Altering standard admission order sets to promote clinical laboratory stewardship: a cohort quality improvement study

2019 ◽  
Vol 28 (10) ◽  
pp. 846-852 ◽  
Author(s):  
Benjamin Leis ◽  
Andrew Frost ◽  
Rhonda Bryce ◽  
Andrew W Lyon ◽  
Kelly Coverett
Keyword(s):  
Clinical Decision Making ◽  
Clinical Laboratory ◽  
Clinical Decision ◽  
Thyroid Stimulating Hormone ◽  
Clinical Indication ◽  
Medical Overuse ◽  
Order Sets ◽  
Cohort Quality ◽  
Careful Design ◽  
Order Set

BackgroundCareful design of preprinted order sets is needed to prevent medical overuse. Recent work suggests that removing a single checkbox from an order set changes physicians’ clinical decision-making.Local problemDuring a 2-month period, our coronary care unit (CCU) ordered almost eight times as many serum thyroid-stimulating hormone (TSH) tests as our neighbouring intensive care unit, many without a reasonable clinical basis. We postulated that we could reduce inappropriate testing and improve clinical laboratory stewardship by removing the TSH checkbox from the CCU admission order set.MethodsAfter we retrospectively evaluated CCU TSH ordering before intervention, the checkbox was removed from the CCU admission order set. Twelve weeks later, we commenced a prospective 2-month assessment of TSH testing and clinical sequelae of thyroid disease among all CCU admissions. If clinical indications were absent or testing had occurred within 6 weeks, TSH requests were labelled as ‘inappropriate’.ResultsPhysician ordering and, specifically, inappropriate ordering decreased substantially after the intervention. In 2016 among physician-ordered TSH tests, 60.6% (66/109) were inappropriate; in 2017 this decreased to 20% (2/10, p=0.01). Overall, the net effect of checkbox removal saw the decrease in TSH testing without clinical indication outweigh an increase in missed testing where indications appear to exist.ConclusionsProvision of an optional checkbox for a laboratory test in an admission order set can promote overuse of laboratory resources. Simple removal of a checkbox may dramatically change test ordering patterns and promote clinical laboratory stewardship. Given our reliance on order sets, particularly by trainees, changes to order sets must be cautious to assure guideline-directed care is maintained.

scholarly journals Impact of implementing a category 1 external quality assurance scheme for monitoring harmonization of clinical laboratories in Spain

2020 ◽  
Vol 1 (1) ◽  
Author(s):  
Carmen Ricós ◽  
Pilar Fernández-Calle ◽  
Fernando Marqués ◽  
Joana Minchinela ◽  
Ángel Salas ◽  
...  
Keyword(s):  
Decision Making ◽  
Quality Assurance ◽  
Clinical Decision Making ◽  
Clinical Laboratory ◽  
Reference Value ◽  
Clinical Decision ◽  
Thyroid Stimulating Hormone ◽  
External Quality Assurance ◽  
External Quality ◽  
Content Type

AbstractBackgroundThe objective of the present study was to examine the evolution of the analytical performance specifications (APS) used in External Quality Assurance (EQA) schemes, as well as the efficacy of a category 1 EQA scheme in monitoring the harmonization of clinical laboratory results in Spain.MethodsA review of the literature on the types of quality specifications used in schemes in other countries and their evolution was performed. In addition, a comparative analysis of the potential impact that different APS from eight countries had on clinical decision-making was made based on three measurands: sodium, thyroid-stimulating hormone (TSH), and activated partial thromboplastin time (aPTT).ResultsHarmonization of analytical methods was demonstrated by assessing whether average results deviated from the certified reference value of control materials within the APS derived from biological variation (BV). The APS used in EQA have evolved from state-of-the-art models to BV. Poor clinical decision-making would occur if the results accepted by some APS were applied.ConclusionsIn Spain, only 2 of the 18 measurands studied are considered to be well harmonized. Closer collaboration between laboratories and analytical system providers would be required to resolve discrepancies.

