Empowering medicine residents to order labs mindfully to improve patient-centered care.

BACKGROUND: Unnecessary laboratory testing of hospitalized patients is prevalent. OBJECTIVE: We conducted a study focused on "mindful ordering" to decrease unnecessary laboratory ordering within an Internal Medicine residency program. DESIGNS, SETTINGS AND PARTICIPANTS: We collected survey data on resident/faculty perceptions of laboratory ordering as well as order information from the electronic medical record (EMR). INTERVENTION: Interventions focused on resident-identified barriers such as knowledge, EMR, habit and faculty expectations. Interventions were cumulative and included resident/faculty education and EMR optimization. MAIN OUTCOMES AND MEASURES: We assessed basic and complete metabolic panels (BMP, CMP) and complete blood counts with and without differential (CBC w/diff, w/o diff). Primary outcomes included: total labs ordered per week, lab and frequency, and resident perception of ordering practices. Secondary outcomes included: length-of stay (LOS) and venipuncture utilization. RESULTS: Survey data demonstrated increased resident perception of both mindful ordering and team discussion. Total labs ordered per week decreased 20% in the first year (1944 to 1500 labs/week). Residents' use of the "one-time draw" option increased; use of "daily" frequency decreased. Trends showed an increase in BMP relative to CMP, and an increase in CBC w/o diff relative to CBC w/diff. These changes were sustained through 127 weeks. There was an approximately 10% decrease in monthly average of patients undergoing venipuncture each day (86.7% to 74.2%). The shifts in laboratory ordering in conjunction with increased discussion about labs suggest a sustained change in resident lab ordering behavior. This study shows the impact of focusing interventions on resident-identified barriers to mindful ordering to create a sustained decrease laboratory orders.

International experience with minocycline, EDTA and ethanol lock for salvaging of central line associated bloodstream infections.

BACKGROUND: The use of long-term central venous catheters (CVCs) could lead to serious bloodstream infections. Removal of the infected CVC and reinsertion of a new CVC are not always feasible and alternative lock therapy may be considered. We conducted a multicenter trial to assess the efficacy and safety of the lock therapy. METHODS: Between October 2013 and August 2014, we prospectively enrolled 20 patients with catheter-related bloodstream infections (CRBSIs) or central line-associated bloodstream infections (CLABSIs) in our sister institutions in three countries including Brazil, Lebanon, and Japan. The 20 patients who received M-EDTA-EtOH lock therapy were compared to 24 control patients who had their CVCs removed and a new CVC inserted. RESULTS: Both groups had comparable clinical characteristics. In the lock therapy group, 95% of the patients had microbiological eradication within 96 h after starting lock therapy versus 83% of the patients in the control group (p = .36). In the lock group, the CVC was salvaged and retained for a median of 21 days (range 7-51) from the onset of bacteremia. CONCLUSION: Our study suggests that M-EDTA-EtOH lock therapy may be an effective intervention to salvage long-term CVCs in the setting of CLABSI/CRBSI and hemodialysis cancer patients with limited vascular access.