Abstract
Context
Medical professionals commonly fail to follow best practice guidelines. Drift, or a return to previous tendencies, is abundant in healthcare even when guidelines are followed initially. This “drift” was found internally at Temple University Hospital with preoperative electrocardiograms (ECGs). Best-practice guidelines were instituted and followed as a first step, but sustaining performance improvement was the ultimate goal.
Objectives
The objectives are to improve and maintain adherence to published guidelines for preoperative ECG testing at Temple University Hospital in a physician-led, nurse practitioner (NP)–staffed preadmission testing (PAT) clinic.
Methods
To start this quality improvement (QI) project, a retrospective chart review was completed to determine the number of ECGs performed in PAT at Temple University Hospital in 2017. New guidelines for ordering preoperative ECGs were then implemented, and Plan-Do-Study-Act (PDSA) cycles were performed over 3 years. A repeat retrospective chart review was completed and looked at ECGs ordered from 2018 through 2020. The number of ECGs completed in PAT before and after implementation of the new guidelines was then compared. In addition, the complexity of our surgical patients was estimated by looking at the yearly average American Society of Anesthesiology Physical Health Status (American Society of Anesthesiology [ASA] status) values assigned. Finally, the cost of performing each ECG was calculated, and the cost savings to the hospital over 4 years was determined.
Results
The baseline ECG rate for PAT in 2017, 2018, 2019, and 2020 at Temple University Hospital was 54.0 , 20.7, 22.3, and 21.9 %, respectively, which was a statistically significant decrease in ECG performance rate in the years after implementation of the PDSA project. The ASA status average remained constant, demonstrating that while patients’ medical diagnoses remained on average the same, reinforced training had been effective in preventing a return to previous liberal ordering tendencies. Over the course of 4 years, the reduction in unnecessary ECGs led to an estimated direct cost savings of $213,000.
Conclusions
Self-adoption of best-practice guidelines among clinicians is often poor; however, the barriers to adoption can be overcome with education and individual feedback. Sustaining performance improvement gains is challenging, but possible, as shown by example in one urban, academic teaching hospital’s physician-led, NP–staffed outpatient clinic.
Routine preoperative tests are defined by the American Society of Anesthesiologists as those done in the absence of any specific clinical indication or purpose and typically include a panel of blood tests, urine tests, chest radiography, and an electrocardiogram (ECG) [1]. Although these routine tests can be helpful to mitigate risk, guide anesthetic choices, and direct management postoperatively, they are often obtained because of protocol rather than medical necessity [1]. The decision to order preoperative tests should be guided by the patient’s clinical history, comorbidities, and physical examination findings [1]. For example, the 2014 ACC/AHA Guideline on Perioperative Cardiovascular Evaluation for Noncardiac Surgery clearly states that patients manifesting active cardiovascular disease should be evaluated with ECGs, regardless of their preoperative status [2]. This guideline also states that patients undergoing low risk surgery who are asymptomatic from a cardiovascular perspective do not require ECGs. The guideline does not provide a detailed definition of low risk surgery, but offers cataract or plastic surgery as two examples [2]. Ultimately the definition of low risk surgery is determined by each institution. These guidelines are founded in evidence-based medicine but cultural change among medical professionals has been shown to be problematic even when scientific evidence is strong.
Previous literature shows that despite multiple specialty society recommendations and evidence, healthcare professionals are slow to adopt changes regarding previous preoperative medical testing practices [3]. Utilizing an observational cohort of an estimated 3,446,418 Medicare beneficiaries undergoing cataract surgery from 2003 to 2004, Schein et al. [3] concluded that preoperative testing before cataract surgery occurred frequently and was more strongly associated with provider practice patterns than with patient characteristics. Unnecessary diagnostic testing was also observed in the context of nonspecific low back pain. Müskens et al. [4] identified 118 papers in a systematic review that looked at the prevalence of diagnostic testing overuse for low back pain. Their review suggests that preoperative testing and imaging for nonspecific low back pain are the most frequently identified low-value diagnostic tests [4].
