588554
research-article2015
AJMXXX10.1177/1062860615588554American Journal of Medical QualityBates et al
Letter to the Editor
Delayed Awareness of Clinically Significant Test Results on Hospital Services Without an Automated Alert System To the Editor: Delayed recognition of clinically significant test results (CSTR) accounts for approximately 7% of medical errors, leading to delayed institution of appropriate management.1 Ideally, electronic health records (EHRs) should minimize such delays without placing unintentional burdens on medical providers. Our study provides a quantitative magnitude analysis of existing delays in awareness of CSTR in general care and intensive care settings in a proprietary EHR without an automated alert system. Significant troponin T trends (measured at 3 or 6 hours) were utilized as a representative laboratory result because they are clinically noteworthy in most clinical scenarios, independent of final diagnosis. All significant troponin trends reported from January 1, 2013, through February 28, 2013, were included for analysis. Time from laboratory report to first recognition by a provider (physician or advanced practitioner) was collected utilizing data recorded by our EHR system. Provider “recognition” was deemed to occur whenever a provider opened the “Labs” tab to view completed results. Contextual data regarding the primary service, location of the patient (intensive care unit [ICU] vs non-ICU), and time of result reporting were collected (2 am-6 am, 6 am-10 am, 10 am-2 pm, 2 pm-6 pm, 6 pm-10 pm, and 10 pm-2 am). During the study period, 419 significant troponin trends were reported. Mean time to troponin recognition was 47 minutes (SD ±70) (median time 20 minutes, interquartile range [IQR] 6-54 minutes). Median time to troponin recognition varied significantly based on time of day with a range of 11 minutes (IQR 4-29 minutes) to 33 minutes (IQR 8-69 minutes, analysis of variance, P < .01). The shortest delays were noted between 6-10 am and 2-6 pm. Time to recognition varied significantly between cardiology and non-cardiology services (55 minutes vs 37 minutes, P = .01) but not significantly between ICU and non-ICU services (49 minutes vs 45 minutes, P = .61). Troponin values were obtained an average of 2.1 ± 5.3 days after admission. There was no correlation between time of admission and delayed awareness of troponin (Spearman’s ρ test, Ρ = .0014). In this study, we quantified existing delays in recognition of CSTR in the absence of an automated alert
American Journal of Medical Quality 2015, Vol. 30(6) 604 © The Author(s) 2015 Reprints and permissions: sagepub.com/journalsPermissions.nav DOI: 10.1177/1062860615588554 ajmq.sagepub.com
system. Though median times were typically 30 minutes or less, our data suggest that there is wide variability in the time elapsed before completed laboratory results are reviewed by providers. The significantly shorter delays noted between 6 am-10 am and 2 pm-6 pm likely reflect typical working patterns: the former corresponding with morning rounds, the latter corresponding with afternoon chart review. The longest delays were observed overnight between 2 am and 6 am. The significantly longer median delays for patients admitted to cardiology versus non-cardiology services were unexpected. Although further investigation is necessary, we suspect that patients admitted to cardiology with acute coronary syndromes are more likely to receive prehospital anti-ischemic therapy, making close follow-up of troponins less urgent. Although the generalizability of our single-center retrospective analysis remains uncertain, little if any comparison data exist. Previous studies have predominantly been surveys relying solely on physician recollection.2,3 In summary, delayed awareness of CSTRs varies considerably by time of day, and possibly primary service, to an extent that could influence patient care. An automated notification service could potentially be effective in decreasing this delay. Ruth Bates, MD Andrew Rosenbaum, MD Christopher McCoy, MD Roger Yu, MD Mayo Clinic, Rochester, MN References 1. Schiff GD, Hasan O, Kim S, et al. Diagnostic error in medicine: analysis of 583 physician-reported errors. Arch Intern Med. 2009;169:1881-1887. 2. Poon EG, Gandhi TK, Sequist TD, Murff HJ, Karson AS, Bates DW. “I wish I had seen this test result earlier!” Dissatisfaction with test result management systems in primary care. Arch Intern Med. 2004;164:2223-2228. 3. Wahls TL, Cram PM. The frequency of missed test results and associated treatment delays in a highly computerized health system. BMC Fam Pract. 2007;8:32.
