Reducing Inappropriate Testing Following NCCN and IDSA Guidelines in Autologous Stem Cell Transplant (SCT) Patients

Background:  Health care institutions are identifying strategies to reduce unnecessary testing, employ better utilization of resources, and decrease patient risk. Both NCCN and IDSA guidelines recommend reserving CXR for febrile neutropenic (F+N) patients with respiratory symptoms. A retrospective review from 2010 showed that 11 of 237 (4.6%) Non Hodgkins Lymphoma and Multiple Myeloma SCT patients had respiratory signs or symptoms when they presented with F+N. Despite national guidelines, 97 of 237 (41%) patients without symptoms also had a CXR when they presented with F+N. None of the CXR in asymptomatic patients showed an active pulmonary process. Based on these results and in accordance with nationally recognized guidelines, we aimed to reduce CXR in asymptomatic autologous F+N patients to less than 10%. Methods:  A series of education sessions with clinical staff including MDs, PAs, nocturnists and moonlighters were implemented. Both oral and written materials were prepared for pass-off between the PAs and nocturnists. Study Population: We evaluated all patients admitted to the Dana-Farber Cancer Institute Bone Marrow Transplant PA service (BMT-PA) for autologous SCT between June 1, 2012 and Aug 31st 2012.  Results:   During the first three month study period, 69 patients were admitted to the BMT-PA service. Of the admissions, 11 (23%) had a CXR without indication. Seven CXR were ordered by PAs and 4 were ordered by nocturnist. Conclusions:  While we did not reach our target of 10% in the first Plan-Do-Study-Act (PDSA) Cycle, we were able to reduce the number of unnecessary CXR in asymptomatic F+N SCT patients by close to 50%. This reduction includes a cost savings of approximately $23,000, as well as a reduction in radiation exposure, overall resource utilization, time off protected air flow units and patient inconvenience. Our second PDSA cycle will include a clinician perception analysis to identify why clinicians may feel it is necessary to order a CXR in asymptomatic SCT patients with F+N, despite the nationally recognized guidelines. We will provide ongoing education sessions and continue toward our aim of less than 10%.