POCT errors can lead to false potassium results

2021 ◽  
Vol 0 (0) ◽  
Author(s):  
Antonio Buño ◽  
Paloma Oliver
Keyword(s):  
Decision Making ◽  
Clinical Decision Making ◽  
Clinical Laboratory ◽  
Point Of Care ◽  
Clinical Intervention ◽  
Clinical Decision ◽  
Whole Process ◽  
Severe Hyperkalemia ◽  
Wrong Diagnosis ◽  
Critical Patients

Abstract Point-of-care-testing (POCT) facilitates rapid availability of results that allows prompt clinical decision making. These results must be reliable and the whole process must not compromise its quality. Blood gas analyzers are one of the most used methods for POCT tests in Emergency Departments (ED) and in critical patients. Whole blood is the preferred sample, and we must be aware that hemolysis can occur. These devices cannot detect the presence of hemolysis in the sample, and because of the characteristics of the sample, we cannot visually detect it either. Hemolysis can alter the result of different parameters, including potassium with abnormal high results or masking low levels (hypokalemia) when reporting normal concentrations. Severe hyperkalemia is associated with the risk of potentially fatal cardiac arrhythmia and demands emergency clinical intervention. Hemolysis can be considered the most frequent cause of pseudohyperkalemia (spurious hyperkalemia) or pseudonormokalemia and can be accompanied by a wrong diagnosis and an ensuing inappropriate clinical decision making. A complete review of the potential causes of falsely elevated potassium concentrations in blood is presented in this article. POCT programs properly led and organized by the clinical laboratory can help to prevent errors and their impact on patient care.

Princess Margaret Cancer Centre (PMCC) Integrated Molecular Profiling in Advanced Cancers Trial (IMPACT) using genotyping and targeted next-generation sequencing (NGS).

2013 ◽  
Vol 31 (15_suppl) ◽  
pp. 11002-11002 ◽  
Author(s):  
Philippe L. Bedard ◽  
Amit M. Oza ◽  
Ming-Sound Tsao ◽  
Natasha B. Leighl ◽  
Frances A. Shepherd ◽  
...  
Keyword(s):  
Targeted Therapies ◽  
Clinical Decision Making ◽  
Clinical Laboratory ◽  
Screening Program ◽  
Illumina Miseq ◽  
Response Assessment ◽  
Clinical Decision ◽  
Molecular Profiling ◽  
Routine Care ◽  
Targeted Next Generation Sequencing

11002 Background: IMPACT is an institution-wide screening program to identify patients (pts) treated at PMCC with somatic alterations that can be matched to targeted therapies. Methods: Pts with advanced breast, colorectal (CRC), non-small cell lung (NSCLC), ovarian cancers and selected other solid tumors treated at PMCC were eligible. Tumor DNA was isolated from a FFPE archived sample and genotyped using a customized Sequenom panel (23 genes, 280 mutations) in a CLIA-certified laboratory. Verified mutations were reported in pts electronic health records. Selected FFPE samples were further characterized by NGS with the Illumina MiSeq TruSeq Amplicon Cancer Panel (48 genes, 212 amplicons, ≥500x coverage) for platform validation. Results: From Mar 1/12-Jan 10/13, 485 pts were enrolled with median 1 prior treatment for advanced disease (range 0-6). Of 33 (7%) screen failures, 5% were for insufficient tissue and 2% for clinical deterioration. Median DNA quantity from FFPE = 4250ng (range 15-32550ng). The median time from tissue receipt to reporting was 5 weeks (range 1-23). Mutations were identified by Sequenom in 137/349 (39%) pts, including 24/79 (30%) breast, 40/80 (50%) CRC, 54/88 (61%) NSCLC, 17/78 (22%) ovarian, and 2/24 (8%) other cancers. Mutations detected were: 76 KRAS, 35 PIK3CA, 22 EGFR, 5 NRAS, 5 ERBB2, 5 CTNNB1, 4 BRAF, and 1 AKT1. MiSeq was concordant with Sequenom in 112/113 (99%) pts, with mutations identified in 94/114 (82%). The average number of mutations detected by MiSeq was 1.72/pt (range 0-7) compared with 0.49/pt by Sequenom (range 0-2). After a median follow up of 5.0 months, 31/137 (23%) pts with mutations have been matched to targeted therapies, including 14 pts enrolled in clinical trials (15 trials) matched to their genotype. Of the 10 trial pts with at least one response assessment, 3 PR (1 confirmed) and 2 SD ≥ 24 weeks have been observed. Conclusions: Molecular profiling can be integrated into the routine care of advanced cancer pts. Genotyping and targeted NGS are feasible in a clinical laboratory using stored archival FFPE tumor samples. NGS identifies additional actionable mutations to inform clinical-decision making. Clinical trial information: NCT01505400.

