centers for Disease Control and Prevention, Division of Laboratory Systems. Dr. Singh was additionally supported by the Houston VA HSR&D Center for Innovations in Quality, Effectiveness, and Safety (CIN 13-413).
Disclaimer
The findings and conclusions in this study are those of the authors and do not necessarily represent the official position of the Centers for Disease Control and Prevention or the Department of Veterans Affairs.
Disclosures
Drs. Whitehead, Graber, and Meleth, Ms. Kennedy, and Mr. Epner received funding for their work on this manuscript (Contract No. 200-2014-F-61251) from the Centers for Disease Control and Prevention. Dr. Graber receives honoraria from several institutions for presentations on diagnostic errors and has a grant from the Macy Foundation to develop a curriculum on diagnostic errors. Unrelated to this publication, Mr. Epner receives payment as a board member of Silicon BioDevices, as a consultant to Kaiser Foundation Health Plan of Colorado, for lectures from Sysmex, Inc., and for meeting expenses from Abbott Laboratories. He has stock or stock options in Silicon BioDevices, Inc. and Viewics, Inc. No other authors have any financial conflicts to report.
