When will less monitoring and diagnostic testing benefit the patient more? (original) (raw)
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Non-essential blood tests in the intensive care unit: a prospective observational study
Canadian journal of anaesthesia = Journal canadien d'anesthesie, 2017
Non-essential blood testing in the acute care setting can be a prominent source of morbidity, patient discomfort, increased workload for the healthcare provider, and wasteful spending. The magnitude of such non-essential blood testing has not been well described. We aimed to measure the extent of unnecessary blood testing in a 33-bed intensive care unit (ICU) at a tertiary-care teaching hospital in Ontario, Canada. Over a period of four weeks, all ICU attending physicians were asked to select, from a comprehensive list, blood tests that they deemed essential to the appropriate care for each of their patients on the following day. The actual tests processed on the following day were recorded. Descriptive statistics were used to determine what proportion of all processed tests were deemed essential blood tests. The association between patient characteristics and the total cost of unnecessary tests was assessed using the Wilcoxon rank-sum test and the Spearman correlation coefficient, ...
Clinical Medicine
Haematology inpatients are subject to extensive blood testing and many of these tests could be deemed inappropriate as they are not indicated for monitoring or clinical symptoms. Unnecessary testing exposes the patient to the risks of phlebotomy and adds resources' strain to the NHS. Our aim was to reduce the number of inappropriate blood tests performed on haematology inpatient wards. Quality improvement projects (QIPs) were performed in four haematology units introducing inpatient blood testing schedules (BTS) or providing staff education on current schedules. A reduction in inappropriate or overall blood testing was achieved at every site where a BTS was implemented, with a median reduction in inappropriate blood testing of 24.7% and estimated cost savings of up to £38,438 per annum. This QIP can be safely adapted to a variety of inpatient settings and is associated with cost savings. This initiative could be extended to other inpatient departments throughout the NHS.
Australian Critical Care, 2016
Background: Anaemia is common in critically ill patients, and has a significant negative impact on patients' recovery. Blood conservation strategies have been developed to reduce the incidence of iatrogenic anaemic caused by sampling for diagnostic testing. Objectives: Describe practice and local guidelines in adult, paediatric and neonatal Australian intensive care units (ICUs) regarding blood sampling and conservation strategies. Methods: Cross-sectional descriptive study, conducted July 2013 over one week in single adult, paediatric and neonatal ICUs in Brisbane. Data were collected on diagnostic blood samples obtained during the study period, including demographic and acuity data of patients. Institutional blood conservation practice and guidelines were compared against seven evidence-based recommendations. Results: A total of 940 blood sampling episodes from 96 patients were examined across three sites. Arterial blood gas was the predominant reason for blood sampling in each unit, accounting for 82% of adult, 80% of paediatric and 47% of neonatal samples taken (p < 0.001). Adult patients had significantly more median [IQR] samples per day in comparison to paediatrics and neonates (adults 5.0 [2.4]; paediatrics 2.3 [2.9]; neonatal 0.7 [2.7]), which significantly increased median [IQR] blood sampling costs per day (adults AUD$101.11 [54.71]; paediatrics AUD$41.55 [56.74]; neonatal AUD$8.13 [14.95]; p < 0.001). The total volume of samples per day (median [IQR]) was also highest in adults (adults 22.3 mL [16.8]; paediatrics 5.0 mL [1.0]; neonates 0.16 mL [0.4]). There was little information about blood conservation strategies in the local clinical practice guidelines, with the adult and neonatal sites including none of the seven recommendations. Conclusions: There was significant variation in blood sampling practice and conservation strategies between critical care settings. This has implications not only for anaemia but also infection control and healthcare costs.
Interventions to prevent iatrogenic anemia: a Laboratory Medicine Best Practices systematic review
Critical Care, 2019
Background: As many as 90% of patients develop anemia by their third day in an intensive care unit (ICU). We evaluated the efficacy of interventions to reduce phlebotomy-related blood loss on the volume of blood lost, hemoglobin levels, transfusions, and incidence of anemia. Methods: We conducted a systematic review and meta-analysis using the Laboratory Medicine Best Practices (LMBP) systematic review methods for rating study quality and assessing the body of evidence. Searches of PubMed, Embase, Cochrane, Web of Science, PsychINFO, and CINAHL identified 2564 published references. We included studies of the impact of interventions to reduce phlebotomy-related blood loss on blood loss, hemoglobin levels, transfusions, or anemia among hospital inpatients. We excluded studies not published in English and studies that did not have a comparison group, did not report an outcome of interest, or were rated as poor quality. Twenty-one studies met these criteria. We conducted a meta-analysis if > 2 homogenous studies reported sufficient information for analysis. Results: We found moderate, consistent evidence that devices that return blood from flushing venous or arterial lines to the patient reduced blood loss by approximately 25% in both neonatal ICU (NICU) and adult ICU patients [pooled estimate in adults, 24.7 (95% CI = 12.1-37.3)]. Bundled interventions that included blood conservation devices appeared to reduce blood loss by at least 25% (suggestive evidence). The evidence was insufficient to determine if these devices reduced hemoglobin decline or risk of anemia. The evidence suggested that small volume tubes reduced the risk of anemia, but was insufficient to determine if they affected the volume of blood loss or the rate of hemoglobin decline. Conclusions: Moderate, consistent evidence indicated that devices that return blood from testing or flushing lines to the patient reduce the volume of blood loss by approximately 25% among ICU patients. The results of this systematic review support the use of blood conservation systems with arterial or venous catheters to eliminate blood waste when drawing blood for testing. The evidence was insufficient to conclude the devices impacted hemoglobin levels or transfusion rates. The use of small volume tubes may reduce the risk of anemia.
