Contributing lab leader: David Gaston & Alisha Ezell
Contributing lab leader: David Gaston & Alisha Ezell
Common respiratory pathogens, such as influenza, SARS-CoV-2, and respiratory syncytial virus (RSV), can be difficult to distinguish as these viruses present with similar symptoms.1 To help accurately diagnose respiratory diseases, clinicians use diagnostic tests performed in a central lab or at the bedside in the form of point of care (POC) testing. Over the last several years, new PCR diagnostic solutions for respiratory infections have become available, making it challenging for healthcare providers to choose the correct test for the right patient.
Performing the incorrect test could lead to misdiagnosis, ineffective treatment strategy, and increased disease transmission. This also leads to downstream increases in healthcare costs, worsening the economic burden for healthcare organizations.2 Therefore, choosing the right respiratory testing panels is critical to meet the patient’s needs.
At the recent Association for Diagnostics and Laboratory Medicine (ADLM) conference, David C. Gaston, M.D., Ph.D., Medical Director, Molecular Infectious Diseases Laboratory (MIDL) Vanderbilt University Medical Center, and Alisha Ezell, MHA, MLS(ASCP)CM, Enterprise Point of Care Manager, Diagnostic Laboratories, Vanderbilt Health, provided insights into how Vanderbilt developed and implemented new respiratory testing algorithms to offer better and more streamlined testing options and workflows for clinicians.
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Nucleic acid amplification tests (NAATs), including PCR testing, remain the standard for diagnosing respiratory infections due to their high sensitivity and specificity.3 Clinicians can choose which tests to perform on patients, ranging from testing for one pathogen (singleplex) and two to five pathogens (targeted multiplex) to testing for 20+ pathogens (expanded multiplex).4
However, now that diagnostic testing has become more complex, especially with the rise of POC testing, the challenge for physicians is choosing the best diagnostic for their patients from the complicated landscape of available tests. Therefore, healthcare systems need to find ways to optimize and streamline diagnostic ordering and testing workflows for all of their providers to address the needs of diverse care settings.
Over the past few years following the height of the COVID-19 pandemic, Vanderbilt Health, a massive yet diverse healthcare organization with seven hospitals and over 200 ambulatory sites, underwent an extensive laboratory transformation project.5 This transition included the move of its central lab to an offsite facility and changes to Vanderbilt’s laboratory information system (LIS), which included the development of new respiratory testing algorithms.
“How can we take some of the testing practices that had gotten away from a diagnostic stewardship focus and realign them as the lab is moving, and having the ear of the hospital and a lot of providers to do a bit of a reset?” said Dr. Gaston. “Should we work on changing testing utilization and other ordering practices with this move to really meet the needs of our patients and change to make sure that we’re providing the best patient care?” added Ezell.
Before the transformation and during the pandemic, Vanderbilt’s providers had trouble determining the best test to order with their respiratory testing algorithm, especially as new technologies and testing panels were becoming increasingly available to the lab. “The algorithm became a bit of a hodgepodge,” said Dr. Gaston. Due to the algorithm's complexity, most providers ordered expanded multiplex testing for all patients, regardless of their symptoms or immune status.
Vanderbilt needed to move away from expanded panel testing and prioritize targeted panels, which is an important strategy with diagnostic stewardship and ordering the proper test for the right patient. According to Dr. Gaston, this approach was necessary, especially with other respiratory diseases, like influenza and RSV, becoming more prevalent as COVID-19 cases subsided.
Vanderbilt designed new respiratory testing algorithms that addressed these challenges, incorporating real-time data and decision tools within their electronic medical record (EMR) system to help providers make informed testing decisions. “When a provider is ordering respiratory testing, they just have to make one or two clicks and it aligns with the institution [guidance] to have focused testing,” commented Dr. Gaston.
To improve the workflow and make it simpler for health workers, the Vanderbilt lab first set the institutional standard for respiratory test order, for example starting with offering a targeted multiplex panel for detection of SARS-CoV-2, RSV, and influenza A and B, as these viruses are the most common. According to Dr. Gaston, this option and other criteria are automated and preselected in the Epic EHR, making it easier for the clinician to select. However, drop-down menus offer different options, providing the clinician flexibility. “It’s the clinician’s decision and we leave that autonomy.”
Vanderbilt’s new system also reduced the number of clicks within EMRs that a healthcare provider must complete to order the best test. “Changing from the prior respiratory algorithm to the current respiratory algorithm decreased clicks between three to five clicks, which for providers matters a lot,” remarked Dr. Gaston.
Another point pivotal to streamlining and optimizing the respiratory algorithms is ensuring high-quality, accurate results for patients and providers. “We want to make sure we are offering the best tests and getting the right results and getting that in absolutely as quickly as possible without sacrificing anything we’re doing from a quality perspective,” said Dr. Gaston.
Before implementing new respiratory testing algorithms, getting input and feedback from clinicians and other stakeholders early in the process is important. This approach will ensure that the providers will use the algorithms for ordering the correct diagnostic test. Through meetings and emails with healthcare professionals, it is important to focus on their preferences to understand how to optimize their workflow and fit their needs.
According to Dr. Gaston, it was important to pull together as many perspectives together as possible. Even if a specific test wasn’t used by everyone, it was at least available to order it if necessary. “We don’t want to make it harder for them to do their jobs and add more to their workflow,” added Ezell.
In developing these new respiratory algorithms and workflows, Vanderbilt needed to consider all patient populations and align the needs of the healthcare workers who were responsible for testing, which included not just clinicians, but nurses as well. “Are we effectively providing what we need across the board, whether it’s point of care or our lab?” said Ezell. For instance, this meant assigning MIDL central lab testing for hospital and regional inpatients, while POC testing would be used for outpatients.
Labs play a critical role in helping clinicians make important diagnostic decisions. However, with the amount of tests available, especially for respiratory illnesses, it can be challenging for physicians to choose the best test for the correct patient. Therefore, lab leaders should consider re-evaluating their current diagnostic offerings. They need to ensure that they still align with institutional standards and best practices, and at the same time, make it easier for clinicians to make the best decisions possible for their patients.
By involving all stakeholders prior to making these algorithm changes, lab leaders can build trust with clinical teams, increasing diagnostic stewardship, improving differential diagnosis, and positively impacting patient outcomes. This will help increase the likelihood that new respiratory testing algorithms are widely adopted.
If you want to hear more from Dr. David Gaston and Alisha Ezell on optimizing respiratory testing algorithms, you can watch the full presentation here.