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REDucing Unnecessary Coagulation Testing in the Emergency Department (REDUCED)

Michael Fralick1, Lisa K Hicks1, Hina Chaudhry1

  • 1Department of Medicine, Department of Laboratory Medicine and Pathobiology, Department of Emergency Medicine, Division of Hematology/Oncology, Li Ka Shing Knowledge Institute St. Michael's Hospital, Toronto, Ontario, Canada.

BMJ Quality Improvement Reports
|May 5, 2017
PubMed

Insights

Routine coagulation testing, including prothrombin time/international normalized ratio (PT/INR) and activated partial thromboplastin time (aPTT), was significantly reduced in the emergency department through a quality improvement initiative. A simple order panel revision led to decreased PT/INR and aPTT testing without adverse effects.

Area of Science:

  • Clinical Pathology
  • Healthcare Quality Improvement
  • Emergency Medicine

Background:

  • Prothrombin time/international normalized ratio (PT/INR) and activated partial thromboplastin time (aPTT) are historically significant coagulation tests.
  • These tests are frequently ordered together in emergency departments despite unique indications.
  • Overutilization of coagulation testing can lead to increased healthcare costs and potential patient harm.

Purpose of the Study:

  • To evaluate the effectiveness of a multimodal intervention in reducing routine PT/INR and aPTT testing in the emergency department.
  • To assess the impact of changes in order panels on coagulation test utilization.
  • To determine if reducing these tests impacts patient care or other laboratory test ordering.

Main Methods:

  • A prospective, multi-pronged quality improvement study was conducted at St. Michael's Hospital.
  • Interventions included stakeholder engagement, decoupling of PT/INR and aPTT orders, educational initiatives, and crucially, a revision of electronic order panels.
  • Weekly testing rates per 100 emergency department patients were tracked, with creatinine testing used as an internal control.

Main Results:

  • Following the order panel revision, weekly PT/INR testing decreased from 38.4 to 17.2 per 100 ED patients (rate ratio=0.45, p<0.001).
  • Weekly aPTT testing decreased from 37.8 to 16.6 per 100 ED patients (rate ratio=0.44, p<0.001).
  • Creatinine testing rates increased (rate ratio=1.09, p<0.0001), and blood transfusion rates slightly decreased (rate ratio=0.66, p=0.0034), indicating no widespread negative impact.

Conclusions:

  • A straightforward process change, specifically modifying order panels, can significantly reduce unnecessary coagulation testing in the emergency department.
  • This intervention achieved meaningful reductions in PT/INR and aPTT utilization without apparent adverse clinical consequences.
  • Optimizing laboratory test ordering through quality improvement initiatives is feasible and beneficial for healthcare resource management.

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