Interventions to Improve Follow-Up of Laboratory Test Results Pending at Discharge: A Systematic Review
Failure to follow up test results pending at discharge (TPAD) from hospitals or emergency departments is a major patient safety concern. The purpose of this review is to systematically evaluate the effectiveness of interventions to improve follow-up of laboratory TPAD. We conducted literature searches in PubMed, CINAHL, Cochrane, and EMBASE using search terms for relevant health care settings, transition of patient care, laboratory tests, communication, and pending or missed tests. We solicited unpublished studies from the clinical laboratory community and excluded articles that did not address transitions between settings, did not include an intervention, or were not related to laboratory TPAD. We also excluded letters, editorials, commentaries, abstracts, case reports, and case series. Of the 9,592 abstracts retrieved, 8 met the inclusion criteria and reported the successful communication of TPAD. A team member abstracted predetermined data elements from each study, and a senior scientist reviewed the abstraction. Two experienced reviewers independently appraised the quality of each study using published LMBP™ A-6 scoring criteria. We assessed the body of evidence using the A-6 methodology, and the evidence suggested that electronic tools or one-on-one education increased documentation of pending tests in discharge summaries. We also found that automated notifications improved awareness of TPAD. The interventions were supported by suggestive evidence; this type of evidence is below the level of evidence required for LMBP™ recommendations. We encourage additional research into the impact of these interventions on key processes and health outcomes.
© 2018 Society of Hospital Medicine
The 2015 National Academy of Sciences (NAS; formerly the Institute of Medicine [IOM]) report, Improving Diagnosis in Health Care, attributes up to 10% of patient deaths and 17% of hospital adverse events to diagnostic errors,1 one cause of which is absent or delayed follow-up of laboratory test results.2 Poor communication or follow-up of laboratory tests with abnormal results has been cited repeatedly as a threat to patient safety.1,3,4 In a survey of internists, 83% reported at least one unacceptably delayed laboratory test result during the previous 2 months.5
Care transitions magnify the risk of missed test results.6,7 Up to 16% of all emergency department (ED) and 23% of all hospitalized patients will have pending laboratory test results at release or discharge.6 The percentage of tests that received follow-up ranged from 1% to 75% for tests done in the ED and from 20% to 69% for tests ordered on inpatients. In one study, 41% of all surveyed medical inpatients had at least one test result pending at discharge (TPAD). When further studied, over 40% of the results were abnormal and 9% required action, but the responsible physicians were unaware of 62% of the test results.8 Many examples of morbidity from such failure have been reported. One of many described by El-Kareh et al., for example, is that of an 81-year-old man on total parenteral nutrition who was treated for suspected line infection and discharged without antibiotics, but whose blood cultures grew Klebsiella pneumoniae after his discharge.9 Another example, presented on the Agency for Healthcare Research and Quality (AHRQ) Patient Safety Network, reported a patient admitted for a urinary tract infection and then discharged from the hospital on trimethoprim–sulfamethoxazole. He returned to the hospital 11 days later with severe sepsis. Upon review, the urine culture results from his previous admission, which were returned 2 days after his discharge, indicated that the infectious agent was not sensitive to trimethoprim–sulfamethoxazole. The results had not been reviewed by hospital clinicians or forwarded to the patient’s physician, so the patient continued on the ineffective treatment. His second hospital admission lasted 7 days, but he made a complete recovery with the correct antibiotic.10
Several barriers impede the follow-up of TPAD. First, who should receive test results or who is responsible for addressing them may be unclear. Second, even if responsibility is clear, communication between the provider who ordered the test and the provider responsible for follow-up may be suboptimal.11 Finally, providers who need to follow up on abnormal results may not appreciate the urgency or significance of pending results.
The hospitalist model of care increases efficiency during hospitalization but further complicates care coordination.12 The hospitalist who orders a test may not be on duty at discharge or when test results are finalized. Primary care providers may have little contact with their patients during their admission.12 Effective communication between providers is key to ensuring appropriate follow-up care, but primary care physicians and hospital physicians communicate directly in 20% or fewer admissions.13 The hospital discharge summary is the primary method of communication with the next provider, but 65%–84% of all discharge summaries lack information on TPAD.13,14
In this work, we sought to identify and evaluate interventions aimed at improving documentation, communication, and follow-up of TPAD. This review was conducted through the Laboratory Medicine Best Practices (LMBP™) initiative, which is sponsored by the Centers for Disease Control and Prevention’s (CDC’s) Division of Laboratory Systems (https://wwwn.cdc.gov/labbestpractices/). The LMBP™ was initiated as the CDC’s response to the IOM report To Err is Human: Building a Safer Health System.15
METHODS
We applied the first four phases of the LMBP™-developed A-6 Cycle methodology to evaluate quality improvement practices as described below.16 Our report follows the Meta-analysis Of Observational Studies in Epidemiology (MOOSE) guidelines.17
