Blood Lines: Up to 2/3 of Tests Unnecessary
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Lack of official guidance, fear of litigation or getting into trouble with superiors has led to too many pointless and expensive blood tests being undertaken, a new study reveals. Research presented at Britain’s oldest surgical Royal College highlighted that up to two thirds in some instances could be entirely unnecessary, and are needlessly costing hospitals thousands of pounds a month.
Compiled by junior doctors who noticed a lack of clear guidelines regarding the number and range of blood tests required at their busy trauma unit, the data was presented at the prestigious Audit Symposium, which took place last month during the Royal College of Surgeons of Edinburgh (www.rcsed.ac.uk) annual President’s Meeting.
The study evaluated hundreds of frequently-requested blood investigations for acute patients, including liver function (LFT) and C-reactive protein (CRP – to detect inflammation from tissue injury or infection) tests, coagulation screens and international normalising ratios (INR – blood clotting).
Research undertaken in the trauma and orthopaedic units at Ninewells Hospital, Dundee and Perth Royal Infirmary found that in the case of Coag/INR tests, close to a third (32%) were redundant, as were 63% of LFTs and a whopping 65% of CRPs.
Working closely with multi-disciplinary input from surgical, anaesthetic and blood science teams, guidelines were subsequently drawn resulting in a dramatic reduction in the number of requests (1040 to 840), with overall costs in their department slashed by a third (33.3%) in just one month.
Over two hundred patients were included in each audit ‘loop’, the first in January 2014 then once again in September, following implementation of newly-crafted recommendations. The guidance was officially adopted within NHS Tayside and there is hope to see similar approaches rolled out in other hospitals across the UK.
Led by junior doctor Alastair Faulkner, the audit compared statistics from blood-testing prior to the implementation of guidelines and after. Alastair, who is 26, explains:
“As a junior doctor, I noticed that blood tests were being requested with little indication as to why they were needed. Blood investigations are costly – not to mention unpleasant for patients – and often contain very little in terms of clinical significance. Our study highlighted the need for clear guidance; for example, once we had implemented controls the total number of liver function tests (LFTs) alone requested dropped by a staggering 65%. This was not at detriment to the patient, in fact, out of the 895 LFTs requested in January, just 4 patients had a previous history of documented liver disease.”
The new guidelines include strict controls on admission and post-op monitoring tests. For example, under-60 year olds with ‘peripheral’, low-velocity injuries (such as a fractured ankle or wrist) who aren’t on medication, and have no significant medical history, are spared any blood investigations on admission. Only those over 60 and on regular medication should undergo more detailed screenings – for example conduct LFTs only if they have a blood or liver disorder, or are on blood thinners (anticoagulants), and CRPs if there is a suspected infection. Full blood works are required only for those with multiple, open and/or long bone fractures, suspected bone disease or possible sepsis. The guidelines also do away with vague ‘monitoring’ or ‘routine’ requests, and require documented clinical indications for any tests.
Dr. Faulker; who conducted the research alongside surgeon Mr. Mike Reidy; continues;
“Reasons for over-investigation include a lack of guidance – it’s not necessarily clear what tests are appropriate for every case, and a busy trauma unit deals with a varying patient demographic, from a child with an ankle injury to older people with hip fractures. Junior doctors may be worried about missing something important and causing delays, incurring the disapproval of their consultant or anaesthetist or simply suffer with fear of litigation.
“To establish guidelines, we sought multi-disciplinary input from many different people, particularly anaesthetists, but also including blood scientists, medical and orthopaedic teams. The results speak for themselves; blood tests on admission dropped dramatically after implementation, and a substantial amount of money was saved with no detriment to patient care or safety – and we continually monitor the efficacy of our new procedures. It’s hoped that these recommendations can be rolled out into many NHS hospitals and sites; we need to emphasise the need to only undertake tests in a clinically justifiable manner.”
According to the RCSEd President Mr. Ian Ritchie, who is also a consultant trauma and orthopaedic surgeon:
“Junior doctors and surgical trainees are at the very coalface of healthcare delivery, and as such are uniquely placed to reveal opportunities for improvement. This study is a great example of the power of several disciplines coming together to implement changes that benefit patients and the Health Service as a whole. Research such as this, presented at our Audit Symposium, alongside proactive collaboration between different specialties should be taking place across all of Britain’s hospitals, to ensure that vital – and scarce – resources aren’t going down the drain.”
About The Royal College of Surgeons of Edinburgh
RCSEd (www.rcsed.ac.uk) was first incorporated as the Barber Surgeons of Edinburgh in 1505, and is the oldest surgical corporation in the world with a membership of over 23,000 professionals in over 100 countries worldwide. The College promotes the highest standards of surgical and dental practice through its interest in education, training and examinations, its liaison with external medical bodies and representation of the modern surgical and dental workforce. It is also home to the UK’s only Faculty of Surgical Trainers, open to all those with an interest in surgical training regardless of College affiliation. Find RCSEd on Twitter www.twitter.com/RCSEd and on Facebook www.facebook.com/rcsed
The College is based at Nicolson Street, Edinburgh, EH8 9DW and can be reached on (0)131 527 1600 or firstname.lastname@example.org. In March 2014, a new base opened in Birmingham, catering to the 80% of the College’s UK membership who are based in England and Wales.
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