Improving diagnostic accuracy of 72-hour supervised fasting test for hypoglycemia evaluation: A quality improvement project

The 72-hour supervised fasting test (72-HSFT) remains the gold standard for investigating fasting hypoglycemia in patients without diabetes, which is a rare but potentially fatal clinical condition. However, testing inaccuracies often lead to diagnostic ambiguities and unnecessary healthcare expenditures. Baseline data collection over 1 year revealed that 66% of 72-HSFT tests at our institution were performed incorrectly, with dynamic hormones such as C-peptide being ordered four times per patient. The goal of this quality improvement project (QIP) was to reduce the frequency of unnecessary or incorrect 72-HSFT for hypoglycemia from 66% to 25% within 24 months. To achieve the goals of the QIP, educational interventions targeting patients, nurses, physicians, and laboratory staff on accurate 72-HSFT were implemented. Further interventions included the introduction of an auto-text protocol in Cerner®, standardization of lab testing via a bundle order set for 72-HSFT, and multiple different models of interactive educational sessions. The project was conducted in the emergency department and the inpatient wards of the medicine department. In a plan-do-study-act 1 cycle, testing inaccuracy was reduced from 66% to 20%, with C-peptide orders reducing from 4 tests to 1.2 tests per patient. In plan-do-study-act 2, testing inaccuracy dropped to 0% with one C-peptide test ordered per patient. This QIP demonstrates that system-level changes, combined with conventional interventions such as targeted education and advanced technology-based interventions like clinical decision support tools, can significantly improve test accuracy and reduce unnecessary resource utilization in endocrinological diagnostics.