Intervention to Reduce Inappropriate Ionized Calcium Ordering Practices: A Quality-Improvement Project

Abstract

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 testordering 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. 50The Permanente Journal/ Winter 2015/ Volume 19 No. 1 ORIGINAL RESEARCH & CONTRIBUTIONSIntervention to Reduce Inappropriate Ionized Calcium Ordering Practices: A Quality-Improvement Project the EMR looking for explicit comments by the HIM clinicians regarding the iCa indication. If no such comment was recorded in the HIM admission or progress notes, the EMR was then reviewed for active and/or historic medical conditions that might warrant iCa assessment (see Sidebar: Clinical Scenarios Generally Regarded to Warrant Ionized Calcium Monitoring) on the basis of available data and expert clinical opinion. 4,5 In situations where the indication for ordering an iCa test was in question, the two authors jointly reviewed the record to determine the indication. If a medical indication for iCa monitoring was not found, we considered this to be "inappropriate" ordering. We then quantitated the total number of iCa measurements and categorized them according to ordering department. We documented the ordering patterns in the ED and ICUs, but no intervention was performed in these departments and we did not interact with those groups.A root-cause analysis indicated that lack of clinician awareness regarding the indications of iCa t...

Impact of an education and multilevel social comparison–based intervention bundle on use of routine blood tests in hospitalised patients at an academic tertiary care hospital: a controlled pre-intervention post-intervention study

“…The magnitude of total reduction is within the range of reduction that has been seen in other studies17 22–27 29 32–38 looking to intervene on utilisation of low-value laboratory testing and the estimated range of overutilisation 2. Studies that used education alone around costs (through fee-display) and indications showed non-significant39 40 reductions, small reductions in utilisation34 or poor sustainability 17.…”

“…Prior studies have shown that higher numbers of routine laboratory tests are ordered in teaching hospitals where testing is ordered by rotating medical learners at different stages of training 20 21. To optimise laboratory testing, interventions that have attempted to address the above causes generally fall into three main categories: education, audit and feedback on ordering practices, and restrictive electronic medical record (EMR) mediated changes; with multifaceted interventions being associated with greater success 22–30…”

Association Between Disease Severity and Calcium Concentration in Critically Ill Patients Admitted to Intensive Care Unit

“…On the other hand, calcium indicators including total, ionized, and corrected calcium are influenced by different factors; therefore, it is not clear which of them is appropriate for assessing calcium status in ICU patients ( 9 ). Moreover, the findings of previous studies conducted about the relationship between hypocalcemia and adverse outcomes in ICU patients are controversial ( 5 , 10 - 12 ). In most studies, only one indicator of calcium status and its correlation with ICU outcomes were investigated.…”

Utility of calcium, magnesium and phosphate testing in the emergency department

“…They reported that laboratory ordering was reduced by 8% cumulatively over 3 years. Newman et al . also reported that a targeted education intervention substantially reduced the frequency of routine Ca testing, including in the ED setting.…”