scholarly journals Developing and maintaining clinical decision support using clinical knowledge and machine learning: the case of order sets

2018 ◽  
Vol 25 (11) ◽  
pp. 1547-1551 ◽  
Author(s):  
Yiye Zhang ◽  
Richard Trepp ◽  
Weiguang Wang ◽  
Jorge Luna ◽  
David K Vawdrey ◽  
...  
Keyword(s):  
Machine Learning ◽  
Best Practices ◽  
Clinical Decision ◽  
Machine Learning Algorithms ◽  
Clinical Knowledge ◽  
Order Sets ◽  
Knowledge Intensive ◽  
Individualized Prediction ◽  
Effective Development ◽  
Order Set

Abstract Development and maintenance of order sets is a knowledge-intensive task for off-the-shelf machine-learning algorithms alone. We hypothesize that integrating clinical knowledge with machine learning can facilitate effective development and maintenance of order sets while promoting best practices in ordering. To this end, we simulated the revision of an “AM Lab Order Set” under 6 revision approaches. Revisions included changes in the order set content or default settings through 1) population statistics, 2) individualized prediction using machine learning, and 3) clinical knowledge. Revision criteria were determined using electronic health record (EHR) data from 2014 to 2015. Each revision’s clinical appropriateness, workload from using the order set, and generalizability across time were evaluated using EHR data from 2016 and 2017. Our results suggest a potential order set revision approach that jointly leverages clinical knowledge and machine learning to improve usability while updating contents based on latest clinical knowledge and best practices.

scholarly journals P033: Reducing pantoprazole infusions in ED GI bleed patients by optimizing electronic order sets

CJEM ◽  
2018 ◽  
Vol 20 (S1) ◽  
pp. S68-S68
Author(s):  
S. K. Dowling ◽  
E. S. Lang ◽  
G. Kaplan ◽  
K. Novak ◽  
C. Hall ◽  
...  
Keyword(s):  
Primary Outcome ◽  
Care Pathway ◽  
Severity Of Illness ◽  
Clinical Decision ◽  
P Value ◽  
Fully Integrated ◽  
Order Sets ◽  
Secondary Outcomes ◽  
Gi Bleed ◽  
Order Set

Introduction: Non-variceal upper gastrointestinal bleeding (NVUGIB) is a common presentation to the emergency department (ED) accounting for significant morbidity, mortality and health care resource usage. In Alberta, a provincial care pathway was recently developed to provide an evidence informed approach to managing patients with an UGIBs in the ED. Pantoprazole infusions are a commonly used treatment despite evidence that suggests they are generally not indicated prior to endoscopy in the ED. The goal of this project was to optimize management of patients with a NVUGIB, in particular reduce pre-endoscopy pantoprazole infusions. Methods: In July 2016, we implemented a multi-faceted intervention to optimize management of ED patients with NVUGIB including 1. de-emphasizing IV pantoprazole infusions in the ED, 2. clinical decision support (CDS) embedded (for endoscopy, disposition and transfusions) within the order set and 3. educating clinicians about the care pathway. We used a pre/post-order set design, analyzing 391 days pre and 189 days post-order set changes. Data was extracted from our fully integrated electronic health records system. The primary outcome was the % of patients receiving IV pantoprazole infusion ordered by an emergency physician (EP) among all patients with NVUGIB. Secondary outcomes included % transfused with hgb >70g/L and whether using the GIB order set impacted management of NVUGIB patients. Results: In the 391 days pre-order set changes, there were 2165 patients included and in the 189 days post-order set changes, there were 901 patients. For baseline characteristics, patients in the post-order set change group were significantly older (64.4 yrs vs 60.9 yrs p-value=0.0016) and had a lower hgb (115 vs 118, p-value=0.049) but otherwise for gender, measures of severity of illness (systolic blood pressure, heart rate, CTAS, % admitted) there were no significantly differences. For the primary outcome, in the pre-order set phase, 47.1% received a pantoprazole infusion ordered by an EP, compared to 31.5% in the post-order phase, for an absolute reduction of 15.6% (p-value= <0.001). For the secondary outcomes, transfusion rates were similar pre/post (22.08% vs 22.75%). Significant inter-site variability exists with respect to the reduction in pantoprazole infusion rates across the four sites (-23.3% to +6.12%). Conclusion: Our interventions resulted in a significant overall reduction in pantoprazole infusions in ED patients with NVUGIB. Reductions in pantoprazole infusions varied significantly across the different sites, future work in our department will explore and address this variability. Keys to the success of this project included engaging clinicians as well as leveraging the SCM order sets as well as the provincial care pathway. Although there were no changes in transfusion rates, it in unclear if this a function of the CDS not being effective or whether these transfusions were clinically indicated.

