What are TPADs and how do they affect patient and financial outcomes?
Tests pending at discharge (TPADs) refer to any test ordered during a hospital stay that is not resulted until after the patient is discharged. All laboratorians intuitively know TPADs are problematic but rarely have insight into how often they occur. Studies have shown that up to 100% of inpatients in some institutions have TPADs and 30%-40% of these tests influence postdischarge care. In one study, two-thirds of outpatient providers reported medical errors caused by TPADs.
There are also financial burdens associated with unnecessary TPADs. If 30%-40% of TPADs influence postdischarge care, this also means 60%-70% do not contribute to patient care. These unnecessary tests can cost hundreds of thousands of dollars and erode Diagnostic Related Group payments. Additionally, poorly managed TPADs may contribute to readmissions and associated excess readmission penalties from the Centers for Medicare & Medicaid Services, which added up to more than $500 million nationwide in 2025.
What kinds of tests typically become TPADs?
No test is immune to becoming a TPAD, but some are more likely to become TPADs than others.
Microbiology cultures commonly become TPADs due to turnaround times (TATs) ranging from days to weeks. While most institutions have systems in place to capture positive culture results postdischarge, the same cannot be said for negative results. However, negative results may drive important clinical decisions in antibiotic de-escalation, promoting antibiotic stewardship, and preventing patient drug side-effects.
Common in-house tests also represent a large proportion of TPADs. Frequently, these test orders are remnants of order sets with overzealous order duration fields that healthcare providers forgot to cancel prior to discharge. These lead to unnecessary tests that often have no impact on inpatient clinical decision-making.
Reference tests are highly susceptible to becoming TPADs given their longer TATs — and the fact that clinicians may be unaware of these TATs. Many reference TPADs are critical, such as those for therapeutic drug levels, and must be carefully documented in discharge summaries. On the other hand, some represent misordered tests or tests not relevant to the hospital stay. Expensive reference tests that are ordered immediately prior to discharge out of convenience tend to fall into this latter category.
How can hospitals improve management of TPADs?
Effective TPAD communication starts with discharge summary documentation. Discharge summaries are highly focused on pharmacy reconciliation ensuring that the patient’s medication list is accurate. This same process should be mirrored for laboratory TPAD reconciliation.
Initial reduction of unnecessary in-house TPADs can be achieved by reviewing standard discharge planning processes. Prior to discharge, what is the process for cancelling pending test orders? Are order sets reviewed to ensure appropriate order duration fields and reduce unnecessary daily tests?
Clinician awareness of reference test TATs often reduces reference TPADs. Some hospitals incorporate reference test TAT estimates within the order entry process. Awareness of the TAT may alter ordering since the results will not be available during the patient stay. An in-house test with faster TAT may suffice. But if the reference test is needed, awareness of the TAT may also prompt TPAD documentation in the discharge summary.
Why should labs get involved with improving TPADs?
Critical TPADs can impact patient care. By raising awareness of TPADs and recommending steps for managing them better, laboratories demonstrate that we are not just a commodity or hospital cost center, but an integral part of any healthcare system.
Andrew H. Fletcher, MD, MBA, CPE, CHCQM, FCAP, is a pathologist and founder of Eutilogic Consulting in Salt Lake City. +Email: [email protected]