Routine testing can also be associated with delays in surgery and decreased safety for the individual patient. Schein et al. [3] concluded that routine medical testing before cataract surgery does not measurably increase the safety of the surgery. In fact, Chen et al. [1] reviewed 248,345 Medicare claims from 2006 to 2014 for cataract surgery. The authors found that patients scheduled for cataract surgery who were under the care of a high-testing physician, experienced a surgical delay of 8 days on average and also had a greater risk (by odds ratio) of falling. Routine testing in the context of vascular surgery has also been studied. Preoperative stress testing is only recommended for unstable angina or active arrhythmia according to the AHA/ACC guidelines [2]. de Virgilio et al. [5] looked at 80 patients scheduled to undergo major vascular surgery, all of whom had a dipyridamole-thallium and sestamibi stress tests before surgery. The authors found that reversible ischemia uncovered by the stress test had 25 % predictive value for adverse events during surgery. In addition, for those patients with a low Lee Cardiac Risk Index, this testing delayed surgery by up to 3 weeks.
Delays in surgery and poor patient outcomes in orthopedic management have also been researched. According to the McGuire et al. [6], from a review of 18,209 Medicare recipients for patients over age 65 presenting for surgical treatment for a closed hip fracture, a delay of surgery for 2 days or more resulted in the patient having a 17 % greater chance of dying by day 30. Ricci et al. [7] showed that in a cohort of 235 patients over age 60 treated for a hip fracture at a level one trauma center, cardiac evaluation did not change the orthopedic management in any case. In fact, patients who had cardiac testing had a significantly greater average delay to surgery (3.3 days) than those who did not (1.9 days) [7]. Unnecessary testing often delays surgery, which can affect patient safety by increasing the risk of morbidity and mortality.
The failure of physicians to adhere to strong recommendations from several professional societies prompted an internal look at the Temple University Hospital department of preadmission testing (practitioner-staffed preadmission testing [PAT]) to determine how the department adhered to published guidelines for preoperative testing. The result of this internal look showed nonadherence to preoperative testing guidelines from the American Society of Anesthesiology (ASA) as well as the AHA/ACC [8]. Subsequently, a performance improvement program was implemented in the department utilizing the Plan-Do-Study-Act (PDSA) model. The purpose of the program was to assess and reduce unnecessary testing within the department, specifically to reduce the performance of unnecessary ECGs. In 2017, a sampling of charts revealed that the nurse practitioners (NPs) in the PAT department were not following any specific, standardized guidelines for our patients’ perioperative testing. In particular, performance of an ECG seemed to be based on the decision of each individual NP. We therefore created and initiated an action plan with the goal to incorporate standardized guidelines for the performance of an ECG as part of preoperative testing. This action plan included educating the NPs and developing in-house written guidelines with examples of procedures not requiring an ECG. We studied and compared pre- and postguideline implementation numbers for our patients. We found that our preguideline ECG rate in PAT was 54.0 % in 2017. This decreased to 20.7 % in the 6 months following education and written guideline implementation [9]. The next step in successful implementation of the action plan was to follow adherence to the plan over time. Would there be a drift to previous practice?
Methods
Submission was made to the Temple University Institutional Review Board, and approval was deemed unnecessary for this project because the study was deemed not to be human subjects research by Temple University’s definition.
Study design
The purpose of this study was to implement the recommended published guidelines for the performance of preoperative ECGs, with the goal of reducing the performance of unnecessary ECGs. The plan for such an implementation is summarized in Table 1. The study is designed following a PDSA cycle. First, the number of ECGs being performed in PAT was quantified. Then, a plan was created to educate NPs about the published guidelines for ordering preoperative ECGs. This plan included: (1) creation of a written in-house guideline including examples of low-risk surgeries not requiring ECGs, as well as patient comorbidities requiring ECGs; (2) education about the new guidelines during a departmental meeting; and (3) individual audits of ECGs performed and feedback for each NP bimonthly. At 6-month intervals, a report of the number of ECGs performed in the PAT was created. Decreased numbers of ECGs performed were celebrated as a department with lunch and cake at the time of each report.
