REDucing Unnecessary Coagulation Testing in the Emergency Department (REDUCED)

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.