An Initiative to Decrease Laboratory Testing in a NICU.

BACKGROUND AND OBJECTIVES: Laboratory testing is performed frequently in the NICU. Unnecessary tests can result in increased costs, blood loss, and pain, which can increase the risk of long-term growth and neurodevelopmental impairment. Our aim was to decrease routine screening laboratory testing in all infants admitted to our NICU by 20% over a 24-month period. METHODS: We designed and implemented a multifaceted quality improvement project using the Institute for Healthcare Improvement's Model for Improvement. Baseline data were reviewed and analyzed to prioritize order of interventions. The primary outcome measure was number of laboratory tests performed per 1000 patient days. Secondary outcome measures included number of blood glucose and serum bilirubin tests per 1000 patient days, blood volume removed per 1000 patient days, and cost. Extreme laboratory values were tracked and reviewed as balancing measures. Statistical process control charts were used to track measures over time. RESULTS: Over a 24-month period, we achieved a 26.8% decrease in laboratory tests performed per 1000 patient days (∽51 000 fewer tests). We observed significant decreases in all secondary measures, including a decrease of almost 8 L of blood drawn and a savings of $258 000. No extreme laboratory values were deemed attributable to the interventions. Improvement was sustained for an additional 7 months. CONCLUSIONS: Targeted interventions, including guideline development, dashboard creation and distribution, electronic medical record optimization, and expansion of noninvasive and point-of-care testing resulted in a significant and sustained reduction in laboratory testing without notable adverse effects.

Attending physician work hours: ethical considerations and the last doctor standing.

Based at least in part on concerns for patient safety and evidence that long shifts are associated with an increased risk of physician error, residents' and fellows' work hours have been strictly limited for the past several years. Little attention has been paid, however, to excessive attending physician shift duration, although there seems to be no reason to assume that this common practice poses any less risk to patients. Potential justifications for allowing attending physicians to work without hourly limits include physician autonomy, workforce shortages in certain communities or subspecialties, continuity of care, and financial considerations. None of these clearly justify the apparent increased risk to patients, with the exception in some settings of workforce shortage. In many hospital settings, the practice of allowing attending physicians to work with no limit on shift duration could pose an unnecessary risk to patients.