Intended for healthcare professionals

Practice Change

Reducing routine inpatient blood testing

BMJ 2022; 379 doi: (Published 26 October 2022) Cite this as: BMJ 2022;379:e070698
  1. William K Silverstein, general internal medicine fellow1 2,
  2. Adina S Weinerman, medical director of quality and patient safety, assistant professor14,
  3. Karen Born, assistant professor5,
  4. Cindy Dumba, patient and public adviser2,
  5. Christopher P Moriates, assistant dean for healthcare value, associate professor of internal medicine6 7
  1. 1Department of Medicine, University of Toronto, Toronto, ON, Canada
  2. 2Choosing Wisely Canada, Toronto, ON, Canada
  3. 3Division of General Internal Medicine, Sunnybrook Health Sciences Centre, Toronto, ON, Canada
  4. 4Centre for Quality Improvement and Patient Safety, University of Toronto, Toronto, ON, Canada
  5. 5Institute of Health Policy, Management & Evaluation, Dalla Lana School of Public Health, University Toronto, Toronto, ON, Canada
  6. 6Department of Internal Medicine, Dell Medical School, University of Texas at Austin, Austin, TX, USA
  7. 7Costs of Care, Boston, MA, USA
  1. Correspondence to W Silverstein William.Silverstein{at}
  2. “Change” articles aim to alert clinicians to the immediate need for a change in practice to make it consistent with current evidence. This article is part of a series of Education articles based on recommendations from international Choosing Wisely campaigns.

What you need to know

  • Routine, repetitive laboratory testing for hospital inpatients who are clinically and biochemically stable is associated with negative patient outcomes (ie, increased length of stay, transfusion requirements, hospital acquired anaemia), wastes laboratory resources, and drives unnecessary healthcare waste

  • Improve test ordering practices to avoid unnecessary testing, and minimise the volume of blood phlebotomised for laboratory tests

  • Targeted initiatives safely reduce unnecessary tests without increasing readmission rates, length of stay, adverse events, missed biochemical diagnoses, or mortality

Blood tests are a fundamental diagnostic tool for hospital clinicians; however, the routine and repetitive ordering of blood tests in patients without a clinical indication is unnecessary and represents low value care that can be avoided up to 60% of the time.1234 Low value care is defined as health services for which there is no evidence of patient benefit or where there is evidence of more harm than benefit.56 Routine and repetitive blood testing on clinically stable hospital inpatients is of low diagnostic yield, seldom changes management, is associated with reductions in haemoglobin and haematocrit, and can trigger a cascade of further unnecessary investigations to investigate this new drop in haemoglobin and haematocrit.78910 No validated criteria exist for what constitutes routine and repetitive bloodwork. Choosing Wisely campaigns consider a complete blood count (CBC), electrolytes, liver enzymes, and coagulation parameters as being routine (table 1).11

View this table:
Table 1

Blood tests considered routine by Choosing Wisely campaigns11

Supply chain shortages associated with the covid-19 pandemic have led to critical shortages of blood specimen collection tubes and human resources, including laboratory technicians, and have further highlighted the importance of reducing routine, repetitive blood tests for stable medical inpatients.12 Additionally, laboratory testing has a substantial impact on planetary health.13 The production, distribution, and disposal of plastic products …

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