Abstract 16357: Reducing Repeat Transthoracic Echocardiograms in the Inpatient Setting

Abstract

Background: Transthoracic echocardiogram (TTE) is a common cardiovascular imaging test for hospitalized patients. Repeat TTE testing, defined as a TTE done within one year of a prior TTE, contribute to high resource utilization without clear impact on changes in management. Hypothesis: An interruptive electronic medical record (EMR) alert deployed for repeat TTEs will decrease TTE overordering and will help elucidate reasons behind TTE ordering practices. Methods: We created an interruptive EMR alert for five hospitals within the Johns Hopkins Health System (JHHS). The alert was triggered when an inpatient TTE was ordered for non-ICU/non-cardiology service patients with a completed TTE within the prior 90 days. The alert displayed most recent TTE results and prompted the clinician to continue with the order or not. If order continuation was selected a free text clinician reason was required. Outcomes were length of stay (LOS) and reduction in repeat TTE orders. Focus groups were held with internal medicine residents to understand practice behaviors, given this was a leading cohort that continued with orders. Results: From July 2021- July 2022 the alert triggered 4,976 times, of these 32% of orders were discontinued while 68% were continued. There was no significant reduction in repeat TTE order attempts per month. More orders were continued at academic hospitals compared to the community setting (71% vs 63%, p=<0.01). Medicine and non-medicine departments continued the order at similar rates (69% and 67%, p=0.12). Patients who had a repeat TTE had a longer average LOS compared to those who did not (14 vs 11 days, p=0.08). Twenty internal medicine residents were interviewed for focus groups. Top reasons for order continuation were a change in clinical status (n=8), worsening of chronic conditions (n=5), and post procedure monitoring (n=3). Majority (70%) requested more education within the alert to guide indications for repeat TTE ordering. Conclusion: EMR alerts can reduce repeat TTEs without increasing LOS, however knowledge gaps persist for ordering providers. Iterative changes to our health system EMR alert with a focus on best practice guideline incorporation and education may better mitigate overordering, and thus acute care utilization, in the future.