Objective:

To identify barriers to the existing process of CSF testing and implement refinements to improve the practice of cost-effective medicine.

Background:

At an urban academic hospital, we identified that many CSF tests sent out for processing were discontinued after specimens were collected. CSF testing is critical to neurologic workup, but inefficiencies in send-out testing lead to repeating invasive procedures and delaying diagnosis and treatment. Our quality improvement project aimed to reduce rates of study cancellation to prevent inadequacies in patient care. 

Design/Methods:

This prospective pre-post intervention QI study had two components. First, a survey was implemented to assess neurology residents’ comfort with CSF studies before and after a comprehensive guide (“tip-sheet”) was provided.  Second, we compared CSF study completion between all hospitalized patients on the neurology service from 2022-2024 before and after tip-sheet implementation. The SMART Aim was to decrease CSF study cancellations from 10% to 6.7% within one year. 

Results:

Across 785 patients, a total of 174 LPs were performed and 546 CSF samples were collected. 32 samples (9.5%) were discontinued before tip-sheet implementation, and 13 (6.2%) were discontinued afterward.  There were statistically significant decreases in discontinued labs for each send-out study (ENC2, p=0.003; VZV, p=0.001) except for the NY Encephalitis Panel, which happened to be not included in the tip-sheet. Forty-four percent of discontinued studies were due to missing requisition forms. Fifty-four percent of LPs were performed by neuro-interventional radiology (NIR). Resident surveys showed an increase in confidence ordering CSF studies but was not statistically significant. 

Conclusions:

The QI Smart Aim resulted in a 35% decrease in CSF study cancellations. The only send-out study without statistically significant change was not on the tip-sheet, lending support to the efficacy of this intervention. Focusing on appropriate requisition form usage and coordinating collection of CSF studies with NIR team are clear next steps.