I applaud Faulkner and colleagues for a well-written article which is relevant to various specialties within the NHS and has generated immense debate. The authors suggest that the status quo of ordering routine blood tests in acute departments should be challenged, citing these as being akin to a clinician’s “psychological support blanket”, and potential for cost savings. I acknowledge that the acute profession has geared towards “knee-jerk” diagnostics, for instance, it has become standard practice for patients with medical ailments to be referred from the ED with the usual gamut of blood tests, ECG, chest X-ray and urinalysis.
As a medical registrar leading a busy acute take who is faced with the responsibility to admit and discharge patients overnight, I disagree with the concept of not having this information at our fingertips. As clinical assessments and impressions can vary between junior doctors, investigations are often the only objective information available. Using these tests in conjunction with the clinical situation supports our Bayesian model for decision making, e.g. the negative predictive value of troponins and D-Dimer for atypical chest pain, and normal blood panel in an elderly patient who is “generally unwell”, affects our clinical impression. In a previous study of routine blood tests conducted in the general medical setting, 12% were abnormal, but only 0.5% led to changes to patient treatment.[1] However, this did not explore the impact of the tests on discharge-related decision making.
Spurred perhaps by an increasingly internet savvy and litigious society, it is healthy and insightful for clinicians to doubt their diagnosis based on history and examination alone. After all, this is the rationale for having differential diagnoses, especially when managing a progressively older demographic with increasing co-morbidity, polypharmacy, and with atypical presentations of serious conditions. It is arguable that in an acute medical setting, a standard panel of blood tests can be helpful, as most medical presentations can theoretically be associated with haematological or biochemical abnormalities. This concept was recently demonstrated in a study of over 4000 Danish medical patients aged 65,[2] which correlated the proportion of abnormal routine blood tests on admission with poorer survival, after adjusting for age and concomitant diagnoses. The authors went as far as proposing the use of routine blood tests as a biomarker of frailty.
In defence of acute physicians, using terms such as “routine bloods” detract from their real purpose or acting as a basic screening tool for potentially serious pathology. In a hospital environment where resources are available at our fingertips, failing to detect malignancy-related anaemia, renal impairment, or liver disease after a medical admission, regardless of cause, may incur longstanding repercussions. Although, I do agree that attention to pathology informatics is required to avoid unnecessary repetition of blood tests, I believe that a routine blood panel should be considered part of holistic medicine and not just as a “psychological support blanket”.
References
1. Hubbell FA, Frye EB, Akin BV et al. Routine admission laboratory testing for general medical patients. Med Care. 1988 Jun;26(6):619-30.
2. Klausen HH, Petersen J, Bandholm T et al. Association between routine laboratory tests and long-term mortality among acutely admitted older medical patients: a cohort study, BMC Geriatrics 2014; 17:67
Competing interests:
No competing interests
08 May 2017
K Siau
JAG Clinical Research Fellow and Gastroenterology ST6
Rapid Response:
Re: Should we abandon routine blood tests?
BMJ Response
I applaud Faulkner and colleagues for a well-written article which is relevant to various specialties within the NHS and has generated immense debate. The authors suggest that the status quo of ordering routine blood tests in acute departments should be challenged, citing these as being akin to a clinician’s “psychological support blanket”, and potential for cost savings. I acknowledge that the acute profession has geared towards “knee-jerk” diagnostics, for instance, it has become standard practice for patients with medical ailments to be referred from the ED with the usual gamut of blood tests, ECG, chest X-ray and urinalysis.
As a medical registrar leading a busy acute take who is faced with the responsibility to admit and discharge patients overnight, I disagree with the concept of not having this information at our fingertips. As clinical assessments and impressions can vary between junior doctors, investigations are often the only objective information available. Using these tests in conjunction with the clinical situation supports our Bayesian model for decision making, e.g. the negative predictive value of troponins and D-Dimer for atypical chest pain, and normal blood panel in an elderly patient who is “generally unwell”, affects our clinical impression. In a previous study of routine blood tests conducted in the general medical setting, 12% were abnormal, but only 0.5% led to changes to patient treatment.[1] However, this did not explore the impact of the tests on discharge-related decision making.
Spurred perhaps by an increasingly internet savvy and litigious society, it is healthy and insightful for clinicians to doubt their diagnosis based on history and examination alone. After all, this is the rationale for having differential diagnoses, especially when managing a progressively older demographic with increasing co-morbidity, polypharmacy, and with atypical presentations of serious conditions. It is arguable that in an acute medical setting, a standard panel of blood tests can be helpful, as most medical presentations can theoretically be associated with haematological or biochemical abnormalities. This concept was recently demonstrated in a study of over 4000 Danish medical patients aged 65,[2] which correlated the proportion of abnormal routine blood tests on admission with poorer survival, after adjusting for age and concomitant diagnoses. The authors went as far as proposing the use of routine blood tests as a biomarker of frailty.
In defence of acute physicians, using terms such as “routine bloods” detract from their real purpose or acting as a basic screening tool for potentially serious pathology. In a hospital environment where resources are available at our fingertips, failing to detect malignancy-related anaemia, renal impairment, or liver disease after a medical admission, regardless of cause, may incur longstanding repercussions. Although, I do agree that attention to pathology informatics is required to avoid unnecessary repetition of blood tests, I believe that a routine blood panel should be considered part of holistic medicine and not just as a “psychological support blanket”.
References
1. Hubbell FA, Frye EB, Akin BV et al. Routine admission laboratory testing for general medical patients. Med Care. 1988 Jun;26(6):619-30.
2. Klausen HH, Petersen J, Bandholm T et al. Association between routine laboratory tests and long-term mortality among acutely admitted older medical patients: a cohort study, BMC Geriatrics 2014; 17:67
Competing interests: No competing interests