Reducing routine inpatient blood testing
BMJ 2022; 379 doi: https://doi.org/10.1136/bmj-2022-070698 (Published 26 October 2022) Cite this as: BMJ 2022;379:e070698Linked Editorial
Sustainable practice: what can I do?
- William K Silverstein, general internal medicine fellow1 2,
- Adina S Weinerman, medical director of quality and patient safety, assistant professor14,
- Karen Born, assistant professor5,
- Cindy Dumba, patient and public adviser2,
- Christopher P Moriates, assistant dean for healthcare value, associate professor of internal medicine6 7
- 1Department of Medicine, University of Toronto, Toronto, ON, Canada
- 2Choosing Wisely Canada, Toronto, ON, Canada
- 3Division of General Internal Medicine, Sunnybrook Health Sciences Centre, Toronto, ON, Canada
- 4Centre for Quality Improvement and Patient Safety, University of Toronto, Toronto, ON, Canada
- 5Institute of Health Policy, Management & Evaluation, Dalla Lana School of Public Health, University Toronto, Toronto, ON, Canada
- 6Department of Internal Medicine, Dell Medical School, University of Texas at Austin, Austin, TX, USA
- 7Costs of Care, Boston, MA, USA
- Correspondence to W Silverstein William.Silverstein{at}mail.utoronto.ca
- “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
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 such as blood sample tubes are large contributors to emissions from hospital sectors and healthcare systems,14 with nearly one third of collected specimens being discarded.915 Thus, one strategy to reduce the carbon footprint of healthcare is to reduce unnecessary testing. This makes reduction of routine, repetitive bloodwork an urgent sustainability issue as well as a quality imperative.
Addressing this complex problem requires individual clinicians and health systems to employ multi-pronged strategies to decrease unnecessary laboratory testing for hospital inpatients. This article summarises the rationale for this recommendation, the challenges encountered, and suggests ways in which we can change our daily practice to reduce routine and repetitive ordering of blood tests in patients without a clinical indication.
The evidence for change
How do routine and repetitive blood tests affect care?
As part of Choosing Wisely campaigns in North America, Europe, and the United Kingdom, societies representing a range of specialties such as critical care, transfusion, and internal medicine advise against routine, repetitive laboratory testing for hospital inpatients who are clinically and biochemically stable1617181920212223 (table 2). This is because these unnecessary tests rarely change clinical decisions for the initial presentation and may lead to unintended clinical consequences. Negative impacts of routine and repetitive blood work on clinically stable patients include:
Choosing Wisely recommendations against routine, repetitive laboratory testing for stable hospital inpatients
Cost—This practice is expensive, costing $150 (£135) per patient per day24
Disruption to patient sleep—Routine laboratory tests are often drawn in the early morning and sleep interruption may be associated with a greater risk of readmissions or emergency department visits after discharge2526
Venipuncture harms—Includes pain, bruising, and vascular injuries27
More frequent bloodwork is associated with increased lengths of stay, readmission rates, and mortality92829
Increased risk of blood transfusion, and if transfused, patients are likely to receive more blood.93031
Initiatives to reduce the incidence and impact of routine and repetitive bloodwork on medical patients have focused primarily on two goals: improving ordering practices to avoid unnecessary testing, and minimising the volume of blood phlebotomised for laboratory tests.
Evidence supporting improved ordering practices to reduce unnecessary testing
This evidence mostly originates from several single centre controlled before-and-after quality improvement initiatives that show routine and repetitive blood tests can be safely reduced through targeted initiatives without increasing readmission rates, length of stay, adverse events, missed biochemical diagnoses, or mortality.32333435 For example, in one study from the US, several measures were introduced to reduce unnecessary laboratory tests. At the end of three years, rates of readmission (2009: 12.16%; 2011:11.92%) and mortality (2009: 2.24%; 2011: 2.07%) did not change significantly.34
Evidence supporting measures that reduce phlebotomised blood volume
The evidence supporting strategies to reduce the volume of phlebotomised blood used for testing is summarised in two systematic reviews, one scoping review, and one narrative review.36373839 These reviews included anywhere from eight to 38 studies (randomised controlled trials, interrupted time-series analyses, and both prospective and retrospective observational studies). They consistently found that volume of routine blood tests can be effectively reduced through strategies such as use of paediatric sized blood collection tubes.
Barriers to change
Routine, repetitive ordering of blood tests in hospital inpatients without clinical indications is a practice primarily enabled by healthcare providers. These tests are often ordered with the intent of excluding a diagnosis, helping with prognostication, or enhancing patient safety.4041 Similar to other types of low value care, this practice is driven by clinician habits, institutional culture, fear of litigation, and perceived pressure from families and caregivers.40 However, hospital inpatients often inherently trust that blood tests are ordered purposefully, and are unlikely to pressure their clinicians into ordering routine, repetitive bloodwork.42 Nearly half of the patients in one cross-sectional exploratory sequential mixed method study conducted on a general internal medicine ward at a Canadian tertiary centre were concerned with inappropriate testing and the associated harms, but expressed trust in their care team that the testing was warranted.42 Thus, patients appear willing to participate in conversations regarding routine, repetitive laboratory testing.42 Empowering them to ask questions and share their concerns regarding blood testing should be encouraged, but may not be sufficient to change practice since patients often only become aware of orders for blood tests when interacting at the bedside with the phlebotomist or nursing staff, who are simply completing medical orders. Patient engagement in quality improvement initiatives at the organisation or ward level, however, might offer support for this as a patient centred change and help dispel the perception that patient demands are driving utilisation of blood tests.43
How should we change our practice?
