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A more thoughtful approach to routine blood testing

Toronto, November 29, 2016

By Emily Holton

Routine blood testing adds up - 7 ml collected in one day - that's 50 units in one month or 36 human blood volumes in one year
Click here or on the image above for a larger, more readable version. (Infographic by Marcelo Silles)

A St. Michael’s hematologist is asking physicians to think twice before ordering routine bloodwork.

Losing just a few milliliters of blood per day – about one full tube’s worth – increases risk of anemia. Among hospital patients, anemia is associated with longer length of stay, blood transfusions and even death.

Not to mention that every poke hurts, and every test costs money.

Dr. Lisa Hicks, a hematologist and Choosing Wisely lead at St. Michael’s, wanted to see if there was room to reduce repetitive, “routine” blood testing at St. Michael’s. Routine bloodwork usually consists of a complete blood count, biochemistry tests and coagulation tests.

“We’ve all been trained to put great emphasis on data collection to inform care, and that’s a positive thing,” said Dr. Hicks. “However, sometimes it can err on the side of excess.”

Dr. Hicks and her team found that about one-half to two-thirds of patients on General Internal Medicine and Hematology/Oncology had routine bloodwork completed on at least three consecutive days during their stay. Of those patients, one-third continued to receive daily blood tests after their numbers had stabilized. This suggested that some patients were getting tests that they didn’t need.

To respond, Dr. Hicks and her team zeroed in on order sets, checklists that bundle together medical orders (such as blood tests) for testing and treatment.

“Technology can sometimes make it easy for us to act in a habitual pattern rather than a thoughtful pattern,” said Dr. Hicks. “We wanted to make sure the order sets weren’t unintentionally encouraging open-ended orders.”

In May, she worked with clinicians to revise order sets that were used frequently on GIM and Hematology/Oncology. The aim was to ensure that time-limited orders were easier to make than open-ended orders. It’s still possible to order daily blood tests with no end date, but that option requires more keystrokes.

The initial results are encouraging.

“Even though these changes are modest and can be worked around, we have seen a drop in routine blood testing,” said Dr. Hicks. “The clinicians have really embraced the idea.”

Nurse practitioners Marnee Wilson and Bertha Hughes are now leading a revision of order sets for Cardiovascular and Peripheral Vascular Surgery, where three-quarters of patients get daily blood tests.

About St. Michael's Hospital

St. Michael’s Hospital provides compassionate care to all who enter its doors. The hospital also provides outstanding medical education to future health care professionals in 27 academic disciplines. Critical care and trauma, heart disease, neurosurgery, diabetes, cancer care, care of the homeless and global health are among the hospital’s recognized areas of expertise. Through the Keenan Research Centre and the Li Ka Shing International Healthcare Education Centre, which make up the Li Ka Shing Knowledge Institute, research and education at St. Michael's Hospital are recognized and make an impact around the world. Founded in 1892, the hospital is fully affiliated with the University of Toronto.