Monday, October 12, 2009

Is the Answer Right There in Front of You?

A couple of weeks ago, I was looking at our workload data and noticed that 47% of our stat testing was coming from our attached nursing home. This seemed like an oxymoron to me. How could nearly half of our requests for stat testing be coming from a long term care unit that should not have patients with acute illness issues?

I shared the information with the staff at our next morning's huddle. They were also surprised by the high percentage, but nothing further was said about the issue at that time. Later that day, however, our Point of Care supervisor, in charge of our glucometers mentioned to me that the stat orders were for the confirmation of high glucose results. Our glucometer policy stated that any glucose fingerstick result greater than 400 mg/dl required a laboratory confirmation. Indeed, the majority of the stats were for confirmations! I should have noticed this, but did not. I was not close enough to the front line for it to click!

The supervisor also reminded me that the manufacturer's recommendations for the new glucometers did not require a laboratory confirmation until the result was greater than or equal to 500 mg/dl. I had completely forgotten that! When we installed the upgraded glucometers, we had made a quick decision not to change our policy because it would require a change to the policy for the nurses and any laboratory-nursing policy change takes a long time and a great deal of effort to implement. This definitely was worth a second look. It would decrease the number of stats that they laboratory would need to respond to, decrease the nurses needing to order a glucose lab confirmation, decrease reagent use, and decrease the time for the nurse to respond to the high glucose. It would improve the quality of patient care and decrease cost at the same time.

We did a correlation study to make sure that the fingerstick glucoses between 400-499 mg/dl correlated well with the lab confirmations. They did and it proved to us that we could change the confirmation of fingerstick glucoses to greater than 499 mg/dl. The solution to the high number of nursing home stats was there all the time, but I could not see it. Yes, the answer was right there in front of me, but it took a staff member closer to the issue to point it out. A perfect example of how Lean initiatives can decrease waste, while improving quality, and it took a front line worker to see it!

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