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

BACKGROUND: Careful 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 PROBLEM: During 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. METHODS: After 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'. RESULTS: Physician 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. CONCLUSIONS: Provision 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.

Single diagnostic pacing maneuver for supraventricular tachycardia.

BACKGROUND: Diagnostic supraventricular tachycardia (SVT) features and pacing maneuvers tend to be specific but insensitive. Therefore, diagnosis often requires the integration of multiple pieces of information and/or pacing maneuvers, which adds to the complexity of catheter ablation procedures. OBJECTIVE: The purpose of this study was to determine if a single diagnostic pacing maneuver, namely, ventricular overdrive pacing including a basal pacing site near the earliest atrial activation, provides a definitive SVT diagnosis in nearly all patients. METHODS: Sixty-seven consecutive patients with SVT undergoing catheter ablation at two institutions were prospectively studied. RESULTS: Overdrive ventricular pacing provided the correct diagnosis in 91% of all patients and in 100% of patients when pacing accelerated the atrium to the pacing cycle length. Fusion due to wavefront collision in the ventricles or distal conduction system was 73% sensitive and 100% specific for accessory pathway-mediated SVT. Basal pacing was superior to pacing from the right ventricular apex for distinguishing accessory pathway-mediated SVT from AV nodal reentrant tachycardia. CONCLUSION: Overdrive ventricular pacing is a highly effective single diagnostic pacing maneuver for sustained SVT. Basal pacing sites near the earliest atrial activation are superior to the right ventricular apex.

Asbestosis and probable microscopic polyangiitis.

Several inorganic dust lung diseases (pneumoconioses) are associated with autoimmune diseases. Although autoimmune serological abnormalities are common in asbestosis, clinical autoimmune/collagen vascular diseases are not commonly reported. A case of pulmonary asbestosis complicated by perinuclear-antineutrophil cytoplasmic antibody (myeloperoxidase) positive probable microscopic polyangiitis (glomerulonephritis, pericarditis, alveolitis, multineuritis multiplex) is described and the possible immunological mechanisms whereby asbestosis fibres might be relevant in induction of antineutrophil cytoplasmic antibodies are reviewed in the present report.