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Audit and feedback to improve laboratory test and transfusion ordering in critical care: a systematic review

School of Epidemiology and Public Health, University of Ottawa, 451 Smyth Road, Ottawa, ON, K1H 8M5, Canada. Ottawa Hospital Research Institute, Clinical Epidemiology Program, The Ottawa Hospital, General Campus, 501 Smyth Road, Centre for Practice Changing Research, Box 201B, Ottawa, ON, K1H 8L6, Canada. School of Psychology, University of Ottawa, 136 Jean-Jacques Lussier, Vanier Hall, Ottawa, ON, K1N 6N5, Canada. Department of Critical Care Medicine, The Ottawa Hospital, General Campus, 501 Smyth Road, Ottawa, ON, K1H 8L6, Canada. Ottawa Hospital Research Institute, Knowledge Synthesis Unit, The Ottawa Hospital, General Campus, 501 Smyth Road, Centre for Practice Changing Research, Box 201B, Ottawa, ON, K1H 8L6, Canada. School of Epidemiology and Public Health, University of Ottawa, 451 Smyth Road, Ottawa, ON, K1H 8M5, Canada: jbrehaut@ohri.ca Ottawa Hospital Research Institute, Clinical Epidemiology Program, The Ottawa Hospital, General Campus, 501 Smyth Road, Centre for Practice Changing Research, Box 201B, Ottawa, ON, K1H 8L6, Canada: jbrehaut@ohri.ca

Implement Sci. 2020;15(1):46
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PICO Summary

Population

Healthcare professionals ordering laboratory tests or blood transfusion components for patients in an intensive care unit (16 studies).

Intervention

17 different Audit and Feedback (A&F) interventions to improve laboratory test and transfusion ordering.

Comparison

Usual care (no intervention; historical or concurrent), or any other single or multifaceted behavioral intervention that did not involve A&F (e.g., education, incentives, reminders, or systems-based changes).

Outcome

The included studies described 17 interventions, mostly (88%) multifaceted interventions with an A&F component. Feedback was most often provided in a written format only (41%), more than once (53%), and most often only provided data aggregated to the group-level (41%). Most studies saw a change in the hypothesized direction, but not all studies provided statistical analyses to formally test improvement. Overall study quality was low, with studies often lacking a concurrent control group.
Abstract
BACKGROUND Laboratory tests and transfusions are sometimes ordered inappropriately, particularly in the critical care setting, which sees frequent use of both. Audit and Feedback (A&F) is a potentially useful intervention for modifying healthcare provider behaviors, but its application to the complex, team-based environment of critical care is not well understood. We conducted a systematic review of the literature on A&F interventions for improving test or transfusion ordering in the critical care setting. METHODS Five databases, two registries, and the bibliographies of relevant articles were searched. We included critical care studies that assessed the use of A&F targeting healthcare provider behaviors, alone or in combination with other interventions to improve test and transfusion ordering, as compared to historical practice, no intervention, or another healthcare behaviour change intervention. Studies were included only if they reported laboratory test or transfusion orders, or the appropriateness of orders, as outcomes. There were no restrictions based on study design, date of publication, or follow-up time. Intervention characteristics and absolute differences in outcomes were summarized. The quality of individual studies was assessed using a modified version of the Effective Practice and Organisation of Care Cochrane Review Group's criteria. RESULTS We identified 16 studies, including 13 uncontrolled before-after studies, one randomized controlled trial, one controlled before-after study, and one controlled clinical trial (quasi-experimental). These studies described 17 interventions, mostly (88%) multifaceted interventions with an A&F component. Feedback was most often provided in a written format only (41%), more than once (53%), and most often only provided data aggregated to the group-level (41%). Most studies saw a change in the hypothesized direction, but not all studies provided statistical analyses to formally test improvement. Overall study quality was low, with studies often lacking a concurrent control group. CONCLUSIONS Our review summarizes characteristics of A&F interventions implemented in the critical care context, points to some mechanisms by which A&F might be made more effective in this setting, and provides an overview of how the appropriateness of orders was reported. Our findings suggest that A&F can be effective in the context of critical care; however, further research is required to characterize approaches that optimize the effectiveness in this setting alongside more rigorous evaluation methods. TRIAL REGISTRATION PROSPERO CRD42016051941.
Study details
Study Design : Systematic Review
Language : eng
Credits : Bibliographic data from MEDLINE®/PubMed®, a database of the U.S. National Library of Medicine