Reducing Inappropriate Use of Broad-Range Polymerase Chain Reaction Testing in Patients with Concern for Infectious Diseases
Caitlin Naureckas Li, Cecilia Thompson, Neil Jordan, Molly Schnieders, Kayla Moore, Ravi JhaveriAbstract
Background
Broad-range polymerase chain reaction (BRPCR) testing is a diagnostic strategy often used to support clinical decision making when traditional microbiological testing is negative. At our center, we found that this test was frequently sent early in patients’ workups in settings in which it was not expected to change clinical management, creating an unnecessary cost burden on the system.
Methods
This quality improvement work took place at our quaternary pediatric center. With input from key stakeholders, we completed a series of plan-do-study-act cycles designed to promote diagnostic stewardship of this test: 1) clarification of microbiology lab processes to ensure that samples would be available for add-on testing if BRPCR testing was not sent up front; 2) Review of electronic medical record panels and creation of a policy with our hospital informatics team that BRPCR cannot be added to any order panel without approval of the infectious diseases (ID) quality director or microbiology lab director; 3) education of ID clinicians, and 4) education of orthopedic surgery and pulmonology colleagues. Our outcome measure of interest was the number of BRPCR tests sent by our hospital during each two-week period. Our process measure was the number of BRPCR tests sent on the recommendation of the ID service, and our balancing measure was the number of patients who had to undergo a repeat procedure specifically to obtain a sample to send for BRPCR, to monitor for patient harm as a result of delaying BRPCR ordering that previously happened at the time of initial procedure. Data were monitored using C statistical process control (SPC) charts, and standard rules for special cause variation were applied to determine centerline shifts.
Results
We experienced a sustained centerline reduction from 17.7 to 4.5 BRPCR tests every two-week period. This shift coincided with the introduction of the project to the ID fellows and advanced practice providers, who propose most initial plans for patients for whom ID is consulted and who complete most of the communication between the ID service and primary teams. No patients in the post-intervention period had to undergo a repeat procedure for the purposes of obtaining a sample to send for BRPCR testing. This reduction is projected to result in a cost savings to the hospital of $141,000 per year.
Conclusions
Through a series of PDSA cycles we significantly reduced the use of BRPCR testing in our hospital without detected patient harm.