Optimizing Lumbar Punctures, Part II

 Hi fellow Clinical Informatics, CMIO, CNIO, HealthIT, and other #workflow friends,

Sorry about the delay in following up my last post - As most people can probably understand, the COVD-19 pandemic has been a very busy time in healthcare.

Anyway, in my last blog post - I introduced the surprising complexity of a lumbar puncture - Not to complicate a fairly simple bread-and-butter clinical procedure that's performed in healthcare settings every day, but to help create clarity and understanding, set expectations, and help reduce clicks while delivering a great user experience that your providers can use to deliver great patient care. 

To help understand the complexity of this workflow, I thought I'd even share this academic poster which was developed by Deandra 'Uju' Momah, MS4, an outstandingly talented medical student from UConn Med who I've had the honor to work with. At a recent AMIA conference, Uju presented her academic poster which very nicely summarizes the workflow issues : 

(Academic poster by Deandra 'Uju' Momah, MS4 - Click to enlarge)

The take-home point : Diagnostic LPs are not one workflow - They are at least four. (That is, if you carve out intrathecal chemotherapy, epidurals, blood patches, and therapeutic LPs.)

I recently had the opportunity to discuss LPs to an online audience of new Informaticists - below are some of the slides from my presentation, which I'll borrow and annotate here for clarity and educational purposes. 

First - A review of some of the complexities of designing a Lumbar Puncture order set : 

Again, it's very important to remember that Lumbar Punctures are not just one workflow - Diagnostically, there are at least four. So for now, we will focus on the third of four below, the outpatient ID/Specialist LP, where in many institutions this is commonly collected by Interventional Radiology: 

Now before we can examine this in more detail, I thought I'd share the large (complex) set of stakeholders who all have an interest in how LPs are ordered, performed, and resulted in your organization : 

In my current role, I'm very fortunate to be able to work with the great Karen Gurba, RN MS, an experienced and outstanding Clinical (Nurse) Informaticist who I partner with to help investigate and design workflows. (Remember, Applied Clinical Informatics is a team sport!) Karen and I have done a number of interviews with the stakeholders in the list above, and through repeated iterations of blueprints, reviews, discussions, and updated blueprints - The picture starts to become more clear. 

In each of these cases, there are a six main features that almost all clinical staff seem to generally agree on : 

1. There are some PRE-LP labs, that are typically collected 24 hours before the procedure, to help establish that it's safe to proceed with the lumbar puncture lab. (They often include a simple BMP, CBC, and PT/INR.)
2. There are other PRE-LP serology labs, that are typically collected 1 hour before the procedure, for diagnostic purposes. (They often include a serum glucose, serum protein, and in some cases, oligoclonal banding.)
3. There is the LP procedure order itself, used to schedule the procedure and plan charges for doing the procedure. 
4. There are four BASIC LP labs, that most docs use for general purposes, including a CSF cell count and differential, a CSF gram stain and culture, a CSF glucose, and a CSF protein. 
5. There are some additional speciality-specific CSF labs, which can be very complex and specialty-specific. (Some of these can be very expensive, and so care should be taken so that they are not ordered unnecessarily or by accident.)
6. Finally, there are a limited number of nursing orders, mostly importantly a nursing communication order that allows the ordering provider to give the Interventional Radiology nurses a 'heads up' on any unique patient needs. 

 The problem is - When you have so many specialties needing access to specific labs in #5 above, how exactly do you build this out?

And so, now I'd like to present a mockup of an Outpatient LP via Interventional Radiology (IR) order set, that helps address all of these needs in one coherent order set, that relies on cascading logic to help guide the ordering provider to the best-practices for their unique clinical needs. (Pardon my amateur cartooning, which I used to customize my presentation.)

And the order set starts with the first clinical decision - Is the ordering provider ordering a DIAGNOSTIC LP, or a THERAPEUTIC LP?

Let's say in this case, the provider is ordering a DIAGNOSTIC LP : 

This then brings up four choices, seen above : 

• FOR ATTENDINGS, FELLOWS, AND RESIDENTS - Routine diagnostic LPs - Mon-Fri 8am-5pm
• FOR ATTENDINGS AND FELLOWS ONLY - ROUTINE Malignancy Evaluations - Mon-Thurs 8am-12pm
• FOR ATTENDINGS AND FELLOWS ONLY - URGENT Malignancy Evaluations - Friday-Sunday 8am-12pm
• FOR ATTENDINGS AND FELLOWS ONLY - PRION Disease Evaluations - Mon-Fri 8am-5pm

 This gives us the opportunity not only to confirm the role of the ordering provider, but also to stratify the routine diagnostic workflow from the more complex workflows that require additional notifications or supervision before ordering. This helps us to make sure that unnecessary orders are not added to the workup. 

In this case, clicking the first option (ROUTINE DIAGNOSTIC LUMBAR PUNCTURES) would then produce the list of specialties that commonly use this order set : 

And here, if an Infectious Disease provider were to click their section, the order set can now produce the tailored, specialty-specific orders that the provider needs : 

Using this naming convention and design, we now know : 

• Scenario = Specialty, outpatient LP for collection in IR
• LP type = Diagnostic
• User = Attending, Fellow, or Resident
• Specialty = Infectious Disease

... and so now the order set can allow a tailored, specialty-specific palette of orders that are most commonly used for the user's needs. 

And with that, a significant reduction in clicks and improvement in utilization, diagnostic accuracy, and diagnostic yield. 

We are now working with our department Chiefs to help confirm the final orders (to appear in the fifth section of each specialty-specific area), and maybe once they are completed, I can help publish the final result here. 

Until then, I hope this helps you develop your own strategy for ordering Lumbar Punctures! If you have any secrets or feedback you can share, please leave them in the comments below!

Remember, this blog is for educational and discussion purposes only - Your mileage may vary! Have any recommendations or tricks to share about designing lumbar puncture workflows? Feel free to share in the comments box below!