PC1231: Decreasing Complete Blood Count with Differential Orders in the Pediatric Intensive Care Unit

Purpose/Objectives: Decrease the number of complete blood counts with leukocyte differentials (CBC-DIFFs) per patient day in the pediatric intensive care unit (PICU) from a baseline of 36 CBC-DIFFs per 10 patient days to a goal of 20 CBC-DIFFs per 10 patient days within 20 weeks.

Design/Methods: A key driver diagram (Figure 1) was developed to identify interventions to decrease daily CBC-DIFFs in the PICU. Using plan-do-study-act (PDSA) cycles, several interventions were implemented based on the identified secondary drivers: 1) Incorporate scheduled lab orders into clinician electronic medical record (EMR) interface 2) Educate clinicians on appropriate indications for CBC-DIFF, 3) Update EMR lab order, 4) Incorporate duplicate lab order alert into EMR, 5) Provide personal feedback on appropriateness of lab ordering to clinicians. A baseline rate of CBC-DIFF orders in the PICU was determined from EMR data from July 2017 to August 2020. CBC-DIFF orders per 10 patient days was tracked for 22 weeks during the period of interventions.

Results: A decrease in CBC-DIFF orders to goal level was noted after the first set of interventions (Figure 2). However, this improvement was not sustained. In November the introduction of the project was provided in-person. The noted increase in CBC-DIFF orders was due to an increase in resident orders despite email education regarding the project to each new rotation of residents starting on November 18th. This prompted the final PDSA cycle of providing personalized feedback to residents daily if repeating CBC-DIFF orders were active that did not meet the guideline. Direct contact with residents decreased CBC-DIFF orders to the goal.

Conclusion/Discussion: Approximately half of all laboratory testing ordered for patients have been shown to be unnecessary. Additional lab tests cause increased central line entries, excess cost, iatrogenic anemia and incidental findings that may lead to excessive work-ups. A CBC-DIFF at our institution costs $46 to the patient compared to $30 for a complete blood count without differential or $24 for a hemoglobin. A differential is appropriate when used for initial evaluations of critical illness, to trend neutrophil counts, or a couple times per week to assess changes during infection or viral-induced bone marrow suppression. To address the issue of appropriate lab stewardship, a quality improvement initiative was executed to specifically target excess ordering of CBC-DIFF in the PICU. A significant decrease in CBC-DIFF orders was achieved with direct contact through in-person education and personalized EMR messages. To sustain this improvement and expand the project to encompass other extraneous labs, a lab stewardship program could be implemented. In addition, appropriate lab stewardship should be an emphasis in medical education due to the benefits of decreasing inappropriate lab testing mentioned above.