Epic Phases of Care to Facilitate Accurate Ordering of Microbiological Testing of Surgical Specimens

Purpose/Objectives: Proper ordering of microbiological tests from the operating room (OR) is necessary to avoid diagnostic delays and therapeutic errors in children undergoing surgery. Following a series of errors in microbiological orders placed from the OR at Texas Children’s Hospital (TCH), a root-cause analysis revealed ad-hoc orders are placed in the OR irrespective of existing orders. The specific aim of this quality improvement project was to utilize an established tool, Phases of Care, in Epic Systems ®, to reduce the order error rate for surgical specimens from patients followed by the pediatric infectious diseases (ID) team by 25 % in 6 months.

Design/Methods: Following a benchmark analysis (Sept – Dec 2020) of microbiological order error rates for surgical specimens from patients followed by the ID team, Plan-Do-Study-Act (PDSA) cycles were designed and conducted over six months. During PDSA 1, the ID team signed and held all microbiological orders through Epic Phases of Care and educated OR nursing staff on changes in workflow regarding the release of held orders. During PDSA 2, further education and training of OR nursing staff was conducted via online video tutorials, tip-sheets for the new workflow, and one-one-one training. During PDSA 3, use of Phases of Care was expanded to physicians in the pediatric intensive care unit (PICU). The primary outcome measure was the percent of microbiological lab tests of specimens sent form the OR with a missing and/or inaccurate order. The process measure was the percent of orders assigned using Phases of Care. We evaluated for balancing measures that led to ongoing order errors despite use of Phases of Care.

Results: During the benchmark analysis, 21/34 (62%) of surgical specimens had incomplete or inaccurate microbiological orders sent from the OR. After 2 months of PDSA 1, the order error rate for surgical specimens decreased to 36% (9/25) and after 2 months of PDSA 2, the order error rate decreased to 18% (4/22). PDSA 3 was recently instituted, and we are gathering data to evaluate order error rates for surgical specimens for PICU patients. The process measure changed from 0% to 100% after PDSA 1. Balancing measures for ongoing order errors included specimen source mismatch (in which the specimen source placed by the ID team did not match the source collected by the surgeon) and ongoing unfamiliarity with the new ordering workflow for some of the OR nursing staff.

Conclusion/Discussion: Using Epic Phases of Care to facilitate ordering of microbiological tests, the TCH ID team reduced the microbiological order error rate for surgical specimens by 44% in 6 months. With future PDSA cycles we hope to expand the use of Phases of Care to other departments to facilitate accurate microbiological ordering of surgical specimens.