Reducing routine inpatient blood testing

Eight Ways General Internists Can Practice High-Value, Low-Carbon Care: The Canadian Society of Internal Medicine's Climate Conscious Choosing Wisely Canada Recommendations

INTRODUCTION

Climate change is the twenty-first century's biggest threat to human health. Paradoxically, North American healthcare delivery is carbon intensive. Addressing low-value interventions stands to reduce healthcare's carbon footprint. In this position paper, we describe eight new climate focused Canadian Society of Internal Medicine (CSIM)-Choosing Wisely Canada (CWC) recommendations to help internists stop or reduce tests, treatments, and procedures that do not benefit patients and harm the environment.

METHODS

The CSIM planetary health task force drafted 14 potential recommendations. This list was refined to eight final recommendations based on feedback from the CSIM membership via an online survey, an online seminar, and expert review by the CWC planetary health panel.

RECOMMENDATIONS

The eight recommendations are as follows: (1) Do not prescribe intravenous antibiotics for patients who can safely be treated with an oral option; (2) do not prescribe heparin or low molecular weight heparin when oral options are effective, preferred by the patient and felt to be safe by the prescriber; (3) do not prescribe greenhouse gas-intensive metered-dose inhalers where a greener alternative with comparable efficacy is available, technique is adequate, and patient preference has been considered; (4) do not recommend/order investigations or interventions before discussing patients' expected trajectory of health and life expectancy, and exploring their goals of care; (5) do not continue medications without confirming clinical indications, particularly for sedative medications, proton pump inhibitors, and inhalers; (6) do not order daily blood tests on hospitalized patients if it will not change management; (7) do not use non-sterile disposable gloves when hand hygiene is sufficient; (8) do not book in-person follow-up appointments when a virtual visit is clinically appropriate and is preferred by the patient.

CONCLUSION

Using a consensus process, the CSIM recommends eight evidenced-based practices that can feasibly be adopted by general internists to reduce the carbon footprint associated with low-value clinical care.

Re-evaluating the Need of Postoperative Blood Testing in Low-Risk Patients After Primary Elective Arthroplasty: A Single-Centre Retrospective Analysis

Introduction Increasing demand and financial burdens are placing significant strain on current health resources. To help ease pressures, there has been increased emphasis on improving patient flow and saving costs within the health service. Routine postoperative blood tests in otherwise healthy patients may add to delays and healthcare costs without influencing subsequent management. Recent studies suggest that routine postoperative blood tests may be unnecessary in fit and healthy patients undergoing elective arthroplasty. We aimed to assess this practice at our institution in the American Society of Anaesthesiologists (ASA) grade 1 and 2 patients undergoing elective hip and knee arthroplasty. Methods We conducted a retrospective review of 1595 consecutive elective hip and knee replacements in ASA 1 and ASA 2 patients at our institution over a one-year period from 2021 to 2022. Operation notes and electronic databases were analyzed to collect data regarding demographics, co-morbidities, treatment, pre and postoperative blood tests, and any documented interventions in these patients. Binomial logistic regression was employed to identify risk factors associated with postoperative abnormalities and the need for clinical intervention.  Results Postoperative blood abnormalities were identified in 75.4% of patients, primarily anaemia (69.2%) and hyponatremia (29.9%). Anaemia was similarly prevalent in both total hip arthroplasty (THA) and total knee arthroplasty (TKA) patients, with 70.2% affected in each group, although the majority of cases were mild (83.8% in THA and 90.5% in TKA). Hyponatremia was significantly more common in TKA patients (40.3%) compared to THA patients (19.3%), although most cases were mild in severity. Only 5% of cases required any intervention, with higher rates observed in the TKA group compared to the THA group (p=0.008). Blood transfusion rates were low, occurring in 0.6% of cases. Factors associated with postoperative anaemia included higher BMI, preoperative antiplatelet use, and lower preoperative haemoglobin levels, while postoperative hyponatremia was linked to preoperative sodium levels, loop diuretic use, and PPI use. Acute Kidney Injury (AKI) was identified in 2.2% of patients and was predominantly mild. Potassium abnormalities were infrequent, with hypokalemia occurring in 1.5% of patients and no cases of hyperkalemia in our series. Conclusions Although postoperative blood test abnormalities were common, the majority were mild and rarely influenced management in this low-risk cohort of patients, with overall low postoperative intervention rates. Selective blood testing may allow safe targeted testing in this low-risk cohort of patients, minimizing costs and saving valuable resources.