Plan-Do-Study-Act (PDSA) outline for decreasing ordering of unnecessary ECGs in preadmission testing.
| Plan: To decrease performance of unnecessary preoperative ECGs through education |
|
| Do: Enact plan as outlined above |
| Study: Analyze data, assessing preoperative ECG ordering every 6 months (repeat steps 5 and 6) |
| Act: Determine success in reduction of preoperative ECG ordering by number and cost analysis |
The health of the surgical patients as a population influences the need for an ECG. If the surgical patients on average become less healthy, then this could cause an increase in necessary preoperative ECGs. Therefore, to follow the general health of our surgical patient population, we also determined the average yearly ASA Health Status assignments of our patients. This health status classification is provided in the Supplementary Material. Briefly, the classification number increases based on the severity of the individual patient's pre-anesthesia medical comorbidities.
Study setting
This study was completed at a single academic medical center in the PAT department. The department is staffed by one consulting anesthesiologist and four NPs on a daily basis, as well as other clinical support staff. The population studied was all surgical patients who come to PAT for evaluation, surgical history, and physical. This population represents approximately 70 % of the medical center’s surgical patients who come into the hospital from home for surgery (including same-day surgery patients and same-day admission after surgery patients).
Quality improvement (QI) intervention
As discussed in the study design, the quality improvement (QI) intervention was essentially educational. NPs in PAT were provided education on the recommended guidelines for performance of a preoperative ECG. The AHA/ACC guideline for the preoperative evaluation of the noncardiac surgical patient is vague in terms of defining low-risk surgery, so a written in-house guideline was created listing low-risk surgeries. This document continues to be updated to correspond to surgeries performed at the medical center, which change due to new procedures or flux in the surgical faculty. This in-house document also contained patient comorbidities that indicate the need for a preoperative ECG. The most current version of our in-house document is shown in Table 2. Finally, each NP was audited and provided feedback on their adherence to the guideline once every 2 months.
Measurements
Six months after the initiation of the action plan, the number of ECGs performed in PAT was determined by running a report in the electronic medical record, EPIC. Subsequently, this same report was run for the years 2018, 2019 and 2020. The exact numbers of patient visits to PAT as well as the number of ECGs performed per year is shown in Table 4, columns 3 and 5. Analysis was completed to determine that the reduction in ECGs from 2017 to 2018 was statistically significant and that the decrease in performed ECGs from 2018 to 2020 remained constant (see the Data Analysis subsection).
Preadmission testing department ECG guidelines for low-risk surgeries (top) and patients requiring an ECG (bottom).
| Low-risk surgeries | |||||
|---|---|---|---|---|---|
| Angiogram +/− intervention | Closed reduction of nasal fracture | Direct laryngoscopy with biopsy | Gamma knife | Interstimulator placement | Prostate biopsy |
| Blepharoplasty | Cold knife cone procedure | Drug-induced sleep endoscopy | Hand surgery – almost all; if in doubt, check with anesthesiologist | Knee arthroscopy | Superficial mass excision |
| Breast surgery (except radical mastectomy) | Cystoscopy | Vulvar resection | Hemorrhoid surgery | LEEP | Temporal artery biopsy |
| Bronchoscopy | D&C | ESWL | Hysteroscopy | Lymph node biopsy | Tenolysis |
| Carpal tunnel release | D&E | Examination under anesthesia | I & D of superficial wound | Manipulation under anesthesia | Trigger finger release |
| Cataract removal | De Quervain’s release | Eye surgery Drug-induced nearly all ophthalmic surgery, except orbital fracture repair | Inguinal hernia repair | Myringotomy tube placement | Upper and/or lower endoscopy |
| Patients requiring ECG |
|---|
|
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The 2014 ACC/AHA Guideline on Perioperative Cardiovascular Evaluation and Management of Patients Undergoing Non-cardiac Surgery was utilized as a reference for these recommendations. They found no benefit for an ECG in an asymptomatic patient having a low-risk procedure regardless of their medical history. Additionally, there was no indication based solely on the age of the patient. If the patient has an ECG within 3 months of the date if surgery, a new ECG is not needed unless there has been a change in functional status or symptomology. ACC, American College of Cardiology; AHA, American Heart Association; CAD, coronary artery disease; CHF, congestive heart failure; CVA, cerebrovascular accident; D&C, dilation and curettage; D&E, dilation and evacuation; DM, diabetes mellitus; ECG, electrocardiogram; Extracorporeal Shock Wave Lithotripsy (ESWL) I&D, incision and drainage; LEEP (Loop Electrosurgical Excision Procedure); PAD, peripheral arterial disease.
