This project extended the AUSLAB retest interval trial project to 33 Queensland Health laboratories with over 25,000 tests ordered per day on this system.
Queensland Health Pathology & Scientific Services (QHPSS)
Aim
to implement a process for intercepting inappropriate pathology.
This aim was achieved by this project.
Outcomes
QHPSS implemented the RETEST interval system in all 33 laboratories, and as a result all public Queensland Health requests for tests targeted by the project were subjected to the RETEST algorithm.
Additional tests codes to the RETEST interval algorithm were implemented.
An accepted and approved method for the interception of inappropriate pathology orders has been implemented across Queensland Health.
The RETEST algorithm is now an accepted business process for QHPSS in every hospital across Queensland Health.
Development of a best practice process for selection of pathology tests by medical staff.
Development of a laboratory procedure for tests that are subject to a RETEST Interval in AUSLAB including a process to assess and analyse the tests that haven’t been ordered within the acceptable retest interval.
Development of a survey tool to measure the extent of unnecessary repeat ordering across the state.
Awareness and training in appropriate pathology ordering and testing for QHPSS and medical staff.
Extraction of data that measures the utilisation of public pathology services.
Presentations have been made to other AUSLAB sites across Australia during annual AUSLAB user group meetings.
Findings
The project was saving considerable amounts of money each month for Queensland Health. Direct savings at the time of the report were almost $150,000, and above $10,000 per month.
Data from all sites involved in the project showed the retest functionality has seen some reduction in the overall test codes ordering used in the RETEST project, although this was not uniform across all sites. Many external factors, such as hospital activity, must be analysed before more formal conclusions could be determined.
Analysis indicated the liver function test (LFT) was over-ordered; 8% of all of these tests in Queensland were on the same patient on the same day. However, the Chemical Pathology Committee did not approve of this test code being added to the interval algorithm.
Thyroid function test (TFT), glycosylated haemoglobin (HbA1c) and cholesterol (lipids) were the most commonly over-ordered or repeated tests in the project. Requests for these tests were successfully intercepted by this project.
Almost all sites experienced a reduction in the number of tests rejected as a result of the RETEST program. Ipswich experienced a marked increase in the number of RETESTs ordered in the pathology department, with no explanation able to be found for this increase.
Key Project Learnings
There was one formal complaint received by the project staff from a senior medical consultant which was handled by the Director of the Division the test came under. A configuration change was made to the test report to indicate the test was subjected to a RETEST interval, even though this is also indicated on rejected reports.
There were difficulties experienced in engaging some areas of QHPSS, including additional new tests for consideration.
The project was perceived to be a poor business decision costing income from areas with QHPSS.
Shortages in qualified AUSLAB configuration staff impacted on the speed that new tests could be implemented.
A project of this type must be driven by the clients of the pathology service (i.e. doctors) not business managers, accountants or pathologists.
It was the support of the senior clinicians at each site that encouraged almost all other clinicians to accept the changes to the pathology ordering process.
Complaints and education must be handled correctly and promptly to ensure smooth acceptance during the implementation phase.
Getting engagement from the largest facility in Queensland Health (Royal Brisbane and Royal Children’s Hospitals) for an implementation meeting was difficult due to constant change in district management and medical administration.
When the program was accepted in some of the major hospital sites (e.g. The Prince Charles Hospital and The Princess Alexandra Hospital) then other sites around Queensland became very willing participants in the project.
Difficulties were experienced in gaining approval for new tests for the algorithm from chemical pathology and haematology. The reduction in the RETEST Interval for TFT and HbA1c was unfortunate but accepted as the decision was made by the committee within QHPSS for expert advice on chemical pathology testing.
The implementation of the New Tests – Microbiology Test code URINE - required modification to work practice in the laboratories.
Area for Future Consideration
Review the AUSLAB project with a view to implementing it in other states.
Previous research performed by the Royal Children’s Hospital (RCH) had shown the CoaguchekTM INR (international normalised ratio) monitor was reliable and accurate when used to monitor children within the hospital environment. This study aimed to determine if this outcome was achievable in the home environment. All children receiving warfarin therapy managed by the Haematology Department of the RCH were invited to participate. Sixteen families responded and all were accepted into the study as funds were available for up to twenty children. Fourteen families completed all of the requirements.
Grant Recipients
The Royal Women’s Hospital and the Royal Children’s Hospital
Aim
to determine the safety and efficacy of a home monitoring program facilitated by a comprehensive education package to families.
This aim was achieved by this project.
Outcomes
INRs performed by parents at home correlated very well with INRs performed in the hospital by dedicated pathology collection staff.
The home INR (H-INR) results would have produced a different management plan than the control INR (C-INR), taken at every second test point, on three test-points out of the total number performed.
All parents completed the education and training program associated with this program.
Findings
28% of parents understood their child’s indication for warfarin therapy at the commencement of the education program, which increased to 93% at the completion of the program. 85.7% maintained this knowledge at the six-month reassessment.
Most parents rated the program 10 out of 10, and all stated they would like to continue performing INR tests on their child in their home.
The estimated total cost of performing an INR at home is $13.56 plus 10 minutes of parental time.
The estimated total cost of performing an INR in hospital settings is $21.96 plus about one hour or more of parent time as well as community impact time.
Home monitoring of warfarin therapy is associated with reduced cost compared to hospital-based monitoring.
There is no avenue to support the cost of ongoing home monitoring of warfarin therapy and it does not receive any form of funding.
Home monitoring of warfarin therapy is unlikely to be widely used, despite the significant savings, unless infrastructure is offered to support this activity.
Recommendation
Develop a “self-monitoring” program where patients of sufficient age are taught to perform their own tests.
Key Project Learning
Several parents noted they had early problems getting a sufficient sized drop of blood to perform the INR test. This problem can be overcome through education about technique.
Further testing of the safe use of POCT devices as part of the Point of Care Testing in General Practice Trial http://www.health.gov.au/internet/main/publishing.nsf/Content/health-pathology-poctt-index.htm.