Anaesthesia and Intensive Care, 2018
Unnecessary pathology tests performed in intensive care units (ICU) might lead to increased costs of care and potential patient harm due to unnecessary phlebotomy. We hypothesised that a multimodal intervention program could result in a safe and effective reduction in the pathology tests ordered in our ICU. We conducted a single-centre pre- and post-study using multimodal interventions to address commonly ordered routine tests. The study was performed during the same six month period (August to February) over three years: 2012 to 2013 (pre-intervention), 2013 to 2014 (intervention) and 2014 to 2015 (post-intervention). Interventions consisted of staff education, designing new pathology forms, consultant-led pathology test ordering and intensive monitoring for a six-month period. The results of the study showed that there was a net savings of over A$213,000 in the intervention period and A$175,000 in the post-intervention period compared to the pre-intervention period. There was a 28...
Scandinavian journal of trauma, resuscitation and emergency medicine, 2017
Prioritization of acutely ill patients in the Emergency Department remains a challenge. We aimed to evaluate whether routine blood tests can predict mortality in unselected patients in an emergency department and to compare risk prediction with a formalized triage algorithm. A prospective observational cohort study of 12,661 consecutive admissions to the Emergency Department of Nordsjælland University Hospital during two separate periods in 2010 (primary cohort, n = 6279) and 2013 (validation cohort, n = 6383). Patients were triaged in five categories by a formalized triage algorithm. All patients with a full routine biochemical screening (albumin, creatinine, c-reactive protein, haemoglobin, lactate dehydrogenase, leukocyte count, potassium, and sodium) taken at triage were included. Information about vital status was collected from the Danish Central Office of Civil registration. Multiple logistic regressions were used to predict 30-day mortality. Validation was performed by apply...
Internal Medicine Journal, 2019
The clinical utility and adverse consequences of the admission and follow-up complete blood count (CBC) in hospitalised patients are unclear. We selected 273 patients chosen from a single internal medicine department. To determine clinical utility and adverse consequences, we interviewed attending physicians and reviewed patients' charts. There were 12 (4.4%) patients hospitalised because of the CBC test result, six referred appropriately with a low haemoglobin concentration found in outpatient clinics and six (2.2%) patients (95% confidence interval 0.8-4.7%) inappropriately hospitalised because of incidental findings. In the hospital, according to the physicians, nearly all treatment changes made were for blood transfusions that were not indicated in 18 (6.6%) patients (95% confidence interval 4.0-10.2%). The only unexpected findings were in four patients with an indication for a blood transfusion admitted with an acute coronary syndrome and haemoglobin values 8-9.9 g/dL, and in one bedridden patient with dementia with acute myeloid leukaemia. There were 290 follow-up CBC tests not resulting in differential treatment. We conclude that admission CBC tests commonly lead to adverse consequences, due to physician errors in judgement. Incidental findings of anaemia justify CBC testing in patients with an acute coronary event. The rare patient with an incidental finding resulting in appropriate differential treatment might justify non-selective admission CBC counts, if physician education reduces the rate of inappropriate blood transfusions.
Anemia in hospitalized patients: an overlooked risk in medical care
Transfusion, 2018
BACKGROUND: This study investigated the association between nadir anemia and mortality and length of stay (LOS) in a general population of hospitalized patients. STUDY DESIGN AND METHODS: A retrospective cohort study of tertiary hospital admissions in Western Australia between July 2010 and June 2015. Outcome measures were in-hospital mortality and LOS. RESULTS: Of 80,765 inpatients, 45,675 (56.55%) had anemia during admission. Mild and moderate/severe anemia were independently associated with increased in-hospital mortality (odds ratio [OR] 1.5, 95% confidence interval [CI] 1.36-1.86, p = 0.001; OR 2.77, 95% CI 2.32-3.30, p < 0.001, respectively). Anemia was also associated with increased LOS, demonstrating a larger effect in emergency (mild anemia-incident rate ratio [IRR] 1.52, 95% CI 1.48-1.56, p < 0.001; moderate/ severe anemia-IRR 2.18, 95% CI 2.11-2.26, p < 0.001) compared to elective admissions (mild anemia-IRR 1.30, 95% CI 1.21-1.41, p < 0.001; moderate/severe anemia-IRR 1.69, 95% CI 1.55-1.83, p < 0.001). LOS was longer in patients who developed anemia during admission compared to those who had anemia on admission (IRR 1.13, 95% CI 1.10-1.17, p < 0.001). Red cell transfusion was independently associated with 2.23 times higher odds of in-hospital mortality (95% CI 1.89-2.64, p < 0.001) and 1.31 times longer LOS (95% CI 1.25-1.37, p < 0.001). CONCLUSION: More than one-third of patients not anemic on admission developed anemia during admission. Even mild anemia is independently associated with increased mortality and LOS; however, transfusion to treat anemia is an independent and additive risk factor. A nemia is a global public health problem. A recent study into the burden of anemia reported that in 2013 nearly 2 billion people or 27% of the world's population were affected, and while prevalence has decreased, the total number of people with anemia has increased over the past decade. 1 Although anemia is more prevalent in developing countries it is also common in developed countries, particularly among hospitalized patients. With advances in medical technologies, diagnostics, therapies, and complex interventions, anemia is often a secondary consequence. Accordingly, hospital-acquired anemia (HAA) has been identified as a danger of modern medical care. 2 The main causes of anemia are blood loss, decreased red blood cell (RBC) production, and hemolysis. Blood loss can be a result of menstrual, digestive, or urinary tract bleeding; invasive procedures; trauma;