Finally, in order to determine if the reduction in ECGs performed resulted in a financial benefit to the hospital, the cost savings was calculated. The American Medical Association (AMA) Resource-Based Relative Value Scale (RBRVS) was utilized to estimate the cost per ECG to the hospital. This is the system utilized by the Centers for Medicare and Medicaid Services (CMS). According to this system, the accepted total physician work to read an ECG is 6 min. The national average total compensation for a cardiologist is $422,481 yearly, with a benefits rate of 21 %. Then the cost per 6 min read of an ECG would be $22.47. The current procedural terminology (CPT) code for a 12-lead ECG performance and interpretation is 39,000. In addition, 0.17 work relative value units (RVUs) are associated with this code. Utilizing the national average Medicare conversion factor of $33.8872, this provides $5.76 of professional revenue per ECG read. The cost of an ECG must also include the cost to the practice. The PAT department provides outpatient services inside the hospital, and these services are bundled under the surgical visit. As an estimate of the cost to the hospital, the cost to an outpatient practice is utilized. A total of 0.24 RVUs are associated with CPT code 39000. Converting these RVUs to dollars, the hospital incurs $8.13 in unreimbursed labor and equipment costs per ECG. The net cost of an ECG to the hospital is then $22.47 + $8.13 − $5.76, or $24.84 per ECG. This calculation is also shown in Table 3. This cost per ECG was then utilized to estimate the cost savings to the hospital when adherence to published guidelines is established and maintained, resulting in decreased performance of ECGs.
Calculation of the average cost to a hospital for performance of an ECG.
| CPT code per 12-lead ECG performance and read | 39,000 | |
|---|---|---|
| $ components of an ECG | ||
| Cost of cardiology read | 6 min of $422,481 | $22.47 |
| Professional revenue generated | 0.17 RVUs × #33.8872 | –$5.76 |
| Expense to the practice | 0.24 RVUs × $33.8872 | $8.13 |
| Cost per ECG | $24.84 |
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CPT, current procedural terminology; ECG, electrocardiogram; RVU, relative value unit.
Data Analysis
The number of ECGs performed per year in PAT as well as the average ASA health status classification are shown in Figures 1A and B in graphical and tabular form.
![Figure 1:
Decrease in ECG performance over four years. (A) Graph of electrocardiogram rate (ECG) during preadmission testing (practitioner–staffed preadmission testing [PAT]) and American Society of Anesthesiology (ASA) class over 4 years at Temple University Hospital Department of Anesthesia. (B) Table of the numbers of ECGs performed in preadmission testing per year and the corresponding average ASA health status value for each year’s surgical patients. This relationship between ECG values in 2017 and 2018 first shows that the intervention of educating Temple nurse practitioners (NPs) and developing a written guideline with examples of procedures not requiring an ECG was effective. A chi-square analysis shown in the fifth column demonstrates statistical significance. The consistency of ECG values between 2018 and 2020 shows that our training was effective in preventing drift, or a return to previous tendencies; the chi-square analysis also shows that the trend seen was significant and that the decrease was stable over the time period. The average ASA status is a measure of the complexity of our patients’ diagnoses. The ASA status average remained constant, demonstrating that while our patients’ medical diagnoses remained on average the same, our reinforced training had been effective in preventing a return to previous tendencies.](/document/doi/10.1515/jom-2022-0196/asset/graphic/j_jom-2022-0196_fig_001.jpg)
Decrease in ECG performance over four years. (A) Graph of electrocardiogram rate (ECG) during preadmission testing (practitioner–staffed preadmission testing [PAT]) and American Society of Anesthesiology (ASA) class over 4 years at Temple University Hospital Department of Anesthesia. (B) Table of the numbers of ECGs performed in preadmission testing per year and the corresponding average ASA health status value for each year’s surgical patients. This relationship between ECG values in 2017 and 2018 first shows that the intervention of educating Temple nurse practitioners (NPs) and developing a written guideline with examples of procedures not requiring an ECG was effective. A chi-square analysis shown in the fifth column demonstrates statistical significance. The consistency of ECG values between 2018 and 2020 shows that our training was effective in preventing drift, or a return to previous tendencies; the chi-square analysis also shows that the trend seen was significant and that the decrease was stable over the time period. The average ASA status is a measure of the complexity of our patients’ diagnoses. The ASA status average remained constant, demonstrating that while our patients’ medical diagnoses remained on average the same, our reinforced training had been effective in preventing a return to previous tendencies.
