During my fourth year of medical school, I was required to design and carry out a QI project on high value care. I joined with a team of students who were all planning on doing our residencies in internal medicine, and we brainstormed ideas about what project could be beneficial to IM services. One problem we had all noticed while on rotation was almost every patient getting daily labs, and many times the patients were not even being monitored for anything in particular and would have completely normal labs. We realized one reason for this problem was due to admission order sets, which would order daily CBCs and chem 7s on every patient.
We discussed this concern with a new fellow at Ohio State who mentioned at her residency program, daily labs would time out after a patient had been hospitalized for three days, thus requiring residents to often evaluate whether or not their patients truly needed daily monitoring. We decided to use this same concept to create an algorithm that asked residents on internal medicine services to evaluate patients after they had been hospitalized for 2 days or greater. If the patient had been stable for the last two days with unchanging labs, the algorithm suggested changing daily labs to q3 day labs.
I talked to two different general medicine services about our project and gave them each a copy of the handout. For the next four weeks my team and I would record how many patients were getting daily labs while noting specifically how many stable patients without any abnormalities were getting daily labs. During my data collection, I noticed most patients were only getting daily labs if they were just admitted or if a specific abnormality was being tracked. I did notice more patients with every 2 day labs or every 3 day labs on the services that we implemented our project when compared to the services we did not implement our project on.
Although our results were not significant, there was a trend towards less daily labs on stable patients who had been in the hospital for several days in the implementation services. Additionally, for future directions for this project, we think that residents/attending physicians will require more than a simple handout to make the transition we wanted. Other ideas that our group would like to see eventually take place would be either a similar system such as daily labs being timed out after a few days in the hospital, or a dot phrase that would require residents to evaluate the number of days of daily labs and the reasons why patients require them.
I think this project was very helpful in teaching our team the process of conducting a QI project. Additionally, it helped us realize there are many practices that do not follow high value care guidelines. Being required to participate in a QI project was important because it allowed students to realize that there are many things to be fixed and give us the confidence and the skills to attempt to fix them in the future. I hope I can continue to work on meaningful QI projects during residency and continue to learn more about the process of carrying out the project and data collection.