Can We Decrease ICU Labs and Chest X-Rays?
Abstract & Commentary
By Andrew M. Luks, MD, Pulmonary and Critical Care Medicine, University of Washington, Seattle, is Associate Editor for Critical Care Alert.
Dr. Luks reports no financial relationship to this field of study.
Synopsis: This retrospective comparative study demonstrated that implementation of a protocol for ordering laboratory tests and chest radiographs in a single intensive care unit was associated with a significant cost savings compared to the pre-protocol period.
Source: Prat G, et al. Impact of clinical guidelines to improve appropriateness of laboratory tests and chest radiographs. Intensive Care Med 2009;35:1047-1053.
Routine laboratory tests (RLT) and chest radiographs (CXR) are a source of considerable expense in the care of ICU patients. In addition to the direct costs of these studies, frequent blood draws may also indirectly increase costs by leading to anemia requiring transfusion or by increasing the risk of infection due to the frequent accessing of intravascular catheters. Prat and colleagues sought to determine whether it was possible to decrease such costs through implementation of guidelines for ordering laboratory tests and chest radiographs in the ICU.
They performed a retrospective study in a 15-bed medical ICU at a single university hospital during which they analyzed practices in two periods, a 1-year observation period when RLT and CXR were ordered at the discretion of the physician and a second 1-year period following implementation of guidelines and education surrounding the ordering of these studies. Because there are no established guidelines in the literature for how frequently to order RLT and debate exists about the utility of daily CXR, the guidelines implemented in this ICU were developed by a consensus process involving 5 ICU physicians. They included recommendations about when to order RLT and CXR on admission and subsequent days in the ICU and broke down these recommendations based on whether the patient was on mechanical ventilation or breathing spontaneously. After educating all physicians and nurses working in the ICU about the process, the guidelines were posted in the patient rooms. The average costs of each test were included in the posted guidelines and physicians received monthly feedback regarding their use of the tests. The investigators then reviewed data from the radiology and laboratory departments regarding expenditures on RLT and CXR during each of the study periods.
During the first period, 541 patients were admitted to the ICU (359 required mechanical ventilation). A total of 634 patients were admitted to the ICU following implementation of the protocol (413 required mechanical ventilation). There were no significant differences between patients in the two groups with regard to age, SAPS II scores, mortality, or duration of mechanical ventilation, although the patients in the post-implementation period did have shorter ICU length of stay. During the post-guideline implementation period, there was a 40.8% relative reduction in the number of CXR ordered (3778 vs 2203) and a 38% to 71.5% relative reduction in the ordering of RLT based on the particular RLT under consideration. The cost per patient declined from €1061 prior to protocol implementation to €437 during guideline use, representing a 59% cost reduction. The cost per patient ICU day also decreased from €114 to €56 and they calculated an overall €300,000 ICU cost reduction directly related to protocol implementation.
Commentary
We should all face a simple fact: We waste a lot of money on daily laboratory tests and routine chest X-rays in the ICU. How often, for example, do physicians or nurses add calcium, magnesium, and phosphate to our morning chemistry panel when the likelihood of these results changing practice in a meaningful way is probably very low? Such unnecessary testing adds to the cost of care in an insidious way as each low calcium or magnesium value spurs calls to a resident or senior physician for replacement orders which lead, in turn, to increased pharmacy costs and even further lab testing to determine if the calcium or magnesium level actually came up in response to the initial replacement order.
The study by Prat and colleagues is intriguing as it suggests that a simple intervention involving guidelines and education of physicians and nurses can decrease the costs associated with RLT and CXR in the ICU. At a time of increasing pressure to lower costs in our over-stressed health care system, these results provide one possible avenue for making important gains. The study was conducted at a single center with a relatively small ICU, however, and whether such a protocol could be implemented in a larger ICU or across institutions is not clear. Such an effort would require changing the habits of a significantly larger number of physicians and nurses than were involved in this particular study. In addition, while the guidelines used in this particular study might be useful in a medical ICU, whether they could be applied in surgical or neurosurgical ICUs is unclear and some modifications might be necessary depending on the setting in which they are to be used.
Another, bigger question that remains to be addressed is whether the reduction in RLT and CXR has any effect on other patient outcomes besides the cost issues that have been the primary focus of this and the other studies done to date on this issue.1,2 It would be useful to know if the reduction in unnecessary testing carries additional benefits such as decreased infection rates, ICU length of stay, and need for transfusions without an adverse impact on patient mortality. Further studies will be necessary to address these issues, but in the interim we should probably be taking a closer look in the mirror to see if we really need all of those labs and radiographs we order each day.
References
- Barie PS, Hydo LJ. Learning to not know: Results of a program for ancillary cost reduction in surgical critical care. J Trauma 1996;41:714-720.
- Calderon-Margalit R, et al. An administrative intervention to improve the utilization of laboratory tests within university hospital. Int J Qual Health Care 2005;17:243-248.
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