Statistical analysis was performed utilizing the Cochran–Armitage Trend Test in SAS software to determine if the decrease in performed ECGs in years 2018, 2019, and 2020 compared to those performed in 2017 was statistically significant. In addition, the chi-square test was utilized to compare the percentage of ECGs performed between 2017 and 2018–2020. Finally the chi-square test was also utilized to compare the percentage of ECGs performed in 2018–2020 to determine that the number of ECGs performed over this time frame was stable and remained lower compared to that of 2017.
The financial benefit to the hospital of performing ECGs in PAT according to published guidelines was also calculated, and the results are shown in Table 4. Briefly, the decrease in the absolute number of ECGs performed in PAT was determined by calculating the difference between the estimate of ECGs performed if the QI improvement plan had not been implemented and the number of ECGs performed after implementation of the action plan for each year. The total decrease in the number of ECGs performed was then multiplied by the cost to the hospital per ECG, yielding the total estimated savings to the hospital for implementing this QI action plan.
Calculation of cost savings per year and in total due to reduction in performance of unnecessary ECGs in preadmission testing.
| Rowb | Year | Visits per year | 54.0 % of total visitsa | ECGs performed | ECGs not performed due to QI | Cost estimate per ECG | Cost savings |
|---|---|---|---|---|---|---|---|
| 1 | 2017 | 10,975 | 5,929 | (5,929) | |||
| 2 | 2018 | 10,560 | 5,702 | 2,186 | 3,516 | $24.84b | $87,337.44 |
| 3 | 2019 | 8,918 | 4,816 | 1,989 | 2,827 | $24.84 | $70,222.68 |
| 4 | 2020 | 6,953 | 3,755 | 1,523 | 2,232 | $24.84 | $55,442.88 |
| Totals, rows 2–4 | 14,273 | 5,698 | 8,575 | $213,003.00 |
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a54 % of ECGs performed in assumed to be the number of ECGs performed in PAT if the Quality Improvement (QI) initiative had not been instituted. bCost savings per ECG calculated utilizing the American Medical Association (AMA) Resource-Based Relative Value System, based on CPT code 39000 for 12-lead ECG performance, interpretation, and report. Please see Methods section for detailed description of calculation. CPT, current procedural terminology; ECG, electrocardiogram; PAT, preadmission testing.
