Emerging principles for health system value improvement programmes

Expected Impacts of COVID-19: Considering Resource-Limited Countries and Vulnerable Population

Coronavirus disease in 2019 emerged in Wuhan, Hubei Province, China, in December 2019. After a month, it was declared a global threat to public health. The effects of the pandemic could be socio-economic, undermining the health system and risking livelihoods. Vulnerability to this infection has been associated with underlying comorbidities such as hypertension, diabetes, coronary heart disease, chronic respiratory diseases, cancer, and compromised immune systems. Co-morbidity has been common to the elderly, the disabled, and the homeless. In addition, more severe coronavirus disease outcomes have been reported in older males than females. Nonetheless, multiple variables are related to the concept of cultural gender that should be taken into account as women in more affected sectors are economically disadvantageous and over-represented. Similarly, although children are not the face of this pandemic, calamity has a profound effect on their welfare, especially for those living in poor and inconvenient situations. Moreover, the economic influence could be profound and universal when viewed through a migration lens as it is exacerbating xenophobic and discriminatory treatment. Protection measures to mitigate the outbreak of a pandemic, such as social distancing, may reduce social support for certain categories relied on for their day-to-day activities. The mental health of people would definitely be affected by the additional psychosocial burden of the pandemic, particularly in vulnerable groups. Integrated approaches are therefore mandatory to assist these groups and contain the pandemic.

Reducing Point-of-care Blood Gas Testing in the Intensive Care Unit through Diagnostic Stewardship: A Value Improvement Project

Introduction

Overutilization of point-of-care (POC) testing may reduce the overall value of care due to high-cost cartridges, need for staff training, and quality assurance requirements.

Methods

The Diagnostic Stewardship group at Cincinnati Children's Hospital Medical Center assembled a multidisciplinary team to reduce the use of POC blood gas testing by 20% in the pediatric intensive care unit (PICU). Key drivers of test overutilization included poor knowledge of cost, concern with testing turnaround time, and a lack of a standard definition of when a POC test was appropriate. We calculated weekly the outcome measure of POC blood gas tests per PICU patient-day and a balancing measure of blood gas result turnaround time using data extracted from the electronic medical record. Interventions focused on staff education, the establishment of a standard practice guideline for the use of POC testing, and improving turnaround time for laboratory blood gas testing.

Results

Over the baseline period starting July 2016, a median of 0.94 POC blood gas tests per PICU patient-day was ordered. After initial staff training, the rate was reduced to 0.60 tests per PICU patient-day and further reduced to 0.41 tests per PICU patient-day after a formal policy change was adopted. We have sustained this rate for 15 months through June 2018. Institutional direct cost savings were estimated to be $19,000 per year.

Conclusions

Our improvement initiative was associated with a significant and rapid reduction in the use of POC testing in the PICU. Interventions focused on cost awareness, and a formal guideline helped establish a consensus around appropriate utilization.