A Canadian survey of perceptions and practices related to ordering of blood tests in the intensive care unit

PURPOSE

The ordering of routine blood test panels in advance is common in intensive care units (ICUs), with limited consideration of the pretest probability of finding abnormalities. This practice contributes to anemia, false positive results, and health care costs. We sought to understand practices and attitudes of Canadian adult intensivists regarding ordering of blood tests in critically ill patients.

METHODS

We conducted a nationwide Canadian cross-sectional survey consisting of 15 questions assessing three domains (global perceptions, test ordering, daily practice), plus 11 demographic questions. The target sample was one intensivist per adult ICU in Canada. We summarized responses using descriptive statistics and present data as mean with standard deviation (SD) or count with percentage as appropriate.

RESULTS

Over seven months, 80/131 (61%) physicians responded from 77 ICUs, 50% of which were from Ontario. Respondents had a mean (SD) clinical experience of 12 (9) years, and 61% worked in academic centres. When asked about their perceptions of how frequently unnecessary blood tests are ordered, 61% responded "sometimes" and 23% responded "almost always." Fifty-seven percent favoured ordering complete blood counts one day in advance. Only 24% of respondents believed that advanced blood test ordering frequently led to changes in management. The most common factors perceived to influence blood test ordering in the ICU were physician preferences, institutional patterns, and order sets.

CONCLUSION

Most respondents to this survey perceived that unnecessary blood testing occurs in the ICU. The survey identified possible strategies to decrease the number of blood tests.

Blood over-testing: impact, ethical issues and mitigating actions

Plenty of studies demonstrate that hospital-acquired anemia (HAA) can increase transfusion rates, mortality, morbidity and cause unnecessary patient burden, including additional length of hospital stay, sleep disruption and venipuncture harms resulting from blood samples unlikely to change clinical management. Beyond patient costs, community costs should also be considered, such as laboratory time and resources waste, environmental impact, increasing pressure on labs and fewer tests available on time for patients who can benefit from them most. Blood over-testing does not support the principles of non-maleficence, justice and respect for patient autonomy, at the expense dubious beneficence. Reducing the number and frequency of orders is possible, to a certain extent, by adopting nudge strategies and raising awareness among prescribing doctors. However, reducing the orders may appear unsafe to doctors and patients. Therefore, reducing blood volume from each order is a better alternative, which is worth implementing through technological, purchasing and organizational arrangements, possibly combined according to need (smaller tubes, adequate analytic platforms, blind dilution, blood conservative devices, aggregating tests and laboratory units).

"4 E's" Ways That Clinicians Can Reduce Low-Value Care on Medical Wards

This JAMA Network Insight demonstrates examples of how clinicians can implement stepwise changes to reduce unnecessary patient harms, using the 4 E’s.

Do Laboratory Blood Tests Change Medical Care in Patients Hospitalized with Community-Acquired Pneumonia?

Background and Objectives: The prevalence of inappropriate laboratory testing is believed to be high, but only a limited number of studies have reviewed medical charts to determine whether tests impact medical care. Materials and Methods: From the electronic database, we selected 500 consecutive patients with community-acquired pneumonia who were hospitalized between January 2020 and October 2021. We excluded eight patients who had COVID-19, but were not identified in the database, and were only identified after chart review. To assess the impact of tests on medical care, we conducted a thorough review of the patients' charts. Results: The age of the patients was 78 ± 16 years, with 42.3% female (n = 208) hospitalized for a median of 4 days (25-75%, 3-6 days). There were 27957 laboratory test results during 2690 hospital days (10.4 tests per day of hospitalization). Of the 2997 tests carried out on admission 5.7% (n = 170) resulted in changes of medical care in 34.5% (170/492) of the patients, nearly all from the results of electrolytes, renal function tests, and serum glucose measurements. Tests that did not lead to any decision on medical care included 75.8% (7181/9478) on admission and 86.0% (15,898/18,479) on repetitive testing, i.e., repetitive testing accounted for 68.9% (15,898/23,079) of tests that did not change medical care. By excluding tests that did not change medical care, the overall testing rate would decrease by 82.6% (23,079/27,947), and from 10.4 tests per day to 2.1 tests per day. Conclusions: We conclude that the estimate of the overuse of laboratory testing, which includes all testing that does not change patient care, is much higher than reported using other methodologies. Most of the overuse was from repetitive testing that included unnecessary testing in patients without admission test results that changed medical care. Further investigation is needed to determine if these findings can be applied to patients with diverse health conditions and in different healthcare settings.