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Intervention to reduce inappropriate ionized calcium ordering practices: a quality-improvement project
Darrell B Newman1, Konstantinos C Siontis2, Krishnaswamy Chandrasekaran3
1Cardiologist in the Division of Cardiovascular Diseases at the Mayo Clinic in Rochester, MN. newman.darrell@mayo.edu.
Insights
Routine monitoring of ionized calcium (iCa) in stable patients is often unnecessary. An educational intervention significantly reduced iCa test ordering by internal medicine clinicians, improving resource utilization.
Area of Science:
- Clinical Chemistry
- Quality Improvement in Healthcare
- Internal Medicine
Background:
- The clinical utility of ionized calcium (iCa) testing in non-critically ill patients remains unclear.
- iCa monitoring is resource-intensive and costly compared to total calcium measurements.
- Hypothesis: iCa tests are frequently ordered for routine monitoring without impacting patient management.
Purpose of the Study:
- To analyze iCa test ordering patterns among hospital-based internal medicine clinicians.
- To implement an intervention to modify iCa test ordering practices.
Main Methods:
- Quality improvement project utilizing retrospective chart review.
- Identified 100 consecutive patients with iCa tests ordered by internal medicine.
- Conducted an educational intervention on appropriate iCa testing.
- Assessed intervention impact by comparing pre- and post-intervention iCa test ordering rates.
Main Results:
- Internal medicine services accounted for 38% of iCa tests pre-intervention.
- Post-intervention, internal medicine services accounted for 13% of iCa tests, a 66% reduction (p=0.0007).
- The intervention significantly decreased iCa test ordering by internal medicine clinicians.
Conclusions:
- Clinician education is an effective strategy to reduce unnecessary ionized calcium monitoring.
- This intervention improved the appropriateness of iCa test utilization in hospitalized patients.
- Reduces laboratory resource consumption and healthcare costs.
Context:
The importance of an abnormal ionized calcium (iCa) measurement in noncritically ill patients is unclear. Furthermore, iCa monitoring is more expensive than measurement of total calcium and consumes more laboratory resources. We hypothesize that most iCa tests are ordered for routine monitoring in asymptomatic patients, and results do not influence clinical management.
Objective:
To characterize and to intervene on iCa test-ordering practices among our institution's hospital-based internal medicine clinicians.
Design:
A quality-improvement project, with retrospective review of clinical records. We retrospectively identified the first 100 consecutive patients admitted to our hospital internal medicine (HIM) services during January 2012 with an iCa test ordered during their hospitalization. We reviewed clinical records to determine the appropriateness of iCa test ordering and of the ordering department. An educational intervention regarding the appropriateness of iCa testing was undertaken targeting HIM clinicians.
Main Outcome Measures:
The effect of the intervention was assessed by identifying a sample of the first 100 consecutive patients admitted to HIM services during November 2012 and by comparing the proportion of iCa tests ordered by HIM clinicians before and after the intervention.
Results:
HIM services were responsible for 38% of iCa measurements before the educational intervention, with the remainder originating primarily from the Emergency Department (29%) and intensive care units (28%). After the intervention, the internal medicine services were responsible for 13% of iCa measurements, which represented a 66% reduction (p = 0.0007).
Conclusion:
A simple intervention based on clinician education can reduce the frequency of routine iCa monitoring in stable hospitalized patients.
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