scholarly journals First Estimation of Reference Intervals for Thyroid-Stimulating Hormone and Thyroid Hormones in Slovenian Population

2021 ◽  
Vol 68 (2) ◽  
pp. 488-493
Author(s):  
Adrijana Oblak ◽  
Ajda Biček ◽  
Edvard Pirnat ◽  
Katja Zaletel ◽  
Simona Gaberšček
Keyword(s):  
Thyroid Hormones ◽  
Thyroid Disease ◽  
Clinical Decision Making ◽  
Clinical Decision ◽  
Reference Intervals ◽  
Thyroid Stimulating Hormone ◽  
Healthy Individuals ◽  
Free Triiodothyronine ◽  
Percentile Method ◽  
Stimulating Hormone

For thyroid function estimation and clinical decision making, use of appropriate reference intervals for thyroid-stimulating hormone (TSH), free thyroxine (fT4) and free triiodothyronine (fT3) is crucial. For each laboratory, establishment of own reference intervals is advised. For the first Slovenian estimation of reference intervals for thyroid hormones a large group of 1722 healthy individuals without thyroid disease was established retrospectively. Hormone analyses were performed on automated analyser Advia Centaur XP Immunoassay System (Siemens Healthineers), which reference intervals for TSH, fT4 and fT3 were 0.55–4.78 mIU/L, 11.5–22.7 pmol/L, and 3.5–6.5 pmol/L, respectively. Statistical analysis followed non-parametric percentile method. Our laboratory reference intervals for TSH, fT4 and fT3 are mostly narrower than intervals given by manufacturer. Median value, lower and upper limit for TSH, fT4 and fT3 were 1.98 (0.59–4.23) mIU/L, 14.5 (11.3–18.8) pmol/L and 4.82 (3.79–6.05) pmol/L, respectively. Most likely, an inclusion of a high number of healthy individuals without thyroid disease was a reason for such results.

Point-of-Care Testing (DRAFT)

2018 ◽  
Author(s):  
Douglas E. Morgan
Keyword(s):  
Decision Making ◽  
Clinical Decision Making ◽  
Driving Forces ◽  
Clinical Laboratory ◽  
Point Of Care ◽  
Diagnostic Testing ◽  
Clinical Decision ◽  
Care Process ◽  
Point Of Care Testing ◽  
Subsequent Decrease

Point-of-care testing (POCT) is defined as medical diagnostic testing performed outside the clinical laboratory in close proximity to where the patient is receiving care. POCT is typically performed by non-laboratory personnel and the results are used for clinical decision making. When used appropriately, point-of-care testing (POCT) is a valuable resource during the rapid response system (RRS) activation. Advantages include shortened time between acquiring a sample from the patient and analysis of that sample and a subsequent decrease in time to clinical decision making. Disadvantages revolve largely around the cost of POCT. Driving forces behind the movement towards POCT include care process optimization, improvement of patient outcomes, changing regulatory requirements, and changes in the face of the workforce.

scholarly journals ClinicNet: machine learning for personalized clinical order set recommendations

