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.

Propylene glycol neurotoxicity due to sodium citrate therapy in an infant with renal tubular acidosis.

Sodium citrate in its liquid formulation is commonly used as therapy for renal tubular acidosis in pediatric patients. Convenient dosing and administration is important to ensure long-term medication adherence and normal growth in the chronic forms of this condition. Liquid sodium citrate formulations contain propylene glycol, a commonly used excipient, which can be toxic at high doses. Propylene glycol toxicity due to medication excipients has been reported in the literature, including many cases secondary to sustained exposure to intravenous anti-epileptics, however toxicity associated with oral sodium citrate therapy has not been described. We report the first case of propylene glycol neurotoxicity in a 6-week-old infant with renal tubular acidosis treated with sodium citrate. Clinical suspicion of risk for medication-related toxicity and awareness of propylene glycol content in sodium citrate led to timely diagnosis and management. Awareness of increased risk of toxicity in pediatric patients due to high sodium citrate requirement and low propylene glycol metabolism capacity is important for optimal care for pediatric patients with renal tubular acidosis.