Test Utilization
Additional Resources:
PowerPoint - How to Successfully Influence Test Utilization & Improve Laboratory Efficiency
PowerPoint - SLH Clinical Pathologist - Responsibilities and Roles
PowerPoint - How the Clinical Laboratory Enhances Patient Care
Below is a summary of initiatives that laboratories can implement to reduce excessive, ineffective, unnecessary and redundant testing.
General
- Educate physicians about appropriate test utilization on a continual basis with a laboratory newsletter
- Respond promptly to physician calls regarding test ordering and interpretation
- Design test requisitions to encourage optimal test ordering
- Discontinue obsolete tests
- Discontinue low volume tests, especially if you are running more quality control samples than patients
- Have pathologists review lab tests incorporated into clinical pathways
- Have pathologists review orders for esoteric tests sent to reference laboratories
- Renegotiate pricing for send out tests on a regular basis
- Review send out test volumes annually and bring high volume tests in house
- Store specimens in lab for one week for add-on tests
- Eliminate replicate testing of normal and abnormal results
- Eliminate large volume venipuncture tubes
- Decrease laboratory error rate to reduce number of repeat test orders
- Set allowable time intervals for repeat testing in hospital information system
- Implement autoverification whenever feasible
- Merge outpatient and inpatient electronic medical records to reduce number of tests ordered on admission
- Discourage writing of daily orders and set limits for mandatory rewriting of orders
- Compare physician test utilization for a specific DRG with their peers
- Discourage routine ordering of preoperative screening tests
- Improve turnaround times to reduce tendency to reorder pending tests
- Determine which confirmatory tests should be performed during the inpatient versus the outpatient setting
- Evaluate reference ranges periodically to decrease follow-up testing for slightly abnormal results
- Establish guidelines to determine medical necessity of new test requests
- Ask clinicians to refer point of care vendors to the medical director of the laboratory
Chemistry
- Change stat urine medical drug screens from comprehensive to Triage drug screen
- Eliminate large chemistry panels except for Medicare approved panels
- Require separate order for arterial blood gases and co-oximetry
- Change anti-nuclear antibody cutoff from 1:40 to 1:160
- Eliminate vancomycin peak levels for therapeutic monitoring
- Eliminate total CK from Cardiac Marker Panel
- Replace Amniostat PG with FLM II as first step in fetal lung profile to reduce two dimensional L/S ratio volume by ~50%
- Do not perform immunofixation without prior serum protein electrophoresis
- Change quality control for precise automated instruments to single 3 SD rule
- Screen for thyroid disease with TSH and reflex to free T4 if abnormal
- Do not perform chemistry panels on body fluids; limit testing to protein, LD, pH, glucose, amylase, triglycerides as needed
- Set limits for maximal dilutions of elevated tests such as enzymes
Hematology
- DIC Panel – quantitative D-Dimer replaced FDP & SFMC
- Standardized heparin protocol based on dosage based on body weight results in a decreased number of bleeding episodes due to heparin overdose
- Continuously review hematology analyzer rules to reduce manual diff rate below 30%
- Replace manual reticulocyte with automated counts
- Implement Protime autoverification for outpatients
- Discontinue bleeding time
- Discontinue band neutrophil counts
- Discontinue RBC folate testing
- Encourage physicians to routinely order CBC instead of CBC with diff
- Encourage physicians to order urinalysis with automatic reflex to microscopic exam if positive for blood, protein or leukocyte esterase
- Implement urinalysis autoverification
- Do not perform Protein C & S for patients receiving warfarin
Microbiology
- Discontinue rapid bacterial antigen tests
- Change diarrhea work-up from full O&P to Giardia antigen for outpatients & C.difficile for inpatients who develop diarrhea >3 days after admission
- Decrease incubation time for urine cultures from 48 to 24 hours
- Reflex HCV EIA positive specimens to TaqMan RT PCR instead of RIBA
- Convert Chlamydia trachomatis (CT) and Neisseria gonorrheae (NG) testing to amplified test to increase detection rate by at least 1%
- Introduce chlorhexidene skin preparation to reduce blood culture contamination rate below 1.5%
- Delete Epstein Barr virus early antigen from EBV panel
- Discontinue Sabaroud slant from initial fungal culture setup
- Convert viral cultures to real time PCR
- Convert Group B Strep to real time PCR
- Discourage rapid Strep test and throat culture if physician intends to treat the patient regardless of the result
- Discourage ordering of urine culture for nonrecurring uncomplicated urinary tract infections in nonpregnant women
- Discourage fecal leukocyte testing and gram stains
- Do not allow HIV PCR or Western Blot for screening
- Encourage Neisseria PCR on urine for males with urethritis
Flow Cytometry
- Publish criteria for appropriate use
- Replace commercial lyse solution with homebrew solution
- Eliminate Flow isotype control reagents
- Discontinue daily normal controls on immune panels
Reference Laboratory
- Reference Laboratory send-out tests monitored by pathologists
- HCV genotyping brought in house
- Cystic Fibrosis Screen brought in house
Hospital transfusion service
Recipient testing
- Use immediate spin crossmatch or electronic crossmatch
- Use of anti-IgG instead of polyspecific AHG
- Perform elutions on DAT positive samples only if transfused within last 3 months
- Eliminate recipient anti-A,B testing
- Eliminate autocontrol
- Eliminate weak D testing
- Eliminate reading antibody screen after immediate spin
- Eliminate antigen typing for clinically insignificant antibodies
Donor testing policies
- Use anti-A,B to confirm group O units instead of separate anti-A and anti-B
- Confirm Rh type only on Rh negative units
Cord blood
- Perform ABO & Rh typing only if mom is group O or Rh negative
- Don’t do elution if DAT is positive
Introduce thawed plasma policy to decrease Fresh Frozen Plasma wastage
Monitor surgeon specific transfusion data annually
Discontinue shed blood collection after open heart surgery