Results
Before implementation of the action plan, 5,929 preoperative ECGs were performed in PAT out of a total of 10,975 visits. This reflects an ECG performance rate of 54.0 % in 2017. ECG performance then decreased to 21.0 % in the 6 months following education. The ECG performance rates in 2018, 2019, and 2020 continued to remain low. In 2018, only 2,186 ECGs were performed out of 10,560 total patient visits to PAT, or a performance rate of 20.7 %. In 2019, 1989 ECGs were performed in PAT, which saw a total of 8,918 patient visits, or a rate of 22.3 %. Finally, in 2020, 1,523 ECGs were performed while PAT had a total of 6,953 visits and a rate of 21.9 %. Both the absolute number of ECGs performed as well as the rate of ECG performance over these 4 years are shown in Figure 1B. Over these 3 years, our average patient ASA status did not decrease, with calculations of 2.62 in 2017, 2.64 in 2018, 2.66 in 2019, and 2.68 in 2020. Both the absolute number of ECGs performed as well as the rate of ECG performance over these 4 years are shown in Figure 1B. The Cochran–Armitage Trend Test was utilized to test the trend of ECGs performed from 2017 to 2020. In addition, the chi-square test was utilized to compare the percentage of ECGs performed in 2017 against 2018–2020. The percentage of ECGs performed in 2017 is significantly higher than in 2018–2020 (54 vs. 21.6 % average, p<0.001). The percentages of ECGs performed in 2018, 2019, and 2020 increased slightly compared with the first 6 months after implementation of the project—20.7 , 22.3 and 21.9 % (p=0.018)—but remained statistically lower than the percentage performed in 2017. In addition, over these 4 years, the average patient ASA status did not decrease, with calculations of 2.62 in 2017, 2.64 in 2018, 2.66 in 2019, and 2.68 in 2020. The purpose of calculating the average ASA health status of our surgical patients per year is to provide a gross estimate of the health and complexity of this population. Our surgical population did not change by this criterion over the years measured, suggesting that the number of ECGs performed would have remained constant except for implementation of new guidelines created for the QI study as well as the reinforced training and periodic evaluation of providers. In short, the QI study actions resulted in maintenance of a reduced performance of ECGs over the period studied.
The cost per ECG to the hospital was calculated and described in detail in the Methods section. To determine the overall cost savings to the hospital over the 3 years studied, the number of ECGs not performed was calculated. Before institution of the PDSA initiative, the PAT department performed ECGs on 54.0 % of the patients seen in that department; 54.0 % of patient visits was determined for years 2018, 2019, and 2020 and is shown in Table 4, column 3. The number of ECGs actually performed during these years subtracted from 54.0 % of the patient visits provides the number of ECGs not performed, as shown in Table 4, column 6. The number of ECGs not performed multiplied by the hospital cost of $24.82 per ECG shows a cost savings of $213,003 over 3 years. This calculation is an estimate because the actual cost of performing an ECG is bundled into the cost to the hospital for patient visits related to the surgical process. The numbers for the calculation were derived from the RBRVS utilized by CMS and do not reflect any geographical variation in either salaries or other costs. The numbers are also derived assuming a patient population whose insurance is 100 % Medicare provided. Thus, the savings cited above may well be an underestimation of the savings to Temple University Hospital.
Discussion
The medical education of an osteopathic physician is structured around the tenet that the patient is treated with a perspective centered around mind, body, and spirit. This holistic approach of treating the entire person, rather than just the symptoms, naturally extends to all forms of treatment, including surgical treatment. In working toward decreasing the number of unnecessary ECGs performed before surgery, the patient, their morbidities, and the risk of the surgery are considered. Following this more holistic approach to our patients has allowed us to follow evidence-based medicine and also substantially decrease this one often unnecessary test (ECG).
Before the action plan was initiated, the NP in PAT ordered ECGs based on his or her own discretion as an advanced practice provider. The practice authority of NPs was also studied by the Veterans Health Association (VHA). In 2017, NPs were given full practice authority within the primary care team of the VHA [10]. Analysis of the difference in productivity between physicians and NPs in the Veterans Affairs (VA) system was then performed and reported in 2022. A working paper was published that showed that compared with physicians, NPs significantly increased resource utilization and cost, even considering the salary differential, and they also achieved worse patient outcomes [11]. Results reported here support those results found in the VHA system. To begin the project then, the number of ECGs performed was determined for the year 2017 and an action plan was initiated to utilize evidence-based guidelines to determine the need for ECG analysis, with the goal of eliminating unnecessary tests. The QI project was an initial success [9]. The QI project was then extended to look at sustainability of the action plan and results after a 4-year period. The consistency of ECG performance rates between 2018 and 2020 shows that the training and reinforcement efforts were effective in preventing drift (a return to previous tendencies). Intuitively, a less healthy population would require more preoperative testing and diagnostics, one of which was certainly an ECG. However, patients’ ASA health status values between 2017 and 2020 remained stable, which shows that the complexity of patients did not change, indicating that the decrease in ECGs performed was not due to a healthier patient population. Elimination of these ECG tests follows known evidence-based medicine and also resulted in an increase in financial efficiency by avoiding unnecessary ECGs in the PAT department.