Initiatives to reduce the incidence and impact of routine and repetitive blood tests in hospital inpatients target both individual provider practices, as well as implementing systems-level changes. The High Value Practice Academic Alliance published a value improvement blueprint outlining best practices to decrease provision of this low value care. The most effective interventions leverage broad stakeholder engagement and a multimodal approach, including educational initiatives, audit, and feedback to individual clinicians with peer comparisons about blood test use, and changes to standard electronic medical record orders.35
Interventions that improve ordering practices to reduce unnecessary testing
Educational initiatives to reduce routine, repetitive bloodwork are usually successful when endorsed by institutional leadership and when they target healthcare workers involved in ordering, drawing, and testing.35 These educational efforts should emphasise appropriate indications for testing, potential adverse effects of routine, repetitive bloodwork, and that routine, repetitive bloodwork can be reduced without increasing risk of missed or delayed diagnoses.35
Audit-and-feedback mechanisms provide clinicians with data on personal ordering patterns as they relate to institutional benchmarks, as well as peer comparisons444546 (table 3). Electronic medical records can also be altered to restrict clinicians’ abilities to order routine, repetitive daily laboratory tests by removing the functionality to do so, limiting ordering periods to defined timeframes, or creating alerts that display prior stable results for the test being ordered.35 Underpinning the success of these initiatives is an institutional culture that promotes patient centred care, value, safety, and efficiency. This multimodal approach has previously reduced testing by 8% to 32% and yielded savings of more than $2m over a three year period for the local hospital.32344748 This proposed implementation blueprint is the basis of Choosing Wisely Canada’s “Pause the Draws” toolkit, which aims to help healthcare organisations develop an approach towards reducing routine, repetitive blood work, and has decreased utilisation by 17% to 27% at one Canadian centre.11 No significant change in length of hospital stay or proportion of tests sent “stat” was observed.11
Examples of audit-and-feedback practices that reduce routine, repetitive laboratory testing in patients without clinical indications
System level changes that reduce volume of blood phlebotomised
Structural changes can also mitigate the volume of blood phlebotomised for testing. Use of paediatric sized blood collection tubes, blood sampling conservation devices (which return the usually discarded blood that is drawn just prior to blood sampling), and non-invasive testing methods (eg, point of care glucose monitoring rather than serum glucose) all reduce blood loss in hospital inpatients.363738 Whether use of small volume tubes leads to clinically meaningful outcomes, such as reduced transfusion rates, is the subject of an ongoing clinical trial.49 Lastly, machine learning—systems that learn from data to recognise patterns and make accurate predictions of future events50—can be leveraged to reduce routine, repetitive bloodwork. Various models have been integrated into electronic medical records and can reliably identify patients receiving low yield laboratory testing (ie, glycated haemoglobin levels, extended electrolytes), thereby potentially providing feedback to clinicians to discourage low value testing.5152
Education into practice
What makes you uncomfortable about limiting the ordering of routine, repetitive laboratory testing?
How often have you changed management in response to the results of routine, repetitive laboratory testing?
What strategies do you think would successfully limit unnecessary blood testing at your hospital?
How patients were involved in the creation of this article
Cindy Dumba, a coauthor of this article, serves as patient and public adviser with Choosing Wisely Canada and patient and family adviser to Choosing Wisely Saskatchewan. She has lived experience with routine, repetitive bloodwork as a hospital inpatient. She reviewed and commented on all versions of the manuscript.
What patients need to know
Reducing routine, repetitive bloodwork can preserve limited resources, and avoid the associated harm and disruption to patients that result from frequent blood draws
Reducing routine, repetitive bloodwork can be done safely, without increasing negative consequences to your health like missed diagnoses
Search methods
We searched Medline using four broad concepts: routine laboratory testing terms, low-value care terms, iatrogenic anaemia terms, and quality improvement terms. Searches were limited to the English language. We also reviewed the reference lists of all relevant articles identified by the search as well as those included in the major international and Choosing Wisely guidelines. We reviewed articles that cited certain articles of interest. Additionally, we consulted experts in low value care and laboratory testing on relevant published evidence.
Footnotes
The BMJ thanks Wendy Levinson and Karen Born at Choosing Wisely for valuable advice and supporting the selection of topics. Choosing Wisely had no input into the peer review process or editorial decision.
Competing interests: The authors have no conflicts of interest to declare.
Provenance and peer review: commissioned; externally peer reviewed.
We thank Wendy Levinson, MD, OC for suggesting the review topic.