Evidence-Based Guidelines to Eliminate Repetitive Laboratory Testing

Eaton, Kevin; Levy, Kathryn; Soong, Christine; Pahwa, Amit; Petrilli, Christopher M.; Ziemba, Justin; Cho, Hyung J.; Alban, Rodrigo F.; Blanck, Jaime Friel; Parsons, Andrew S.

doi:10.1001/jamainternmed.2017.5152

Cited by 140 publications

(161 citation statements)

References 47 publications

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“…22 There is no evidence that routine laboratory testing in this context improves patient outcomes, and it may even result in worse outcomes and, ultimately, compromised quality of care. 7,23 Although many interventions to reduce daily blood work have been reported, 24 before the design and implementation of these strategies it is important to know where they may be effective. The results of this study support the notion that routine daily diagnostic phlebotomy in hospitalized patients requires reevaluation.…”

Section: Discussionmentioning

confidence: 99%

A contemporary description of patients’ estimated blood losses from diagnostic phlebotomy in a census of hospital episodes from a Canadian tertiary care center

et al. 2019

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BACKGROUND: Phlebotomy for diagnostic testing is among the commonest hospital procedures, but hospitalwide surveys of all inpatients characterizing blood draw volumes have not been published. The objectives were to characterize the daily blood volumes drawn for diagnostic testing from patients discharged from a Canadian tertiary care center, describe the daily distributions of phlebotomy volumes across service locations, and describe changes in hemoglobin (Hb) and transfusion across service locations. STUDY DESIGN AND METHODS: Data wereobtained on all patients discharged between 2012 and 2014 using linked discharge abstract and laboratory data. Cumulative daily blood volume and draw frequency were reported by service and days since admission. Changes in Hb and red blood cell (RBC) transfusion rates were reported for nontransfused and transfused patients.RESULTS: Data were included on 59,715 subjects.Mean daily estimated blood loss varied from 8.5 AE 6.5 mL/day onward to 27.2 AE 20.0 mL/day in the intensive care unit (ICU; p < 0.001). Phlebotomy volumes were highest on the first day of admission and declined thereafter (p < 0.001). For nontransfused individuals in the first week of admission, Hb levels decreased by the highest percentage in the ICU. The rate of RBC unit transfusion was highest in the ICU (232.4 units/1000 patient-days; 95% confidence interval, 225.8-239.2; p < 0.0001 compared with all other locations). CONCLUSION:Considerable variation was observed in estimated blood loss due to diagnostic phlebotomy across different services within one teaching hospital. Thi information is foundational for planning interventions to minimize estimated blood loss from phlebotomy.ABBREVIATIONS: AMI = acute myocardial infarction; ICU = intensive care unit; IMCU(s) = medical intermediate care unit(s);

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Section: Discussionmentioning

confidence: 99%

A contemporary description of patients’ estimated blood losses from diagnostic phlebotomy in a census of hospital episodes from a Canadian tertiary care center

et al. 2019

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“…While we are currently revisiting the adequacy of our routine practices in laboratory testing [25], as per the best available evidence, we call for the simplification of the diagnosis of exudates on the pleural fluid.…”

Section: Discussionmentioning

confidence: 99%

Simplified Criteria Using Pleural Fluid Cholesterol and Lactate Dehydrogenase to Distinguish between Exudative and Transudative Pleural Effusions

et al. 2019

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Background: An important part of the investigation of pleural effusion is the identification of markers that help separate exudate from transudate. Objectives: The purposes of this study were to compare the accuracy of published and new sets of criteria to distinguish between exudative and transudative pleural effusions, and to determine whether serum biochemical analysis is necessary. Methods: An externally validated cohort study was performed. Pleural effusions were determined to be transudative or exudative on the basis of an assessment of the medical record by two clinicians blinded to biochemical results. Sensitivity, specificity, positive likelihood ratio, negative likelihood ratio, and area under the receiver operating characteristic curve were determined for each proposed combination of criteria. Results: Pleural fluid analysis was available for 311 thoracenteses in the main cohort and for 112 thoracenteses in the validation cohort. The best sensitivity (97% [95% CI 94–99]) and negative likelihood ratio (0.04 [95% CI 0.02–0.08]) for identifying exudative effusions were observed with criteria combining pleural fluid lactate dehydrogenase greater than 0.6 the upper limit of normal serum lactate dehydrogenase and pleural fluid cholesterol greater than 1.04 mmol/L (40 mg/dL). The overall diagnostic accuracy was similar to Light’s criteria. Findings were similar in the validation cohort. Conclusions: Our proposed criteria using simultaneously pleural fluid lactate dehydrogenase and pleural fluid cholesterol can identify an exudate with a sensitivity and an overall diagnostic accuracy similar to Light’s criteria. It avoids simultaneous blood sampling, thus reducing patient discomfort and potential costs.

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“…In addition, the main intervention categories focus on one or more of three strategies: education, audit and feedback on provider ordering practices, and electronic medical record enabled restrictive ordering. The most successful interventions have implemented multifaceted approaches involving a combination of these strategies 15. In this study, we assessed the adequacy of total and ionised blood calcium requested in our hospital 1 year before, and 2 years after, the implementation of a decision algorithm developed and published by our group 6.…”

Section: Discussionmentioning

confidence: 99%

Improving serum calcium test ordering according to a decision algorithm

et al. 2018

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AimTo detect differences in the pattern of serum calcium tests ordering before and after the implementation of a decision algorithm.MethodsWe studied patients admitted to an internal medicine ward of a university hospital on April 2013 and April 2016. Patients were classified as critical or non-critical on the day when each test was performed. Adequacy of ordering was defined according to adherence to a decision algorithm implemented in 2014.ResultsTotal and ionised calcium tests per patient-day of hospitalisation significantly decreased after the algorithm implementation; and duplication of tests (total and ionised calcium measured in the same blood sample) was reduced by 49%. Overall adequacy of ionised calcium determinations increased by 23% (P=0.0001) due to the increase in the adequacy of ionised calcium ordering in non-critical conditions.ConclusionsA decision algorithm can be a useful educational tool to improve adequacy of the process of ordering serum calcium tests.

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Evidence-Based Guidelines to Eliminate Repetitive Laboratory Testing

Cited by 140 publications

References 47 publications

A contemporary description of patients’ estimated blood losses from diagnostic phlebotomy in a census of hospital episodes from a Canadian tertiary care center

A contemporary description of patients’ estimated blood losses from diagnostic phlebotomy in a census of hospital episodes from a Canadian tertiary care center

Simplified Criteria Using Pleural Fluid Cholesterol and Lactate Dehydrogenase to Distinguish between Exudative and Transudative Pleural Effusions

Improving serum calcium test ordering according to a decision algorithm

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