Transcript Daily bmp ordering business of medicine cost conscious care project

DAILY BMP ORDERING
BUSINESS OF MEDICINE
COST CONSCIOUS CARE PROJECT
ALLEN CHANG, PGY2
5/18/15
Objectives
 Identify appropriate usage of BMP
 Evaluate UCI Medicine Ward teams on usage
of daily BMP and determining how often
residents over-order BMP.
 Educate residents on the harmful effects of
obtaining too many laboratory tests
 Encourage UCI residents to obtain BMPs
when indicated to prevent extraneous costs
Indications for BMP
 Initial monitoring of electrolytes and renal
function.
 Trending electrolyte abnormalities
 Medications that may alter electrolytes or
cause renal dysfunction
Background
 BMPs are routinely ordered at UCI – is it
always necessary?
 BMPs are rather costly to patients as each
test is 22 dollars and can lead to physical pain,
iatrogenic anemia, or infection with each
blood draw
Study Design
 10 patients admitted to UCI Internal Medicine
ward service from 4/28/15 to 5/18/15 were
selected in a cross-sectional study
 Number of BMPs ordered per patient and
reason for ordering the BMP was evaluated.
Results
 In the 10 patients reviewed, there were 90
total hospital days. Total number of BMPs
ordered was 110.
 Daily BMPs were ordered on ALL patients
 Total BMP to patient ratio was 1.22.
Results
Pt
Dx
HD
# of
BMPs
AKI (HD
wnl)
Electrolytes
Abnormal
Vanco
Other
Nephrotoxins
Why Extra BMPs?
Through Chart Review
1
Sepsis 2/2
UTI , UGIB
7
7
Yes (3)
Yes (2)
No
No
Daily monitoring
2
Neck
Abscess
9
10
No
No
Yes
Yes
Monitor Cr while on
Vancomycin
3
R fibular
fracture
7
7
Yes (2)
Yes (2)
No
No
Daily monitoring
4
PNA
7
7
No
No
Yes
Yes
Monitor Cr while on
Vancomycin
5
R femur
fracture
10
11
No
Yes (3)
No
No
One episode of
Hyperkalemia on HD2
and daily monitoring
Results
Pt
Dx
HD
# of
BMPs
AKI (HD
wnl)
Electrolytes
Abnormal
Vanco
Other
Nephrotoxins
Why Extra BMPs?
Through Chart Review
6
PBC
7
11
No
No
No
Yes (ACE
inhibitors)
CMP monitoring
7
Ascending
Cholangitis
11
17
No
No
No
No
CMP monitoring
8
Empyema
21
25
Yes
Yes
Yes
Yes
Vancomycin
9
COPD
4
4
No
Yes (3)
No
No
Daily monitoring
10
PNA
7
11
Yes (5)
Yes (4)
No
No
Elevated Glucose while
in house lead to extra
BMPs ordered on HD2-3
Discussion
 Basic Metabolic Panel $22
 Liver Function Test $21
 Comprehensive Metabolic Panel $27
 22 Extraneous BMPs ordered, leading to $484
spent in 90 hospital days, NOT including
physician interpretation fee.
Discussion
 Observations:
 Patients with any type of laboratory abnormality
appear to have daily electrolyte monitoring, even
after abnormalities have resolved.
 Vancomycin leads to daily BMP monitoring.
 Monitoring LFTs with CMP appears to confound
the data as the BMP is normal while LFTs are
abnormal.
Discussion
 Daily BMP ordering continues to remain an area to improve
in cost effectiveness.
 2 patients had more BMPs ordered for acute electrolyte
abnormalities which were promptly treated.
 3 patients had daily BMPs for monitoring electrolytes as
they had abnormalities on admission which subsequently
improved and 2 patients had daily CMPs ordered when
electrolytes and renal function were normal, leading to 22
extra daily BMPs
 3 patients had daily BMPs ordered while on Vancomycin.
What are the guidelines for Creatinine monitoring for
Vancomycin usage?
Areas for Improvement
 Think about the hospital bill the patient may
have. Although the laboratory test for CMP is
$27, the cost for physician interpretation will
increase the patients bill to $1000.
 No indications for daily BMP if Vanco levels are
within range. Literature search revealed weak
guidelines that Cr should be monitored for the
first few days until Vanco trough is normal at
least 2x and then BMP may be ordered weekly or
if the trough is too high.