Implementation of a Clinical Decision Laboratory Ordering Algorithm for Preeclampsia: A Quality Improvement Initiative

OBJECTIVE:Pregnant women with suspected or diagnosed preeclampsia receive laboratory investigations. Our institutional protocols were outdated and not evidence based. However, guidelines lack clear direction to support cost-effective use. We aimed to reduce unnecessary laboratory tests, while supporting physicians with investigation selection. METHODS:A quality improvement (QI) approach was used to analyze the ordering process in the obstetrics wards of a tertiary care centre. Health care providers were surveyed on their laboratory ordering practices, and their responses corroborated with chart reviews. An algorithm for ordering preeclampsia investigations was developed by a multidisciplinary team, implemented, and posted on the wards. Pocket aides were also distributed, and the algorithm tool was supported by educational seminars. Laboratory usage volume and costs were analyzed pre- and post-intervention. Post-intervention impact surveys, informal interviews, and chart reviews were performed in plan-do-study-act (PDSA) cycles. RESULTS:Most health care providers ordered broad panels of investigations and re-evaluated patients at inconsistent intervals. Almost none were aware of the laboratory costs associated with this testing. Most respondents acknowledged that some of the investigations they ordered did not affect patient care. Baseline data (Sept 2016-Aug 2017) showed 2923 tests ordered monthly (CAD$18 306). Post-intervention data (Sept 2017-Aug 2019) revealed a 39.9% reduction in costs related to blood tests (a savings of CAD$7304/mo), particularly those tests of lower clinical utility. The performance of essential investigations, such as measurement of creatinine levels, were similar pre- and post-intervention, and thus acted a control measure. The effects of this intervention were sustained. CONCLUSIONS:This simple and inexpensive intervention reduced unnecessary ordering of preeclampsia investigations. This resulted in annualized savings of CAD$87 643 and reduced iatrogenic blood loss, with no evidence of harm. Efforts to scale and spread this clinical tool will further improve health care delivery for pregnant patients.