JAMIA Open ◽  
2020 ◽  
Vol 3 (2) ◽  
pp. 216-224
Author(s):  
Jonathan X Wang ◽  
Delaney K Sullivan ◽  
Alex C Wells ◽  
Jonathan H Chen
Keyword(s):  
Machine Learning ◽  
Logistic Regression ◽  
Decision Support ◽  
Clinical Decision ◽  
Clinical Event ◽  
Learning Methods ◽  
Machine Learning Methods ◽  
Order Sets ◽  
Institutional Order ◽  
Order Set

Abstract Objective This study assesses whether neural networks trained on electronic health record (EHR) data can anticipate what individual clinical orders and existing institutional order set templates clinicians will use more accurately than existing decision support tools. Materials and Methods We process 57 624 patients worth of clinical event EHR data from 2008 to 2014. We train a feed-forward neural network (ClinicNet) and logistic regression applied to the traditional problem structure of predicting individual clinical items as well as our proposed workflow of predicting existing institutional order set template usage. Results ClinicNet predicts individual clinical orders (precision = 0.32, recall = 0.47) better than existing institutional order sets (precision = 0.15, recall = 0.46). The ClinicNet model predicts clinician usage of existing institutional order sets (avg. precision = 0.31) with higher average precision than a baseline of order set usage frequencies (avg. precision = 0.20) or a logistic regression model (avg. precision = 0.12). Discussion Machine learning methods can predict clinical decision-making patterns with greater accuracy and less manual effort than existing static order set templates. This can streamline existing clinical workflows, but may not fit if historical clinical ordering practices are incorrect. For this reason, manually authored content such as order set templates remain valuable for the purposeful design of care pathways. ClinicNet’s capability of predicting such personalized order set templates illustrates the potential of combining both top-down and bottom-up approaches to delivering clinical decision support content. Conclusion ClinicNet illustrates the capability for machine learning methods applied to the EHR to anticipate both individual clinical orders and existing order set templates, which has the potential to improve upon current standards of practice in clinical order entry.

scholarly journals Clinical Utility of CLIA-Grade AR-V7 Testing in Patients With Metastatic Castration-Resistant Prostate Cancer

2017 ◽  
pp. 1-9 ◽  
Author(s):  
Mark C. Markowski ◽  
John L. Silberstein ◽  
James R. Eshleman ◽  
Mario A. Eisenberger ◽  
Jun Luo ◽  
...  
Keyword(s):  
Prostate Cancer ◽  
Clinical Trial ◽  
Messenger Rna ◽  
Clinical Decision Making ◽  
Clinical Laboratory ◽  
Specific Antigen ◽  
Clinical Decision ◽  
The United States ◽  
Castration Resistant Prostate Cancer ◽  
Castration Resistant

Purpose A splice variant of the androgen receptor, AR-V7, confers resistance to AR-targeted therapies (ATTs) but not taxane chemotherapies in patients with metastatic castration-resistant prostate cancer. Since August 2015, a clinical-grade assay to detect AR-V7 messenger RNA expression in circulating tumors cells (CTCs) has been available to providers through a Clinical Laboratory Improvement Amendments–certified laboratory at Johns Hopkins University. Methods We contacted ordering providers of the first 150 consecutive tests by using a questionnaire-based survey to determine how the results of AR-V7 testing were used to influence clinical practice. Results In all, 142 (95%) of 150 questionnaires were completed by 38 providers from 29 sites across the United States and Canada. AR-V7 test results were reported either as CTC– (28%), CTC+/AR-V7– (30%), or CTC+/AR-V7+ (42%). Prevalence of AR-V7 detection increased with prior exposure to ATTs (abiraterone and enzalutamide naïve, 22%; after abiraterone or enzalutamide, 35%; after abiraterone and enzalutamide, 43%). Overall, management was affected by AR-V7 testing in 53% of the patients and even more often with CTC+/AR-V7+ results. AR-V7+ patients were commonly switched from ATT to taxane chemotherapy (43%) or were offered a clinical trial (43%); management remained unchanged in only 14% of these patients. Overall, patients who had a change in management on the basis of AR-V7 testing were significantly more likely to achieve a physician-reported 50% decline in prostate-specific antigen response on next-line therapy than those who did not change treatment (54% v 31%; P = .015). Conclusion Providers used AR-V7 testing to influence clinical decision making more often than not. Physicians reported that men with AR-V7+ results had the most treatment changes, and such men were preferentially managed with taxane therapy or offered a clinical trial, which may have improved outcomes.