In the JAMA journal, Guyatt et al. [12] argues that EBM requires new skills from the physician, and while physicians and other clinicians are quite familiar with EBM, its actual implementation can be hindered by the human tendency to resist change, even when the benefits are understood. In a 2014 research article, Ament et al. [13] states that sustainability occurs “when a newly implemented innovation continues to deliver the achieved benefits over a longer period of time and definitely does not return to the previous processes, even after the implementation project is no longer actively carried out.” In the study presented here, implementation of EBM required imposition of formal guidelines to be followed by clinicians regarding ECGs in PAT. Sustainability is important to process improvement, and to curb unnecessary procedures at Temple University Hospital, which can ensure financial efficiency. Moreover, no medical test is without risk, so sustainability is also important to improve patient safety.
This QI project demonstrates that adoption and maintenance of the use of EBM in clinical practice is possible, but the study has limitations. PAT departments are not uniformly structured. The PAT department at Temple University Hospital is staffed daily by a small number of NPs (4–5 daily) as well as a consulting anesthesiologist. The approach to decrease the ECGs described here may not be successful in larger departments or those staffed differently. In addition, an average ASA health status number was utilized as an estimated measure of the complexity of the perioperative patient population. While this health status classification system is widely utilized to denote the health of a surgical patient, an average value is a blunt instrument to indicate that our patient population hadn’t significantly changed over 4 years. Finally, due to the bundled payment model for our surgical patients, estimation of the cost savings of fewer ECGs is truly that. The AMA RBRVS was utilized to calculate cost savings per ECG without any geographical modifiers for payments and costs to the hospital.
The existing literature argues against routine testing for a patient preoperatively; delays in surgery, decreased safety, and cost wasting have been found. The financial inefficiency was evident firsthand at Temple University Hospital as approximately $213,000 was saved over the course of the QI project. While this cost savings is a very small portion of a hospital operating budget, reducing the performance of a single preoperative test indicates that more unnecessary tests can be eliminated by means of similar QI projects, therefore adding to the cost savings described. Although sustaining change among healthcare professionals is not easy, it is certainly possible, as demonstrated by the results of efforts reported here. This successful implementation of EBM guidelines could easily be expanded to other preoperative tests with the dual mutual interest of safety for our patients and efficiency for our healthcare system.
Conclusions
In order to bring our PAT department into compliance with published evidence-based guidelines for the preoperative performance of ECGs, a QI project was implemented utilizing the PDSA format. This QI project intervention was educational, but more importantly, the education was reinforced on a routine basis over a 4-year time frame. The project was successful in that the number of ECGs decreased significantly, and this decrease was maintained, thereby saving costs and some patient inconvenience, and possibly increasing patient safety. Many medical associations routinely publish evidence-based guidelines whose purpose is to improve patient outcomes. Most medical professionals are aware of these guidelines, but implementing changes to personal practice can be a challenge secondary to a perceived increase or change in work or work habits. The QI project presented here demonstrates that implementing change to clinical practice is relatively simple; in the presented case, education and then follow up with individual practitioners on their performance was provided over time. The widespread use of electronic medical records provides an easy avenue to follow individual practitioner performance, so that the implementation of this and similar QI projects can be a relatively low-effort endeavor. The authors hope that demonstration of this successful QI project will provide an example and encourage greater levels of implementation of evidence-based guidelines in medical practice. Additional QI projects to reduce the ordering of type and screen blood work are currently underway in PAT.
Acknowledgement
The authors would like to thank Dr. Gordon Morewood for his help providiing costs according to the BRVS used by CMS to allow our financial analysis of the benefit of reduced EKG performance.
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Research funding: None reported.
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Author contributions: All authors provided substantial contributions to conception and design, acquisition of data, or analysis and interpretation of data; all authors drafted the article or revised it critically for important intellectual content; all authors contributed to the analysis and interpretation of data; all authors final approval of the version of the article to be published; and all authors agree to be accountable for all aspects of the work in ensuring that questions related to the accuracy or integrity of any part of the work are appropriately investigated and resolved.
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Competing interests: None reported.
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Supplementary Material
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