Children's Hospitals Today - Fall 2017 - 15

LAB TESTING / FEATURE

CASE STUDY

pre-authorization as a requirement for
review and conducted the review in real
time. When a provider approved a genetic
test, the send-out lab received the request
and held it for the genetic counselor to
review. The genetic
Learn more
counselor reviewed
about Arkansas
the test with a twoChildren's efforts
to streamline
prong approach: Is
its process at
the case clinically
childrenshospitals
.org/TUM.
appropriate, and does
it have insurance
pre-authorization if the test is necessary?
When a case meets both requirements,
the lab processes the sample.
Implementation of this process helped
the hospital reduce waste and tech time
in the lab, educate clinicians on clinically
appropriate testing and insurance preauthorization strategies, and identified
knowledge gaps among clinicians and
hospital staff members regarding insurance pre-authorization. At the time,
there was confusion among staff members about whose job it was to obtain
pre-authorization, and some were passing that job on to the family.

How it works
Today, Arkansas Children's has a onehalf, full-time equivalent devoted to test
review-the genetic counselor. If there
are red flags about a test, the genetic
counselor initiates a discussion with the
physician who ordered the test, and only
with physician approval are tests modified, canceled or changed. Tests that need
modification fall in to three categories:
errors of order entry (typos, confusing
names); duplicate testing (same test twice,
tests that overlap); or clinically inappropriate (wrong test for the wrong patient).
In this example of an error in order
entry, a doctor ordered genetic testing

for campomelic dysplasia on a 14-yearold-girl admitted from the emergency
room. This condition is associated with
dwarfism, abnormalities of the genitalia and a cleft palate. The patient had a
movement disorder, but she had no signs
of campomelic dysplasia. Because this
discrepancy raised red flags, the genetic
counselor contacted the physician and
together, they conducted a chart review.
During the discussion, it became apparent there was a handwritten note in
the record for a "CMP in the morning."
CMP is also known as complete metabolic profile-a common test in any setting.
However, in the order entry system at
Arkansas Children's, the pneumonic for
a complete metabolic profile is similar to
campomelic dysplasia, which is CAMP. A
quick conversation with the physician
resolved the issue, and the provider canceled the test. This prevented an unnecessary expenditure of more than $1,000.
In another example, providers ordered
testing for the CDKL5 gene in a pair of
siblings. This gene is associated with
developmental delay, which the siblings
did not have upon chart review. The genetic counselor noticed the siblings were
admitted for tuberculosis, and a large
panel of cluster of differentiation (CD)
antigens had been ordered at same time
as the genetic test. It became clear that
among the CD antigens, CDKL5 had been
selected because it started with CD. After
canceling the inappropriate test, the hospital avoided almost $6,000 in costs.
Sometimes the lab notices testing has
already been performed for a patient.
For example, the lab noticed a provider
ordered RET gene testing for a child
with a neuroendocrine tumor. This was
a clinically appropriate test, but during chart review, the genetic counselor

Learning that
less is more
A team at Monroe Carell
Jr. Children's Hospital in
Nashville set out to decrease
the number of unnecessary
repeat complete blood counts
(CBCs) and basic metabolic
panels (BMPs) from 13.5
percent of total ordered to
less than 5 percent on the
Pediatric Hospital Medicine
Service. To engage providers,
the team encouraged effective
communication; expanded
knowledge of lab charges;
and increased providers'
understanding of the
magnitude of the problem. The
improvement team also asked
interns to include lab plans
in daily notes and posted lab
charges on computers in work
areas. Throughout the process,
nurses began to understand why
fewer patients were undergoing
phlebotomy each morning.
Residents began to understand
not only the financial cost of
ordering tests that did not affect
their clinical decision making
process, but also sometimes in
medicine, less is more. Today,
the hospital has reduced the
percentage of unnecessary
lab tests to about 5 percent of
tests ordered and has not had
any increase in the average
length of stay or seven-day
readmission rates. This
translates to about $126,000 in
charge reductions a year.
Learn more about the hospital, a 2015
Pediatric Quality Award semifinalist, at
childrenshospitals.org/qualityaward.

CHILDREN'S HOSPITAL S TODAY Fall 2017

15


http://childrenshospitals.org/TUM http://www.childrenshospitals.org/qualityaward

Table of Contents for the Digital Edition of Children's Hospitals Today - Fall 2017

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