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Large variation in laboratory tests for chest pain in emergency departments

12th September 2021

Laboratory tests requested by emergency care clinicians are often outside of guidelines and driven by both local and systemic factors.

Within an emergency care setting, the use of diagnostic tests helps with the detection or exclusion of a disease. Although diagnostic tests only account for a small proportion of a hospital’s budget, between 60 and 70% of all clinical decision-making is estimated to be based on the results of a diagnostic test. Despite this, in a review of studies, it was found that 45% of laboratory tests in healthcare are under-utilised compared to 21% which are over-utilised. In an effort to ensure both consistent and rational use of diagnostic and laboratory tests, the Sensible Test ordering Practice initiative was developed in Australia. However, in an analysis of tests ordered following the introduction of the initiative, it was found that just over a third (34.4%) of laboratory tests requested were unnecessary, i.e., generally not indicated. In trying to gain a better understanding of why such tests were being ordered, a team from the Australian Institute of Health Innovation, Sydney, Australia, undertook a qualitative study with clinicians. The team conducted semi-structured interviews and based on the themes identified developed targeted questions to be used with focus groups and focused on patients who presented with undifferentiated chest pain at an emergency department (ED).

Findings
While clinical staff were fully aware of the need to rationalise requests for laboratory tests, the adherence to sensible test ordering was affected by several local and systemic factors. For example, clinicians would order tests that were beyond the patient’s ED encounter often because of requests from other departmental specialists, e.g., can you also order this or that test. Furthermore, laboratory tests would be ordered in anticipation of the those required by the team admitting a patient, even though such tests were somewhat irrelevant within the ED setting. In other words, clinicians ordered tests beyond their remit to facilitate the entire patient’s hospital journey.

Another factor identified was the existence of conflicting guidelines. Although advice on the required tests were contained with the decision-support, electronic medical record (eMR), clinicians noted for example, that the clinical pathway on the eMR required additional tests to those in the order set for ischaemic chest pain, leading to an inconsistency. Moreover, with limited in-house speciality and diagnostic services in some hospitals, clinicians pre-emptively ordered tests for which they knew there would be a longer turnaround time after hours. Additional and unnecessary tests were also requested when patients were transferred to another centre, simply because clinicians were aware of the need for these tests to ensure acceptance at the receiving centre. Finally, while greater use of technology enabled laboratory testing requests much easier, the existence of multiple order screening within the eMR made it difficult to establish a common ordering process.

Summarising their findings, the authors noted that the variability in ordering of laboratory tests was influenced by requirements for admission, conflicting guidelines, availability of in-house resources and the features of of the eMR system. Given that the ED is perceived as the ‘front door’ it was not uncommon to see the ordering of laboratory tests which were beyond the scope of the ED but pertinent for other or later aspects of patient care. The authors concluded that beyond standardisation of laboratory and clinical decision-support systems, attempts to address the variation in laboratory tests need to address both local and systemic factors.

Citation
Li J et al. Why is there variation in test ordering practices for patients presenting to the emergency department with undifferentiated chest pain? A qualitative study. Emerg Med J 2021.