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OBJECTIVES: Overutilization of laboratory services is now recognized as harmful to patients and wasteful. In fact, the American Board of Internal Medicine’s Choosing Wisely campaign recommends against ordering routine testing that does not answer a clinical question. Per peer benchmarking, our institution as a whole occupied an extreme outlier position at the 100th percentile for laboratory utilization. We sought to address this problem starting in our medical ICUs with a quality improvement project. DESIGN: Quality improvement project using the design, measure, analyze, improve, and control process. The primary endpoint was a sustained reduction in laboratory utilization. Counterbalance metrics were also followed, and these included mortality, renal replacement therapy initiation rates, stat laboratory orders, and central catheter–associated blood stream infections. SETTING: The medical ICU at the Ohio State University Medical Center. PATIENTS: All patients admitted to the medical ICU from March 2019 to March 2020. INTERVENTIONS: Root causes were identified and addressed with the implementation of a wide range of interventions involving a multidisciplinary team led by trainee physicians. MEASUREMENTS AND MAIN RESULTS: There was a sustained 20% reduction in the number of tests performed per patient day, with no change in the counterbalance metrics. CONCLUSIONS: Trainees can affect positive change in the culture and processes at their institutions to safely reduce laboratory utilization.

Background Central venous catheters (CVC) are generally recommended for norepinephrine administration due to risk of tissue ischemia. Early resuscitation, leading to decreased infusion duration, may minimize the need for CVCs if norepinephrine can be administered safely through a peripheral intravenous catheter (PIV). Objective A protocol was developed for peripheral administration. Safety, CVC placement, and adherence with protocol elements were evaluated. Methods A single-center, prospective, observational pilot was conducted for patients receiving norepinephrine in the Medical Intensive Care Unit (MICU). Patients were considered for PIV administration of low dose norepinephrine for less than 24 hours based on clinical status and anticipated short-term use. Protocolized interventions for PIV’s included criteria for gauge, number, and site as well as visual inspection and evaluation every 2 hours. Data was collected on protocol elements to evaluate safety and effectiveness of the protocol. Results There were 316 occurrences of norepinephrine infusions including 92 via PIV (patients may have received multiple treatments). 34% (31/92) did not require a CVC. 3 had infiltrated PIV’s without tissue injury. Maximum dose adherence was 73%. 97% of infusions ran less than 24 hours. Nursing adherence included: 91% gauge, 65% proper site, 99% adequate number, 49% blood return on initiation, 55% ongoing blood return, and 61% IV site checked. Conclusion Our results suggest that norepinephrine is safe to administer through a PIV at low doses for less than 24 hours using a protocol. Prevention of unnecessary CVC insertion is beneficial by minimizing the risk of central line complications thus improving patient morbidity.

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