Implementation of a Second Sign Process to Reduce Plasma Metagenomic Next Generation Sequencing
Caitlin Naureckas Li, Neil Jordan, Shannon Haymond, Ravi JhaveriAbstract
Background
Plasma metagenomic next-generation sequencing (mNGS) can be a powerful tool for diagnosis of infectious diseases, but best practices for use have not been defined. Many retrospective studies have shown that plasma mNGS tests rarely change management. At our institution, we had high rates of plasma mNGS use, which added significant costs to patient care.
Methods
At our quaternary pediatric center, we implemented a second sign process in which the infectious diseases (ID) service must co-sign all plasma mNGS orders before the test can be sent. Our outcome measure of interest was number of plasma mNGS tests sent monthly. Our balancing measures were the number of bronchoalveolar lavage (BAL) galactomannan tests sent (as a surrogate of number of BALs performed to evaluate for infection) and number of plasma mNGS tests rejected by ID that resulted in any level of patient harm. We followed our outcome measure and number of BAL galactomannans on C statistical process control charts.
Results
Following implementation of a second sign process, the average number of plasma mNGS tests sent per month decreased from 7.8 to 4.6 and this change has been sustained for over two years. Plasma mNGS testing was declined by ID five times after the implementation of the second sign process; there was no patient harm because of these declined tests. There was no change in the number of BAL galactomannan tests sent after the intervention. This decrease in test utilization resulted in an average reduction in costs to the hospital of $76,800 per year.
Conclusions
A second sign process in which the infectious diseases service must review a patient’s case and provide approval before plasma mNGS is sent can reduce the use of this test with no noted adverse events and provides an opportunity to reduce hospital resource use.