Unnecessary medical testing has been shown to be rife in modern medicine, with estimates in the literature typically in the range of 20-25%. This has also been shown to be a problem that isn’t going away, with most clinical laboratories experiencing 5 to 10% increases in workload each year. In recognition of this, Eastern Health performed some background measures in late 2013 and formed a clinical working group called “NUTs – No Unnecessary Tests”. Initial improvement modelling performed in our Emergency Department identified a number of root causes of this ordering, such as:
- lack of education
- fear of missed diagnoses
- institutional habit
- lack of ordering pattern transparency
A number of projects were then formulated to address these issues. The first of these was launched in late 2014 and consisted of a clinical guideline to assist ED physicians in determining whether to send urine samples for formal laboratory microscopy. A 30% reduction in ordering was recorded during a 6 month implementation period.
In 2015 the availability of a full time senior ED physician allowed many more of the projects to commence and the initial results have been striking: Overall ED pathology ordering has fallen by 16% over the past 6 months, CRP testing has dropped by 50% and a pulmonary embolism decision pathway has reduced CT pulmonary angiograms by 35%. One of the keys to this initial success has been to use a clinician led approach and to address multiple root causes. A combination of clinical pathways, electronic decision support and an aggressive ongoing education campaign within the ED has contributed to the success and sustainability of the project to date.
We are excited by these initial results and feel that we are now seeing evidence of a sustainable culture change. Conversations about rational testing have become common place amongst our clinical staff and many tests that haven’t been explicitly targeted have started to reduce. But we have only just started. There is further work to be done within our emergency department and we plan to transplant this work to our other network EDs. More importantly, however, we plan to use the same methodology to expand this work into a broader inpatient setting with the hope that clinicians from all areas of medicine might start to rethink about this important topic.
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