Transcript of Spotlight Case No News May Not Be Good News. 2 Source and Credits This presentation is based on the...
- Slide 1
- Spotlight Case No News May Not Be Good News
- Slide 2
- 2 Source and Credits This presentation is based on the August
2012 AHRQ WebM&M Spotlight Case See the full article at
http://webmm.ahrq.govhttp://webmm.ahrq.gov CME credit is available
Commentary by: Carlton R. Moore, MD, MS; University of North
Carolina, School of Medicine Editor, AHRQ WebM&M: Robert
Wachter, MD Spotlight Editor: Bradley A. Sharpe, MD Managing
Editor: Erin Hartman, MS
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- 3 Objectives At the conclusion of this educational activity,
participants should be able to: Describe the frequency with which
ambulatory test results are not followed up by providers Appreciate
that inadequate follow-up of ambulatory test results needs a
system-based solution State how automated results management
systems can help with ambulatory test results Understand the
hazards of alert fatigue in automated results management
systems
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- 4 Case: No News (1) A 10-year-old girl with a history of asthma
was brought by her mother (a nurse) to see a pediatrician because
of a 15-pound weight loss over a period of 3 months. There were no
notable changes in the child's diet or urination and no other
systemic symptoms. A physical examination was unremarkable, and the
pediatrician ordered basic labs on a Thursday morning. On Monday
morning, the patient's mother called the pediatrician's office to
obtain results of the blood tests. The pediatrician was busy all
day long but near the end of the day found the result.
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- 5 Case: No News (2) He was shocked to learn the patient's
glucose level was 320 mg/dL (normal random blood sugar: 70125
mg/dL). The pediatrician immediately contacted the mother and had
her bring her daughter to the office. A repeat stat blood test
showed that the patient's blood sugar was now 450 mg/dL and she had
moderate ketones on urinalysis (showing early signs of diabetic
ketoacidosis, which can be life threatening). She was given insulin
and specific instructions on management at home.
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- 6 Case: No News (3) The patient and mother had to return to the
clinic each day for the next few days for ongoing management. The
patient did not experience any long-term consequences. When
reviewing the case, the pediatrician was surprised that no one had
been notified about the elevated blood sugar level. He came to
learn that a fax of the laboratory results had been sent to the
clinic on Saturday with the urgent result but, for unclear reasons,
the physician covering for the weekend never saw it. This clinic
did not have an electronic medical record (EMR).
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- 7 Background: Ambulatory Testing (1) Almost one quarter of all
medical errors in ambulatory settings are due to inadequate
follow-up of abnormal test results Fastest growing area of
malpractice litigation involves failures or delays in diagnosis Up
to 25% of these lawsuits are from avoidable failures in the test
follow-up system See Notes for references.
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- 8 Background: Ambulatory Testing (2) Follow-up of outpatient
test results has become a major priority for many organizations
Safety concerns are echoed by physicians In one survey, 83% of
physicians reported at least one delay in reviewing test results
over the past 2 months In a survey of internal medicine residents,
46% stated that, at least a few times a year, they have seen a
patient worsen due to delays in lab test follow-up See Notes for
references.
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- 9 Missed Test Results are Common (1) Many studies document how
often tests are missed in the outpatient setting In one study, 15%
of abnormal tests suggestive of diabetes were never followed up by
clinicians; about 9% of these patients had unrecognized (and
untreated) diabetes See Notes for reference.
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- 10 Missed Test Results are Common (2) In a study in a primary
care practice over a 4- year period, the median time for follow-up
for marked hyperkalemia was 3 days In 14% of these cases, no
follow-up occurred until patients returned for routine follow-up or
they visited the practice for other reasons See Notes for
reference.
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- 11 Missed Test Results are Common (3) In another study, in more
than 2% of patients with abnormal thyroid function tests (either
hypo- or hyperthyroid), there was no follow-up An additional 5% of
patients were lost to follow- up or unaware of their results See
Notes for reference.
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- 12 Reasons for Missed Test Results Not likely due to lack of
provider effort Physicians report spending more than 70 minutes per
day on test result management, reviewing more than 1000 results per
week on average Inadequate test result follow-up should be viewed
as a system problem requiring a system solution See Notes for
reference.
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- 13 Information Technology Solutions Automated test results
management systems are usually integrated into electronic medical
records (EMRs) and can help with results management Well-designed
systems alert clinicians to the presence of abnormal results
Automated systems ideally classify the degree of the abnormality
(e.g., mild, moderate, severe) and present relevant clinical
information to providers
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- 14 Results Management Systems Automated results management
systems can improve result follow-up One study showed that timely
follow-up of marked hyperkalemia improved after implementation
Patient satisfaction has also been shown to improve with automated
test results systems See Notes for references.
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- 15 Capability of determining when ordered laboratory tests have
been completed Highlighting laboratory test results that require
urgent attention Presenting results in the context of previous
results, medication lists, and problem lists Forwarding capability
and allowing the use of surrogates during planned absences See
Notes for references. Features of an Ideal Results Management
System (1)
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- 16 Ability to order additional tests or treatments in the
computer system while reviewing results Capability of creating
reminders to perform tasks in the future Capability to select
important or critical laboratory test results for more urgent
review and customizing alerts to prevent alert fatigue A
population-based view that allows clinicians to easily identify
laboratory test results that appear to have not been reviewed See
Notes for references. Features of an Ideal Results Management
System (2)
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- 17 Improving Results Management Ensure that all laboratory
tests include the correct ordering provider Ensure staff have
adequate time specifically to review test results Create policies
and systems to ensure that results are consistently communicated to
patients in a timely manner Provide clear handoff procedures to
manage results during times of provider absence (i.e., weekends)
See Notes for references.
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- Limitations to Systems Solutions In one study, after
implementation of a results management system 10% of alerts for
abnormal tests were unacknowledged by the clinicians 7% of abnormal
labs lacked timely follow-up after 30 days The authors believed
this was due to "fatigue" on the part of the clinicians (too many
alerts become overwhelming) 18 See Notes for references.
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- Alert Fatigue Any well-designed results management system
should have some method for clinicians to reduce alert fatigue Most
common solution is modifying or turning off alerts for non-critical
events 19
- Slide 20
- Back to the Case It appeared the pediatrician had no tracking
system and relied on finding time during his hectic schedule A
results management system would have facilitated timely follow-up
The mother's diligence prompted follow-up We should continue to
encourage patients' engagement in health care to ask about results
of tests taken 20
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- 21 Take-Home Points (1) Inadequate follow-up of laboratory test
results is fairly common and can lead to patient harm Barriers to
effective management of laboratory test results are time pressures
and cognitive overload on clinicians Inadequate laboratory test
result follow-up is a system problem requiring a system
solution
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- 22 Take-Home Points (2) Well-designed automated results
management systems combined with clinical workflow changes can
improve laboratory result follow-up Alert fatigue from poorly
designed automated results management systems can be a significant
barrier to timely follow-up of laboratory results