400. Reducing excessive laboratory investigations for preeclampsia: A quality improvement project

Objectives Pregnant women suspected of having preeclampsia receive laboratory workup for diagnosis and surveillance. However, many investigations are ordered from past protocols currently deemed inappropriate- with considerable healthcare cost and the potential for iatrogenic harm. This quality improvement (QI) project aimed to reduce unnecessary patient blood draws and healthcare costs. Methods QI tools were used to analyze the workup process on the labour and delivery, triage, and antepartum wards of a tertiary care centre. Healthcare providers were surveyed regarding laboratory ordering practices to identify problems, which was corroborated with 20 inpatient chart reviews. Laboratory usage and costs were analyzed pre- and post-intervention. An algorithm for ordering preeclampsia investigations was developed by a multidisciplinary team, implemented, posted on wards, and pocket aide distributed to residents. Practitioners were invited to educational seminars to support adoption, and posters raised awareness of the issue. Post-intervention surveys and chart reviews were conducted, and interventions refined. Results Survey data indicated most providers ordered broad panels of investigations, rarely re-evaluated frequency, and were unaware of laboratory costs. A majority of respondents acknowledged that some investigations did not affect patient management and based these decisions on institutional convention. Baseline data showed 10,462 investigations were ordered ($69,350) (Jan-Apr, 2017). Post-intervention data (Sept 2017-April 2018) revealed a 39% reduction in investigation cost ($6851/month), particularly those of low clinical utility including D-dimer (69%) and urea (71%). Weekly data show the post-intervention reduction in excessive laboratory investigations were sustained and stable. Discussion This simple and inexpensive intervention reduced overall laboratory investigations for preeclampsia, particularly those of low clinical utility. This resulted in annualized savings of $89060 (39%). However, institutional ordering conventions are a significant barrier to change and some providers are resistant. Ongoing efforts to quantify balancing measures will safeguard against delayed diagnosis or treatment of preeclampsia.