scholarly journals Pathogenic Heparin Induced Thrombocytopenia and Thrombosis (HIT) Antibodies Determined By Simple Rapid Functional Flow Cytometry

Blood ◽  
2018 ◽  
Vol 132 (Supplement 1) ◽  
pp. 3801-3801
Author(s):  
Varda R Deutsch ◽  
Michal Cipok ◽  
Ilya Kirgner ◽  
Sigi Kay ◽  
Ismail Elalamy ◽  
...  
Keyword(s):  
Platelet Activation ◽  
Clinical Decision Making ◽  
Clinical Laboratory ◽  
Control Sample ◽  
Relative Sensitivity ◽  
Clinical Decision ◽  
Positive Control ◽  
Serotonin Release ◽  
Serum Samples ◽  
Positive Events

Abstract Background: HIT diagnosis is mandatory for patient management, yet prompt determination of pathogenic antibodies remains an unmet clinical challenge. Commonly used immunoassays carry inherent limitations and functional assays which determine antibody-mediated platelet activation are not readily available being technically demanding and require high level expertise. Additionally, they are time consuming and not rapid enough to provide quick detection of the pathologic antibodies required at time of diagnosis. Aims: To overcome these limitations, we aimed to develop an easily performed functional flow cytometric assay (FCA) to rapidly detect platelet activating antibodies for the initial diagnosis and/or confirmation of HIT. Methods: Serum samples from patients clinically suspected of HIT (n=650) were tested by the PF4/H-PaGIA immunoassay (DiaMed, Switzerland). The capacity of the patient's serum to induce platelet activation in the presence of heparin was assessed by a rapid 2-hour functional FCA. Platelets were gated by CD41 expression and a positive cut-off gate of the high 2% CD62p positive events was set on normal control sample. Each assay assessed the fraction of positive events above the 2% cut-off gate of the control sample. Background fluorescence was normalized in each sample. TRAP stimulation provided the positive control. A positive test result was defined as a value ≥2 fold greater than that of the control. Results were compared to those of the radioactive serotonin-release assay (SRA) and to the clinical 4Ts score HIT presentation Results: Consecutive HIT-suspected patient samples were tested, 15.3% were positive by the PaGIA-Heparin/PF4 immunoassay and only 4.8% by FCA. When compared to TRAP, PaGIA+/FCA+ samples were 11-fold higher in fluorescence vs. PaGIA-/FCA- samples +2SD. SRA was performed on 63 samples. Of 21 SRA positive samples, 19 were positive by FCA (relative sensitivity 90.5%), and of 42 SRA negative samples, 40 were negative by FCA (specificity 95.2%). The robustness of the FCA was confirmed by an alternative calculation, using the ratio of the % platelet activation induced by patient samples/the % activated by thrombin-receptor-activating-peptide (TRAP). Platelet activation, generated by the patient samples was 11-fold higher in PaGIA+/FCA+ vs. PaGIA-/FCA- samples, confirming the high resolution of this assay to facilitate discrimination between positive and negative values. The FCA showed significantly higher correlation with the clinical presentation of HIT (4Ts score) performed on 182 patients, compared to PaGIA-Heparin/PF4 (ROC-plot analysis, AUC 0.93 vs. 0.63, p<0.001). At 92% sensitivity, the assay specificity was 96%. Conclusions: We demonstrate that pathologic HIT antibodies can be detected rapidly by routine clinical laboratory methodology. Thus, the present assay provides a feasible answer to the unmet clinical need of prompt and reliable diagnosis of true HIT. Hence, validation of this assay by other laboratories, might offer a practical replacement for the non-readily available radioactive SRA, or other complex tests, thus contributing to improved clinical decision making and patient care. Disclosures Tomer: Azapharm: Other: patent pending and consultation fees from Azapharm outside of submitted work..

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