Downloaded from ajm.sagepub.com at DEAKIN UNIV LIBRARY on November 14, 2015
research-article2015
AJMXXX10.1177/1062860615588554American Journal of Medical QualityBates et al
Letter to the Editor
Delayed Awareness of Clinically Significant Test Results on Hospital Services Without an Automated Alert System To the Editor: Delayed recognition of clinically significant test results (CSTR) accounts for approximately 7% of medical errors, leading to delayed institution of appropriate management.1 Ideally, electronic health records (EHRs) should minimize such delays without placing unintentional burdens on medical providers. Our study provides a quantitative magnitude analysis of existing delays in awareness of CSTR in general care and intensive care settings in a proprietary EHR without an automated alert system. Significant troponin T trends (measured at 3 or 6 hours) were utilized as a representative laboratory result because they are clinically noteworthy in most clinical scenarios, independent of final diagnosis. All significant troponin trends reported from January 1, 2013, through February 28, 2013, were included for analysis. Time from laboratory report to first recognition by a provider (physician or advanced practitioner) was collected utilizing data recorded by our EHR system. Provider “recognition” was deemed to occur whenever a provider opened the “Labs” tab to view completed results. Contextual data regarding the primary service, location of the patient (intensive care unit [ICU] vs non-ICU), and time of result reporting were collected (2 am-6 am, 6 am-10 am, 10 am-2 pm, 2 pm-6 pm, 6 pm-10 pm, and 10 pm-2 am). During the study period, 419 significant troponin trends were reported. Mean time to troponin recognition was 47 minutes (SD ±70) (median time 20 minutes, interquartile range [IQR] 6-54 minutes). Median time to troponin recognition varied significantly based on time of day with a range of 11 minutes (IQR 4-29 minutes) to 33 minutes (IQR 8-69 minutes, analysis of variance, P < .01). The shortest delays were noted between 6-10 am and 2-6 pm. Time to recognition varied significantly between cardiology and non-cardiology services (55 minutes vs 37 minutes, P = .01) but not significantly between ICU and non-ICU services (49 minutes vs 45 minutes, P = .61). Troponin values were obtained an average of 2.1 ± 5.3 days after admission. There was no correlation between time of admission and delayed awareness of troponin (Spearman’s ρ test, Ρ = .0014). In this study, we quantified existing delays in recognition of CSTR in the absence of an automated alert
American Journal of Medical Quality 2015, Vol. 30(6) 604 © The Author(s) 2015 Reprints and permissions: sagepub.com/journalsPermissions.nav DOI: 10.1177/1062860615588554 ajmq.sagepub.com
system. Though median times were typically 30 minutes or less, our data suggest that there is wide variability in the time elapsed before completed laboratory results are reviewed by providers. The significantly shorter delays noted between 6 am-10 am and 2 pm-6 pm likely reflect typical working patterns: the former corresponding with morning rounds, the latter corresponding with afternoon chart review. The longest delays were observed overnight between 2 am and 6 am. The significantly longer median delays for patients admitted to cardiology versus non-cardiology services were unexpected. Although further investigation is necessary, we suspect that patients admitted to cardiology with acute coronary syndromes are more likely to receive prehospital anti-ischemic therapy, making close follow-up of troponins less urgent. Although the generalizability of our single-center retrospective analysis remains uncertain, little if any comparison data exist. Previous studies have predominantly been surveys relying solely on physician recollection.2,3 In summary, delayed awareness of CSTRs varies considerably by time of day, and possibly primary service, to an extent that could influence patient care. An automated notification service could potentially be effective in decreasing this delay. Ruth Bates, MD Andrew Rosenbaum, MD Christopher McCoy, MD Roger Yu, MD Mayo Clinic, Rochester, MN References 1. Schiff GD, Hasan O, Kim S, et al. Diagnostic error in medicine: analysis of 583 physician-reported errors. Arch Intern Med. 2009;169:1881-1887. 2. Poon EG, Gandhi TK, Sequist TD, Murff HJ, Karson AS, Bates DW. “I wish I had seen this test result earlier!” Dissatisfaction with test result management systems in primary care. Arch Intern Med. 2004;164:2223-2228. 3. Wahls TL, Cram PM. The frequency of missed test results and associated treatment delays in a highly computerized health system. BMC Fam Pract. 2007;8:32.
Downloaded from ajm.sagepub.com at DEAKIN UNIV LIBRARY on November 14, 2015
