Rounding Up Problems
One of our quality indicators is how quickly we turn around a request to recollect a contaminated urine specimen. In other words, a reflex urinalysis is ordered that should be cultured but has enough squamous epithelial cells to indicate contamination. If this information isn’t relayed quickly enough treatment can be started or delayed before another collection. To track this, a list of inpatient urines is maintained on the bench and checked periodically by auditing inpatient charts during morning rounds.
Unexpectedly, we discovered not all urines were ordered correctly. The physician ordered a “U/A” that reflexes to a microscopic only or a “U/A +” or “U/A reflex” that reflexes to a microscopic and culture if indicated, but in almost all cases the latter was ordered in our information system.
Daily team rounding helped solve the problem. Every so often we would have an inpatient order to review, and we would have a chance to speak directly to the nurse or clerical person who ordered the test.
Here’s our Duh moment:
Our information system has a short menu of “most common” lab tests to be ordered. This was originally designed for use by all departments, so it included commonly ordered tests for lab, ED, and the floor. A ward clerk entered an account number, clicked on Laboratory, and selected from the list. If an item was not on the list it was entered in the search box.
You guessed it: only the “U/A+” that reflexes to culture was on the list of most common tests. Worse, the description said “Urinalysis Reflex” for the sake of brevity. The clerks and nurses checking the charts didn’t see the difference when entering and checking orders, because they didn’t know there was a difference. On one of our rounds, a ward clerk pointed this out.
The solution: Add a routine reflex to microscopic to the list and add “U/A” and “U/A+” to the ends of each descriptor to match how docs order the test. Thanks to a simple daily routine, we rounded up this problem in no time.
NEXT: Junky Cultures