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"We realized early on that many of the tests being ordered for our acute myocardial infarction [AMI] patients were not being used," says Jay Cyr, MSN, RN, director of cardiovascular medical services at the University of Massachusetts Medical Center (UMMC) in Worcester, and the person instrumental in the redesign of his facility’s cardiovascular unit. "Test results might be scanned, but physicians weren’t using them in the decision-making process. Decisions were typically made ahead of time regardless of the information."

Five years ago, the staff of the cardiovascular medical services division began to look at what they were doing for AMI and other cardiac patients on each day of their hospitalization. Length of stay at that time was about 11 days, principally because "every lab under the sun was being ordered every day for these patients right up to the day they left," Cyr says. "We found out, for example, that patients who were in the intensive care unit for three days would be transferred out. Then on day four, we’d reorder all the same tests."

The staff plotted their findings on a care map and showed some trends to the house officers and nurses. Cyr continues, "We saw how many CBCs we drew on each consecutive day, and realized that we were drawing these CBCs on day 7 or 8, and the next day we were discharging. What was happening to that hemoglobin and hematocrit information?"

They were able to squeeze down their critical path from 11 days to nine, then to seven. "Today we’re in the 61¼2 range," says Cyr, "and we’re trying to squeeze that back still further. What we’re looking at now is the tail end of the stay to see how we can get patients out of the hospital and still give them the service they need by getting them into outpatient cardiac rehab. That will affect our costs significantly and won’t affect — in fact may improve — quality."

Not a matter of rocket science

The key to process redesign, Cyr says, is to question procedures. "People just have to use common sense and intuitive thinking," says Cyr. "This doesn’t involve rocket science."

The staff at UMMC’s cardiac unit is constantly reevaluating what they do to see where improvements can be made. Cyr talks with the house officers on a regular monthly basis as well as informally on a patient-by-patient basis about resources needed for the AMI patient. They also discuss all the cardiac-related DRGs— congestive heart failure, angina, angioplasty — to look for trends.

"We see if anything is slipping through the cracks or if perhaps we’re overutilizing new technologies simply because they’re new, not because they necessarily improve care. Our cardiac care unit chief, Richard Becker, MD," says Cyr, "has been very supportive of this change process. He closely examines the care of patients and makes sure we give them the best without wasting resources."

One team focused on a cardiac surgery DRG and developed a protocol for extubation of post-op coronary artery bypass patients.1 The issue was identified by examining data that indicated that a number of patients who extubated themselves didn’t require reintubation. Each time that happened, an occurrence report was generated. Critical success factors measured were patient self-report, number of unplanned extubations, rate of adherence to the weaning protocol, number of arterial blood gases per case, and number of hours of ventilation time. The latter generated the direct costs of respiratory therapy treating ventilated patients, the use of the ventilator, and the hours of patient care required of nursing.

Patient interviews identified the time that they were awake and intubated as the worst part of the ICU experience. That data led to an examination of the clinical process followed for post-op weaning in the ICU. The goal was to extubate the patients as soon as they were clinically ready. The objectives were to increase patient satisfaction, reduce variance in the process of extubating, reduce unnecessary tests, and reduce clinical resource use.


1. Boland P, ed. Redesigning Healthcare Delivery: A Practical Guide to Re-engineering, Restructuring, and Renewal. Berkeley, CA: Boland Healthcare; 1996.